Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.

Introduction: Women experiencing early pregnancy loss or threatened loss frequently seek care in emergency departments (ED) or early pregnancy clinics (EPC). The dearth of existing qualitative studies has left understudied questions about how these women perceive their healthcare and which strategies best meet their supportive care needs, particularly in the Canadian context. The objective of this study was to deepen our understanding of these women's experiences and gain insight into how clinicians and healthcare services can lessen the impact of this traumatic event on patients and their families. Methods: We conducted a descriptive qualitative study of women who presented to the ED or EPC at an urban tertiary care hospital and an urban community hospital for early pregnancy loss or threatened loss. Purposive sampling was used to recruit patients for in-depth, one-on-one telephone interviews conducted 4-6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Data analysis was led by two qualitative researchers with support from a multi-disciplinary research team following standard thematic analysis techniques. Results: Interviews were completed with 59 women between July 2018 and August 2019. Participants ranged in age from 22 to 47 years and reflect the diversity of the multicultural city where the study occurred. Our analysis revealed that the medicalization and normalization of early pregnancy complications among ED and EPC clinicians is at odds with women's general lack of knowledge about the frequency, personal risk, causation, duration, and physical intensity of the miscarriage experience. Women identified the value of rapid access to appointments, point of care ultrasound, detailed care plans, and knowledgeable advice as key to lessening the physical and emotional trauma related to early pregnancy loss. Conclusion: This research highlights the physical, emotional, and psychological complexity of a medical situation frequently minimized within the current healthcare system. The results impart important knowledge about which aspects of ED and EPC care are most valued by women experiencing early pregnancy loss or threatened loss and demonstrate the clear need for women and their families to be provided with more education about the totality of the early pregnancy experience, including the possibility of pregnancy complications and loss.

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The objective of this study was to explore the lived experiences and perceptions of care of women treated for early pregnancy complications in the ED and early pregnancy clinic (EPC). Methods: We conducted an interpretive phenomenological qualitative study of women who presented to the ED or EPC of an urban tertiary care hospital with early pregnancy loss or threatened loss. We employed purposive sampling to recruit participants for in-depth, one-on-one telephone interviews conducted approximately 6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Our research team of two qualitative researchers, a clinician, a clinical researcher, and a research student performed a phenomenologically-informed thematic analysis including three phases of coding to identify essential patterns of lived experience and meaning across the sample. Results: Interviews were completed with 30 women between July and August 2018. Participants ranged in age from 22 to 45 years and reflected the diversity of the multicultural city where the study occurred. Four key themes of patient experience were identified: tensions between what is known and unknown by women and ED staff about early pregnancy complications and care in hospital, stigmatization of early pregnancy complications and ED use, normalization of a chaotic experience, and the overwhelm of unexpected outcomes during the ED visit. Conclusion: The perspectives of women attending the ED or EPC for early pregnancy complications highlights the ways in which the current health care system minimizes and medicalizes early pregnancy complications in this setting and fails to adequately support these women. The emotional complexity of this medical situation is often overlooked by ED staff and can produce encounters that are traumatic for patients and families. However, the participants’ negative experiences occurring in the ED were often mitigated with their care in their follow-up with the EPC.

Introduction: The Ontario emergency department (ED) Return Visit Quality Program (RVQP) launched in 2016 and aims to promote continuous quality improvement (QI) in the province's largest EDs. The program mandates routine audits of cases involving patients who had ED return visits within 72hrs that led to admission to hospital, in order to identify quality issues that can be tackled through QI initiatives. Our objective was to formally evaluate how well the RVQP achieved its aim of promoting continuous QI at participating sites using the constructivist grounded theory. Methods: Using a semi-structured interview guide, we employed a maximum variation sampling approach to ensure diverse representation across several geographical and institutional experiences (e.g., urban vs. rural, academic vs. community). Selected RVQP program leads were invited to participate in a phone interview to yield maximal insight, additionally using a snowball sampling approach to reach non-lead physicians to capture the penetration of the program. Interviews were conducted until thematic saturation was reached and no new insights were gleaned. Interviews were initially cross-performed by two members of the research team, recorded, transcribed, and de-identified. Data analysis was conducted using a constant comparative approach through the development of a coding framework and triangulation with the respondents’ ED setting. We then grouped, compared and refined our analytic categories through an inductive, iterative approach. Results: Between June and August 2018, we interviewed 32 participants, including 21 RVQP program leads and 11 non-lead physicians, from a total of 23 diverse sites (out of 84). Our analysis suggests that the RVQP provides a structured method for EDs to frame the continuous collection of data in order to channel activities towards quality improvement projects based on identified needs. Success factors included: greater involvement with QI processes prior to the RVQP leading to more openness to improvement, a more collaborative approach to RVQP implementation which led to greater front-line workers’ understanding and engagement, and more resources dedicated to implementing the RVQP as well as tackling the quality issues it identified. Conclusion: This study evaluated the impact of an innovative and large-scale program aimed at improving the culture of quality in Ontario EDs. While the program is still relatively new, early results show that there are key elements of EDs that support building a culture of QI.

Introduction: Email and text messaging holds the potential to not only contact patients after emergency department (ED) care for clinically important communications such as appointment reminders, but also to solicit feedback for quality improvement and/or participation in research. A necessary first step though is the collection of electronic contact information, but little is known about current practice in Ontario EDs. In this study, we sought to characterize current collection, consent and use of patient email and texting to communicate with ED patients at academic and community hospitals across Ontario. Methods: We developed a questionnaire, with a blend of multiple choice and open-ended questions, targeted at ED registration administrators. The questions focused on if and how EDs collect, store and consent for patient emails, how and what they utilize those emails for and if they text patients. The questionnaire was administered both online and by phone. Participants were recruited through snowball sampling, including facilitated dissemination of the questionnaire via an existing listserv of the Patient Registration Network of Ontario (PRNO). Results: Twenty-two respondents (41% response rate) completed the questionnaire. Seven of the 22 institutions were academic health centres (32%). Nine institutions (41%) collected patient email addresses in the ED and none collected or used text message technology. In all 9, registration staff were tasked with asking, consenting, collecting and storing patient details within their hospital admissions, discharge and transfer system (ADT). For sites with email address collection, respondents estimated 40-60% of ED patients shared an email address. Seven of 9 institutions had a verbal consent process, while 2 used implied consent. Only 2 institutions used email to send patients post-discharge feedback questionnaires and four used email to facilitate access to patient portals. Four institutions were looking at using text messages to direct patients at triage, sometime in the future. Conclusion: Engagement in optimized care and feedback requires communication which is quickly shifting to electronic format. Collection of electronic contact information continues to be slow and uneven in Ontario. There is an immediate need for clearer guidance to accelerate collection, storage, consent and use of email and text messaging technology.

Introduction: 9-1-1 telecommunicators receive minimal education on agonal breathing, often resulting in unrecognized out-of-hospital cardiac arrest (OHCA). We successfully piloted an educational intervention that significantly improved telecommunicators’ OHCA recognition and bystander CPR rates in Ottawa. We sought to better understand the operations of Canadian 9-1-1 communications centers (CC) in preparation for a multi-centre study of this intervention. Methods: We conducted a National survey of all Canadian CCs. Survey domains included information on organizational structure, dispatch system used, education curriculum, and performance monitoring. It was peer-reviewed, translated in French, pilot-tested, and distributed electronically using a modified Dillman method. We designated respondents in each CC before distribution and used targeted follow-up and small incentives to increase response rate. Respondents also described functioning of neighboring CCs if known. Results: We received information from 51/51 provincial and 1/25 territorial CCs, representing 99.7% of the Canadian population. CCs largely utilize the Medical Dispatch Priority System (MPDS) platform (93%), many are Province/Ministry regulated (50%) and most require a High School diploma as minimum entry level education (78%). Telecommunicators receive initial in-class training (median 1.3 months, IQR 0.3-1.9; range 0.1-2.2), often followed by a preceptorship (84.4%) (median 1.0 months, IQR 0.7-1.7; range 0.4-6.0). Educational curriculum includes information on agonal breathing in 41% of CC, without audio examples in 34%. Among responding CCs, over 39,000 suspected OHCA 9-1-1 calls are received annually. Few CCs maintain local performance statistics on OHCA recognition (25%), bystander CPR rates (25%) or survival rates (50%). Most (97%) expressed interest in future research collaborations. Conclusion: Most Canadian telecommunicators receive no or minimal education in recognizing agonal breathing. Further training and improved OHCA monitoring may assist recognition and enhance outcomes.

Introduction: Patient-reported outcome measures (PROM) are questionnaires that can be used to elicit care outcome information from patients. We sought to develop and validate the first PROM for adult patients without a primary mental health or addictions presentation receiving emergency department (ED) care and who were not hospitalized. Methods: PROM development used a multi-phase process based on national and international guidance (FDA, NQF, ISPOR). Phase 1: ED outcome conceptual framework qualitative interviews with ED patients post-discharge informed four core domains (previously published). Phase 2: Item generation scoping review of the literature and existing instruments identified candidate questions relevant for each domain for inclusion in tool. Phase 3: Cognitive debriefing existing and newly written questions were tested with ED patients post-discharge for comprehension and wording preference. Phase 4: Field and validity testing revised tool pilot tested on a national online survey panel and then again at 2 weeks (test-retest). Phase 5: Final item reduction using a Delphi process involving ED clinicians, researchers, patients and system administrators. Phase 6: Validation - psychometric testing of PROM-ED 1.0. Results: Four core outcome domains were defined in Phase 1: (1) understanding; (2) symptom relief; (3) reassurance and (4) having a plan. The domains informed a review of existing relevant questionnaires and instruments and the writing of additional questions creating an initial long-form questionnaire. Eight patients participated in cognitive debriefing of the long-form questionnaire. Expert clinicians, researchers and patient partners provided input on item refinement and reduction. Four hundred forty-four patients completed a second version of the long-form questionnaire (add in retest numbers) which informed the final item reduction process by a modified Delphi method involving 21 diverse contributors. The questionnaire was validated and underwent final revisions to create the 21 questions that constitute PROM-ED 1.0. Conclusion: Using accepted PROM instrument development methodology, we developed the first outcome questionnaire for use with adult ED patients who are not hospitalized. This questionnaire can be used to systematically gather patient-reported outcome information that could support and inform improvement work in ED care.

Introduction: Hospital-based gun violence is devastatingly traumatic for everyone present and recent events in Cobourg, Ontario underscore that an active shooter inside the emergency department (ED) is an imminent threat. In June 2016, the Ontario Hospital Association (OHA) added Code Silver to the list of standardized emergency preparedness colour codes and advised member hospitals to develop policies and train staff on how best to respond. Given that EDs are particularly susceptible to opportunistic breach by an active shooter, the impact of a Code Silver on ED functioning and staff members may be particularly acute. We hypothesized that there may not be a simple, one-size-fits-all-hospital-staff solution about how best to prepare EDs to respond to Code Silver. In order to inform and support future staff training initiatives related to Code Silver and other disaster situations in hospitals, we sought to investigate staff perspectives and behaviour related to personal safety at work and, in particular, an active shooter. Methods: We undertook a qualitative interview study of multi-disciplinary ED staff (MDs, RNs, clericals, allied health, administrators) at a single tertiary care centre in Toronto. The primary methods for data collection were in-depth qualitative interviews and focus groups. Participants were recruited using stakeholder and maximum variation sampling strategies. Data collection and analysis were concurrent and standard thematic analysis techniques were employed. Results: Sixteen (16) staff members participated in interviews and 40 participated in small focus group discussions. Data analysis revealed workplace violence and personal health risks have been normalized as expected, acceptable features of everyday life at work in the ED given that patients are perceived to be sick people in need of help that ED staff are trained for and prepared to provide. In contrast, weapons and active shooters challenge the boundaries of professional responsibility and readiness to respond to Code Silver is perceived by staff as a fallacy. Conclusion: Knowledge from this study gives us crucial insight into important areas for targeted training and opportunities for knowledge translation on the topic of implementing Code Silver in EDs across the country. Future interventions must include how to overcome normalization of workplace violence in the ED setting and negotiating competing professional obligations during crisis situations. Attention to these are crucial if we are to truly keep our staff safe during these traumatic events.

Introduction: Hospital-based gun violence is devastatingly traumatic for everyone present and quite tragically on the rise. The Ontario Hospital Association (OHA) has recently designated active shooter situations as “Code Silver” and advised member hospitals to develop policies and train health care workers on how best to respond. Given that emergency departments (ED) are particularly susceptible to opportunistic breach by an active shooter and staff members are likely to be called upon as first responders, the impact of a Code Silver on ED functioning and staff members may be particularly severe. We hypothesized that there may not be a simple, one-size-fits-all-hospital-staff solution about how best to prepare ED physicians and staff to respond to a Code Silver situation. Methods: In order to inform and support future staff training initiatives related to Code Silver and other disaster situations in hospitals, we conducted a robust qualitative study to investigate perspectives and behaviour related to personal safety at work and Code Silver in particular among the multi-disciplinary ED staff at a single tertiary care centre in Toronto, Ontario. Participants for in-depth interviews and focus groups were recruited using a combination of stakeholder and maximum variation sampling strategies. Data analysis occurred in conjunction with data collection and standard thematic analysis techniques were employed. Results: Initial data analysis has revealed the following thematic concepts: the ubiquitous banality of personal health risk as an expected, acceptable feature of everyday life at work for ED staff, the perception of active shooters as a transgressive threat that violates the boundaries of professional responsibility, and the perceived fallacy of “readiness” to respond to disastrous situations. A fulsome analysis will be ready for presentation in June. Conclusion: Knowledge from this study indicates that ED staff members have unique and specific training needs in relation to an active shooter situation, and gives us deeper insight into potential areas of focus for training and opportunities for knowledge translation on the topic of Code Silver for EDs across the country.

Introduction: The Canadian Medical Education Directives for Specialists (CanMEDS) framework defines the competencies that postgraduate medical education programs must cover for resident physicians. The 2015 iteration of the CanMEDS framework emphasizes Quality Improvement and Patient Safety (QIPS), given their role in the provision of high value and cost-effective care. However, the opinion of Emergency Medicine (EM) program directors (PDs) regarding the need for QIPS curricula is unknown, as is the current level of knowledge of EM residents in QIPS principles. We therefore sought to determine the need for a QIPS curriculum for EM residents in a Canadian Royal College EM program. Methods: We developed a national multi-modal needs assessment. This included a survey of all Royal College EM residency PDs across Canada, as well as an evaluative assessment of baseline QIPS knowledge of 30 EM residents at the University of Toronto (UT). The resident evaluation was done using the validated Revised QI Knowledge Application Tool (QIKAT-R), which evaluates an individual’s ability to decipher a systematic quality problem from short clinical scenarios and to propose change initiatives for improvement. Results: Eight of the 13 (62%) PDs responded to the survey, unanimously agreeing that QIPS should be a formal part of residency training. However, challenges identified included the lack of qualified and available faculty to develop and teach QIPS material. 30 of 30 (100%) residents spanning three cohorts completed the QIKAT-R. Median overall score was 11 out of 27 points (IQR 9-14), demonstrating the lack of poor baseline QIPS knowledge amongst residents. Conclusion: QIPS is felt to be a necessary part of residency training, but the lack of available and qualified faculty makes developing and implementing such curriculum challenging. Residents at UT consistently performed poorly on a validated QIPS assessment tool, confirming the need for a formal QIPS curriculum. We are now developing a longitudinal, evidence-based QIPS curriculum that trains both residents and faculty to contribute to QI projects at the institution level.

Introduction: Travel-based continuing medical education (CME) has become a popular format for physicians looking to combine education with travel. However these programs do not usually include shared group activities and when they do, they are often social, sedentary events. Emergency Medicine Update (EMU) Europe is a unique biennial accredited CME program which combines high quality Emergency Medicine focused education with organized group physical and social activities in European locales. Methods: We undertook a participant observation-based ethnographic study of the EMU Europe program in Provence, France in 2015. Participant interviews and in-depth observation methods were used to understand (1) the impact of shared group activities on learning and (2) the ethos that is created during this type of program. Results: We describe three phenomena from the data that we feel are highly influential in the success of the program and impact on learning. The first is “social engagement and a sense of community”. Involvement in group physical and social activities supports more interactive learning and people affiliate with this as a group that they enjoy and feel good learning with. The second is “a stimulating escape”. This is the opportunity for high quality education and stimulating travel to be provided in an efficient package. The third is “the ‘flat’ faculty-learner relationships”. This is created through accessibility and innovative teaching and is a key component of the quality of the education. Conclusion: While each trip in and of itself might be unique, there appears to be some common elements - building a sense of community, providing a stimulating escape and choosing faculty with specific teaching styles - that contribute to the educational success of this model. We will discuss how this relates to medical education theory and how it is generalizable to other groups considering this type of program. To our knowledge this is the first empirical research in this area and improves our understanding of how to leverage this approach for more effective continuing medical education.

Introduction / Innovation Concept: The 2015 CanMEDS framework requires all Canadian residency programs to increase their focus on Quality Improvement and Patient Safety (QIPS). A survey of the FRCP Emergency Medicine Residency Program Directors in Canada (63% response rate, 8/13) found that 75% (6/8) of programs have QIPS curricula with 84% (5/6) in the form of didactic lectures and 67% (4/6) as resident participation in a local project. Lectures alone do not expose learners to the practicality of conducting a QIPS project, and local resident projects often do not expose learners to the complexities of organization-wide QI initiatives. Furthermore, QI initiatives require working in interdisciplinary teams. We therefore hypothesize that an effective QIPS curriculum will require multiple education methods delivered using a multi-disciplinary lens. Methods: A collaborative longitudinal QIPS curriculum for emergency medicine residents at the University of Toronto (UT) was developed using multiple educational methods by physicians and non-medical QI specialists. The curriculum addresses three levels of QIPS training: Knowledge (lectures in PGY1 and 2), practical skills at the local clinical microsystem level (QI project in PGY3), and practical skills at the organization level (problem solving using the case method in PGY5). Curriculum, Tool, or Material: The lectures are taught by physicians involved in local and organization-wide QI projects and by those in senior management. The PGY3 residents enrol in a co-learning curriculum developed by the Department of Medicine, where residents and faculty conduct a local QI project together. The PGY5 teaching cases were created with management consultants using material from a real hospital QIPS initiative. PGY5s are taught using the case method that places the learner in the role of the organization’s manager who discusses the issues in class and proposes actions. Residents learn about the practicality of their recommendations by discussion with the management consultants, who disclose the case outcomes and review the lessons learned. Conclusion: A longitudinal QIPS curriculum for emergency medicine residents at UT was developed collaboratively. Multiple teaching methods address all three levels of QIPS training. This curriculum represents a novel use of the case method to instruct QIPS project leadership and management outside of the business school setting. Discussions with management consultants provide a different perspective of the real-life challenges of conducting QIPS initiatives.

Although Malta is historically linked with the zoonosis brucellosis, there had not been a case of the disease in either the human or livestock population for several years. However, in July 2013 a case of human brucellosis was identified on the island. To determine whether this recent case originated in Malta, four isolates from this case were subjected to molecular analysis. Molecular profiles generated using multilocus sequence analysis and multilocus variable number tandem repeat for the recent human case isolates and 11 Brucella melitensis strains of known Maltese origin were compared with others held on in-house and global databases. While the 11 isolates of Maltese origin formed a distinct cluster, the recent human isolation was not associated with these strains but instead clustered with isolates originating from the Horn of Africa. These data was congruent with epidemiological trace-back showed that the individual had travelled to Malta from Eritrea. This work highlights the potential of using molecular typing data to aid in epidemiological trace-back of Brucella isolations and assist in monitoring of the effectiveness of brucellosis control schemes.

The Ca intake and food sources of Chinese postmenopausal women are quite different from those of their Western counterparts. But, little information on Ca metabolism is available in Chinese populations. We determined true fractional calcium absorption (TFCA), true Ca absorption ( = TFCA × Ca intake, Va), urinary Ca excretion (Vu) and the difference between Va and Vu (Va − u), in response to three dietary Ca intake levels. Twenty-one healthy postmenopausal Chinese women aged 49–64 years were recruited for this randomized crossover trial from a general community, Guangzhou, China. Subjects were randomly assigned to receive 0, 500 and 1000 mg Ca/d for 5 weeks separated by 2-week washout periods. TFCA using Ca stable isotopes, total urinary Ca excretion and Ca intake were determined after 4 weeks of adaptation. Mean values for total Ca intake (Vi) of the three phases were 391 (sd 197), 880 (sd 130) and 1382 (sd 160) mg/d. On usual diet, TFCA, Vu, Va and Va − u were 0·57 (sd 0·12), 175 (sd 59) mg/d, 216 (sd 98) mg/d and 41 (sd 99) mg/d, respectively. With the supplementations of 500 and 1000 mg Ca/d, TFCA significantly decreased to 0·52 (sd 0·12) and 0·43 (sd 0·13) (P < 0·001); whereas urinary Ca (P = 0·003), Va and Va − u increased significantly (P < 0·001). Using a mixed-effects nonlinear regression model, it was estimated that Va − u was approaching a plateau when mean Ca intake reached 1300 mg/d. In conclusion, the present findings suggest postmenopausal Chinese women have high Ca absorption efficiency and a mean Ca intake of about 1300 mg/d is required to maximize the Va − u.