Background: Every 30-minute delay to ST-Elevation Myocardial Infarction (STEMI) reperfusion increases one-year mortality by 7.5%. A local audit found that the third of patient electrocardiograms (ECGs) not initially meeting classic STEMI criteria had an ECG-to-Activation (ETA) time of over 90 minutes, more than five times that of classic STEMIs. However, three quarters of “STEMI negative” ECGs met STEMI-equivalent patterns or rules for subtle occlusion, uncovering an opportunity for improvement. Aim Statement: We aimed to reduce ETA time, from initial emergency department (ED) ECG to activation of the cath lab, for patients whose ECGs did not meet classic STEMI criteria, by 30 minutes within one year (i.e. by Dec 2019). Measures & Design: We reviewed all ED Code STEMIs over a 35-month pre-intervention period. Root Cause analyses, including Ishikawa diagram and Pareto chart, led to our Plan-Do-Study-Act cycles: 1) a survey to engage our team; 2) a Grand Rounds presentation as an educational strategy; and 3) weekly web-based feedback to all ED physicians on STEMI-equivalents and subtle occlusions, using recent local cases. Our outcome measures were ETA times, stratified by ECGs not initially meeting STEMI criteria (primary) and those that did (secondary). Our process measures were the number of website visits and page views. Our balancing measure was the proportion of Code STEMIs without culprit lesion. We used Statistical Process Control (SPC) charts with usual special cause variation rules. Evaluation/Results: ETA time for the 37.5% of 56 ECGs that did not meet classic STEMI criteria decreased from 97.5 to 53.7 minutes (min), a 43.8-min absolute decrease (p = 0.037), while those meeting STEMI criteria remained the same (16.5 to 18.2min, p = 0.75). SPC charts did not show special cause variation. There were 2,634 page views (65.9/week) and 1,092 visits (27.3/week), in a group of 80 physicians—i.e. a third of the group each week. There was no change in Code STEMIs without culprit lesions (28.0 % to 23.3%, p = 0.41). Discussion/Impact: We reduced ETA time by 43.8min for the one third of patients with culprit lesions not initially meeting classic STEMI criteria, a magnitude associated with mortality impact. To do so, we used a multi-modal educational strategy including a novel web-based feedback approach to all ED physicians. Local feedback and education on this challenging-to-diagnose subgroup, guided by ETA time as a quality metric, could be replicated in other centres.

Introduction: Electrocardiogram (ECG) diagnosis of acute coronary occlusion has been broadening in recent years, from classic ST-Elevation Myocardial Infarction (STEMI) criteria to STEMI-equivalents and rules for subtle occlusions. However, there is no quality metric focused on emergency physicians’ decision-making. We hypothesized that the time from initial emergency department (ED) ECG to activation of Code STEMI could quantify diagnostic delay associated with automated interpretation, classic STEMI criteria, and other signs of occlusion. Methods: This multi-centre retrospective study reviewed all ED Code STEMI patients with confirmed culprit lesions from two urban academic EDs over a three-year period (Jan 2016 to Dec 2018). We reviewed charts to calculate ECG-to-Activation (ETA) time, measured from the time stamp on the initial ED ECG to the time a Code STEMI was activated (based on the hospital call centre log). We examined ECGs to determine: 1) if automated computer interpretation labelled “STEMI” or not; and 2) whether they met classic STEMI criteria, STEMI-equivalent patterns, or rules for subtle occlusion, based on a priori criteria from published guidelines or studies. All ECGs were reviewed by the lead author (JTTM) and those not obviously meeting classic STEMI criteria were independently reviewed by the other author. Results: There were 180 Code STEMIs from the ED with culprit lesions, including 177 with complete information. Average ETA time was 46.5 minutes (95% Confidence Interval [CI] 36.3-56.7min). Automated interpretation labelled 55.4% of initial ECGs as “STEMI” (ETA 13.9 min, 95%CI 9.8-18.0min), and 44.6% not as “STEMI” (ETA 86.9min, 95%CI 67.9-105.9min). Initial ECGs included 62.1% with classic STEMI criteria (ETA 17.3min, 95%CI 12.8-21.8min), 11.3% with STEMI-equivalents (ETA 49.5min, 95%CI 29.5-69.5min), 18.1% with subtle occlusions (ETA 118.3min, 95%CI 81.5-155.1min) and 8.5% with no initial sign of occlusion (ETA 102.9min, 95%CI 53.9-151.9min). Inter-rater reliability was very good (Cohen's kappa 0.84). Conclusion: Over 90% of Code STEMI patients with culprit lesions had initial ECGs diagnostic of acute coronary occlusion, but automated interpretation and classic STEMI criteria only identified 55.4% and 62.1%, respectively. STEMI-equivalents and subtle occlusions were associated with significant diagnostic delays. ETA time can serve as a quality metric for emergency physicians and may help guide ED quality improvement initiatives.

Our objective was to measure the efficacy of ivermectin (IVM) and benzimidazoles (BZ, i.e. fenbendazole and albendazole) in 15 cattle farms in western France and southern Italy. A total of 11 groups were treated with IVM and 11 with BZ. Efficacy was assessed by calculating the percentage of faecal egg count reduction (%FECR) using the pre- and post-treatment arithmetic means. Anthelmintic resistance was considered to be present when the %FECR was <95% and the lower limit of the 95% confidence interval <90%. For IVM, the percentages of FECR ranged from 73% to 100%. Lack of efficacy to IVM was detected in two farms out of four in France, but was not detected in any of the seven farms in Italy. For BZ, the percentages of FECR ranged from 95% to 100%. No case of BZ resistance was detected in the five farms in France and the six farms in Italy.

Introduction: Emergency department (ED) care allows for the rapid assessment of patient concerns, but often leads to tests being performed that are not finalized or reviewed prior to patients leaving the ED. The follow-up for these tests pending at discharge (TPADs), most commonly final diagnostic imaging (DI) reports and microbiology cultures, is a major medico-legal concern for ED providers and significant safety concern for patients. We therefore performed a systematic review of the literature to identify existing ED quality assurance (QA) processes to address TPADs relating to final DI reports and microbiology cultures. Methods: Comprehensive literature searches were developed with a medical librarian and conducted in Ovid Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL from inception through May 8, 2018. Studies were included if they described an intervention or program designed to follow-up relevant ED TPADs, and excluded if they pertained to communication between departments or clinicians only rather than with patients. Study selection was performed independently by two reviewers in two steps (title and abstract review, then full-text review), with all discrepancies resolved by consensus with a senior reviewer. The primary outcome was the description of any QA process to follow-up on TPADs and secondary outcomes included quantifiable results of successful interventions or programs. Results: From the 11,685 articles identified, 58 were selected for full-text review, and 12 met eligibility criteria. In the included studies, the responsibility for following up on TPADs was owned by different members of the care team (e.g., ED physicians, nurses or radiologists) and recorded in a variety of ways (e.g., electronic medical record, paper chart, system designed for TPADs). Follow-up pathways with variable standardization were described, ranging from dedicated assignment for TPAD duties with protected/remunerated time to do so, to follow-up completion done by the first clinician to receive the TPAD result. Studies that evaluated their QA process implementation found that more patients were notified of abnormal test results, follow-up times decreased, and fewer unnecessary antibiotics were used. Conclusion: A variety of QA processes have been implemented to follow up on ED TPADs in terms of personnel involved, charting and logistics, and when evaluated, they have improved patient care.

Background: Greater than 80% of patient visits to emergency departments (EDs) are for a pain-related concerns. Approximately 38,000 patients per year have such complaints in our academic hospital ED. 3,300 (8.6%) of those visits are for musculoskeletal (MSK) pain (i.e. back or extremity injury/pain), which are typically triaged as low-acuity presentations, leading to longer times to clinician assessment. Delays to adequate analgesia result in unnecessary suffering, worse patient care and satisfaction, and increased patient complaints. Aim Statement: We aimed to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 minutes) in 9 months’ time (May 2018). Measures & Design: Our outcome measures were TTA (in minutes) and ED length of stay (LOS; in minutes). Process measures included nurses’ use of medical directive and rate of analgesia administration. Balancing measures included patient adverse events and time spent triaging for nurses. We utilized weekly data capture for the Statistical Process Control (SPC) chart, and we used Mann-Whitney U test for our before-and-after evaluation. Utilizing the Model for Improvement, we performed wide stakeholder engagement and root cause analyses, and we created a Pareto chart. This led to our Plan-Do-Study-Act (PDSA) cycles: 1) nurse-initiated analgesia (NIA) at triage; 2) new triage documentation aid for medication administration; 3) quick reference medical directive badge tag for nurses; 4) weekly targeted feedback of the project's progress at clinical team huddle. Evaluation/Results: TTA decrease from 129 minutes (n = 153) to 100 minutes (22.5%; n = 87, p < 0.05). ED LOS decreased from 580 minutes (n = 361) to 519 minutes (10.5%; n = 187; p = 0.77). Special cause variation was identified on the ED LOS SPC chart with eight consecutive points below the midline, after PDSA 1. The number of patients who received any analgesia increased from 42% (n = 361) to 47% (n = 187; p = 0.13). The number of patients who received medications via medical directives increased from 22% (n = 150) to 44% (n = 87; p < 0.001). Balancing measures were unchanged. Discussion/Impact: The significant reduction in the TTA and increase in the use of medical directives in the before-and-after analyses were likely due to our front-line focused improvements and deliberate nursing engagement. With continued success and sustainable processes, we are planning to spread our project to other EDs and broaden our initiative to all pain-related concerns.

Introduction: Quality improvement and patient safety (QIPS) activities in healthcare have become increasingly important, but it is unclear what the current national landscape is with regards to how individual EM departments are supporting QIPS activities and evaluating their success and sustainability. We sought to assess how Canadian medical school EM departments/divisions and major Canadian teaching hospitals approach QIPS programs and efforts, with regards to training, available infrastructure, education, scholarly activities, and perceived needs. Methods: We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee, including a)formal training/skill capacity; b)operational infrastructure; c)educational activities; d)academic and scholarship, and e)perceived gaps and needs. Surveys were pilot-tested and revised by authors. “Survey 1” (21 questions) was sent by email to all 17 Canadian medical school affiliated EM Department Chairs and Academic Hospitals Department Chiefs; “Survey 2” (33 questions) to 11 identified local QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey. We present descriptive statistics including proportions, means, medians and ranges where appropriate. Results: 22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. 45% of respondents described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per center ranging from 1-10 over the past 5 years. A minority of participants reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%). Conclusion: This environmental scan provides a snapshot of QIPS activities in EM across academic centers in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.

Introduction: Quality improvement and patient safety (QIPS) are increasingly recognized as integral to the provision and advancement of emergency medicine (EM) care. In 2015, QIPS were added to the Canadian Medical Education Directives for Specialists (CanMEDS) framework. However, the level of QIPS education and support that Canadian EM residents receive is unknown. In order to better plan national QIPS efforts aimed at enabling EM residents to improve their local care settings, we sought to assess the current state of QIPS education and support in Canadian EM residency programs. Methods: This was a descriptive, cross-sectional electronic survey that was disseminated to all current Canadian EM residents from both Royal College (RC) and Family Medicine - EM training streams. Residents were recruited either directly or through their program's administrative assistant. The survey consisted of multiple-choice, Likert and free-text entry questions. Themes included a) familiarity with QIPS; b) local opportunities for QIPS projects and mentorship; and c) desire for further QIPS education and involvement. The survey was open for a five-week period, with formal reminders after the first and third weeks. Descriptive statistics are reported. Results: 189 (35%) of 535 current EM residents completed the survey, representing all 17 medical schools. 77% of respondents were from the RC stream. 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS. 47.2% of respondents reported “not knowing” or “not having readily available” QIPS projects to participate in their local environment, and 51.5% had equivalent responses with respect to QIPS mentorship opportunities. Only 17.5% of respondents reported that QIPS methodologies were already formally taught in their residency program, and 66.9% indicated a desire for increased QIPS teaching. The majority of respondents were “slightly” (35.9%), “moderately” (23.2%) or “very” (11.3%) interested in becoming involved with QIPS training and initiatives. Conclusion: Responding Canadian EM residents are interested in obtaining greater QIPS education as well as project and mentorship opportunities, but many perceive that they do not have adequate access to these at the current time. As the importance of QIPS increases in the EM community, supporting residents with more robust educational infrastructures may be necessary. Future efforts may include the standardizing of QIPS postgraduate curricula and improving access to QIPS opportunities across the country.

Introduction: Treat and Release (T&R) patients are seen and discharged home from the emergency department (ED), and asked to return within 12-72 hours for follow-up care (e.g., ultrasound, repeat blood work). Our two academic teaching hospitals see approximately 2,000 T&R patients per year. Handover of care for T&R patientsdone through charting only and therefore dependent on the charts adequacy and completenessis crucial to the safety and quality of care they receive. An 18-month retrospective chart audit at our sites identified quality gaps, including suboptimal documentation that ultimately impedes patient disposition. Our projects aim was to reduce the time-to-disposition (TTD; time spent by patients between provider initial assessment and discharge from the ED) by a third (from 70min) in 6-months time (March 2017), a target felt to be both meaningful and realistic by our stakeholder team. Methods: Our primary outcome measure was the TTD (in minutes). Our process measure was the quality of documentation, using a modified version of QNOTE, a validated tool used to assess the quality of health-care documentation. PDSA cycles included: 1) Involvement of stakeholders for the creation and refinement of an improved T&R handover tool to cue more specific documentation; 2) Education of health-care providers (HCPs) about T&R patients; 3) Replacement of the previous T&R handover tool with a newly designed and mandatory tool (i.e. a forcing function); 4) Refinement of the process for T&R patients and chart hold-over. Results: Run charts for both the median TTD and median modified QNOTE scores over time demonstrate a shift (i.e., run chart rule) associated with the second and third clustered PDSA cycles. After the first three clusters of PDSA cycles (i.e., before-and-after), mean TTD was reduced by 40% (70min to 42min, p=0.005). The quality of documentation (mean modified QNOTE scores) was also significantly improved (all results p<0.0001): patient assessment from 81% to 92%, plan of care from 58% to 85% and follow-up plan from 67% to 90%. Conclusion: We reduced the time-to-disposition for T&R patients by identifying gaps in the quality of documentation of their chart. Using iterative PDSA cycles, we improved their time-to-disposition through improved communication between health-care providers and a new T&R handover tool working as a forcing function. Other centers could use similar assessment methods and interventions to improve the care of T&R patients.

Introduction: Over 1 million patients with head injuries (HIs) are seen every year at emergency departments (EDs) in North America, with over 90% being minor HIs. Over-utilization of computed tomography (CT) scans in these patients results in unnecessary exposure to radiation and increases health-care resource utilization. Using recommendations from the Choosing Wisely Campaign (CWC) and quality improvement (QI) methodology, we developed a local initiative targeting this issue. Our aim was to reduce the CT scan rate for patients presenting with HIs by 10% over a 6-month period at two academic EDs. This was considered both achievable and meaningful by our stakeholders. Methods: Baseline CT scan rates for patients with HIs were determined through a 10-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and PDSA cycles, which included: 1) Assessing and improving provider knowledge about the CWC recommendations; 2) Testing, refining and implementing a modified Canadian CT Head Rule checklist in the ED; 3) Developing and giving patients CWC-themed handouts pertaining to HI best practice; 4) Bimonthly reporting of CT scan rates to providers. Our primary outcome measure was the number of CT scans performed for patients with HIs. Process measures included the number of checklists completed and ED length of stay (LOS). Our balance measure was return ED visits within 72 hours. Results: Baseline rate of CT scans prior to our interventions was 47.9%. Our QI initiative resulted in a significant shift in the run chart of the weekly CT scan rates, associated with the second PDSA cycle cluster. We observed a 16% relative decrease in CT scans at 3 months (47.9% to 40.5%, P=0.005) and 10.4% at 8 months (47.9% to 43.1%, P=0.02). Non-sustained trends and shifts were seen in the run chart of median ED LOS for HI patients, but overall before-and-after median times were not significantly different (237min to 225min, P=0.18). 33% of total checklists were completed. 72-hr return visits did not change during the 8-month study period (4.0% to 4.16%, P=0.85). Conclusion: Our local QI initiative was successful in decreasing CT rates for patients presenting with a HI. The decrease in effect at 8 months suggests the need for continued feedback and reminders to ensure long-term sustainability. Other centres could use similar QI methods, as well as the materials we developed, to achieve similar results of improved evidence-based utilization of diagnostic tests.

Magnesium alloys (Mg-0.5%Zr and Mg-1.2%Mn) and graphite from spent nuclear fuel that has been used in the former French gas cooled reactors, have been stored together in AREVA La Hague plant. The recovery and packaging of these wastes is currently studied and several solutions are under consideration. One of the developed solutions would be to mix these wastes in a grout composed of industrially available cement, e.g. OPC, OPC blended with blast furnace slag or aluminous cement. Within the alkaline pore solution of these matrixes, magnesium alloys are imperfectly protected by a layer of magnesium hydroxide (Mg(OH)2, Brucite) resulting in a slow process of corrosion releasing hydrogen. As the production of this gas must be considered for the storage safety, and the quality of wasteform, it is important to select a cement matrix capable of lowering the corrosion kinetics of magnesium alloys. This is especially true when magnesium alloys are conditioned together with graphite wastes. Indeed, galvanic coupling phenomena may increase early age corrosion of the mixed wastes, as magnesium and graphite will be found in electrical contact in the same electrolyte. Many types of cements have been tested and most of them have caused strong hydrogen production when magnesium alloys and graphite are conditioned together into such cement pastes. Exceptions are geopolymer binder which is already known for that and another binder based on alkali hydroxide activated ground granulated blast furnace slag (AHABFS) which is presented in the present article. First are presented hydrogen production experiments that demonstrate the efficiency of AHABFS towards reduction of corrosion of Mg alloys embedded. In a second part, a formulation of fluid mortar based on this binder is proposed.

The high power RF device performance decreases as operation temperature increases (e.g. fall of electron mobility impacting the cut-off frequencies and degradation of device reliability). Therefore the determination of device temperature is a key issue for device topology optimisation. This work presents the comparison between pulsed I-V at different temperature and DC measurements of AlGaN/GaN HEMTs grown on two different substrates: sapphire and silicon. This technique allows the determination of mean channel temperature and the device thermal resistance. The thermal resistance is a classical way to define the average channel temperature as a function of the dissipated power. In this work the thermal resistance ratio of the HEMT grown on sapphire compared to the one grown on silicon is found to be 1.7 instead of 3 as expected from straightforward thermal conductivity ratio. This lower difference is clearly attributed to the contribution of the GaN buffer layer.

En dosimétrie des neutrons, les situations pratiques rencontrées couvrent un large domaine d'énergie s'étendant sur plus de 10 décades. En outre, les grandeurs dosimétriques utilisées en radioprotection ne sont pas directement accessibles à la mesure. Ce dernier point est principalement dû à la variation de la "qualité" du rayonnement neutronique, exprimé au moyen des facteurs de pondération radiologiques (pour le calcul de la dose efficace) et des facteurs de qualité (pour le calcul de l'équivalent de dose). En dépit des progrès considérables réalisés dans le domaine de la dosimétrie des neutrons, il n'y a pas encore aujourd'hui de dosimètre susceptible de mesurer la dose due aux neutrons avec une précision acceptable quel que soit le spectre en énergie. Cet article présente les grandeurs dosimétriques utilisées en radioprotection. Il traite également des méthodes et des procédures d'étalonnages adaptées à la détermination de la dose aux postes de travail avec les appareils actuels dont les performances sont limitées. Les propriétés de ces instruments, incluant les dosimètres de zone, les dosimètres individuels et les ensembles de spectrométrie, sont décrites et les améliorations nécessaires exposées. En conclusion, la situation actuelle requiert des recherches complémentaires pour le développement des techniques de dosimétrie et l'étude des postes de travail.