Introduction: Inspired by the Choosing Wisely® campaign, St. Michaels Hospital (SMH) launched an initiative to reduce unnecessary tests, treatments and procedures that may cause patient harm. Stakeholder engagement identified inappropriate ordering of urine culture & sensitivities (C&S) in the emergency department (ED) as a focus area. Inappropriate urine C&S increase workload, healthcare costs and detection of asymptomatic bacteriuria which can lead to unnecessary antibiotics. The project’s purposes were to describe the scope of inappropriately ordered urine C&S in the SMH ED and to conduct a root-cause analysis to inform future quality improvement interventions. Methods: Criteria for determining appropriateness was developed a priori using evidence-based guidelines from the University Health Network together with additional literature review. A retrospective chart review was performed on all urine C&S ordered in the ED from Jun 1 Aug 30, 2016. Each chart was reviewed for order appropriateness, demographic information and ordering provider. All inappropriate urine C&S were reviewed to identify root causes which were then grouped into common themes. A pareto chart was constructed to analyze the frequency of causes. Results: Of 425 urine C&S ordered, 75 (17.7%) were inappropriate. The top 3 reasons were: inappropriate urosepsis work-ups (53%), order processing errors (17%) and inappropriate work-ups for weakness (16%). Inappropriate urosepsis work-ups were defined as urine C&S that were ordered empirically despite there being a clear focus for infection elsewhere (i.e. cough, cellulitis) and in the absence of urinary symptoms. Order processing errors were defined as urine C&S which were sent despite there being no documented order. Inappropriate testing was more likely to occur overnight, in females and when a urine routine and microscopy was not ordered prior to C&S. 29% of patients with inappropriate C&S received antibiotics. Conclusion: 17.7% of urine C&S ordered in the SMH ED during the 3-month study period were inappropriate. The top cause was septic patients who were empirically tested despite having another source for infection identified from the outset. A possible reason for this is the recent ED emphasis on early recognition of sepsis which may encourage early use of antibiotics and empiric urine C&S. One question to resolve is whether a 17.7% overutilization rate is sufficient to make it a target for change. Interventions designed to reduce inappropriate urine C&S may inadvertently increase the number of missed cultures in patients admitted with sepsis not yet diagnosed. Next steps involve discussions between the ED, Internal Medicine, Infectious Disease and Microbiology, and patient partners to identify patient-centered change ideas and sustainable strategies. This may involve establishing guidelines for ordering urine C&S and incorporating lab services to provide oversight into urine C&S processing.

Introduction: Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). To date, there are no prospective studies describing the performance of an ED-to-OPAT clinic program. Furthermore, there are no studies that have examined physician rationale for intravenous therapy, despite this being a critical first step in the decision to refer to an OPAT program. Methods: We conducted a prospective observational cohort study of adults (age 18 years) with non-purulent SSTIs receiving parenteral therapy at two tertiary care EDs. Patients were excluded if they had purulent infections or could not provide consent. The emergency physician completed a form documenting rationale for intravenous therapy, infection size, and choice of antimicrobial agent, dose and duration. OPAT treatment failure was defined as hospitalization after a minimum of 48 hours of OPAT for: (i) worsening infection; (ii) peripheral intravenous line complications; or (iii) adverse antibiotic events. Patient satisfaction was assessed at a 14-day telephone follow up. Results: We enrolled a consecutive sample of 153 patients (mean age 60 years, 82 male (53.6%) and 38 (24.8%) with diabetes). A total of 137 patients (89.5%) attended their clinic appointment. Of the 101 patients prescribed cefazolin, 50.5% received 1000 mg and 48.5% received 2000 mg per day. There were low rates of OPAT treatment failure (3.9%). None of the adverse peripheral intravenous line events (9.8%) or adverse antibiotic events (7.2%) required hospitalization. Patients reported a high degree of satisfaction with timeliness of clinic referral (median score 9 out of 10) and overall care received (median score of 10 out of 10). The top 5 reasons given by physicians for selecting intravenous therapy were: clinical impression of severity (52.9%); failed oral antibiotic therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). Conclusion: This is the first study to identify physician rationale for the use of intravenous antibiotics for SSTIs. There was significant variability in antibiotic prescribing practices by ED physicians. This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction.

Introduction: Patients with diabetes who are in emerging adulthood, defined as the life stage between 18-29 years, have unique challenges in managing their illness and are at risk of acute complications and loss to follow-up. The studys objective was to describe emergency department (ED) utilization for hyperglycemia in emerging adults with diabetes and to characterize 30-day outcomes including return visits and admission for hyperglycemia. Methods: This was a health records review of emerging adults presenting over a one-year period to four tertiary care EDs with a diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Research personnel collected data on patient characteristics, treatment, disposition, and determined if patients returned to the ED for hyperglycemia within 30 days. Descriptive statistics were used to summarize the data where appropriate. Results: There were 185 ED encounters for hyperglycemia, representing 116 unique emerging adult patients. Mean (SD) age was 23 (3.5) years and 50.9% were female. 80 (69.0%) had known type 1 diabetes, 11 (9.5%) had type 2, and 25 (21.5%) were newly diagnosed in the ED. Of 185 visits, 98 (53.0%) resulted in hospital admission. 56 (30.3%) returned to the ED for hyperglycemia within 30 days of their initial encounter, and 21 (11.4%) resulted in admission on this subsequent visit. Conclusion: We characterized ED utilization and 30-day outcomes of emerging adults with diabetes for hyperglycemia. Future research should focus on earlier identification of those at higher risk for recurrent ED visits or admission and the efficacy of interventions to prevent these adverse outcomes.

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), carry significant morbidity for individuals even after discharge. The objective of this study was to describe the patient-important outcomes and burden of disease for emergency department (ED) patients with hyperglycemia after discharge from hospital. Methods: This was a prospective cohort study of patients 18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS over a 15-month period (Jul 2016-Oct 2017). During the ED visit, consent was obtained for a telephone follow-up call to determine patient-important outcomes. Trained research personnel collected data from medical records and completed a 14 day telephone follow-up using a standardized questionnaire to determine medication changes, missed days of school or work, and repeat admissions or visits to a healthcare provider. Descriptive statistics were used where appropriate to summarize the data. Results: Thus far, 172 patients have been enrolled in our study. Mean (SD) age is 53.9 (19.3) years and 97 (56.4%) are male. 65 (37.8%) patients were admitted from their initial ED visit. Of the 125 patients (72.7%) providing post-discharge outcomes, 75 (60.0%) required an adjustment to their diabetes medications or insulin. 21 (16.8%) patients missed days of school or work for a median (IQR) duration of 3.5 (1.3, 7.0) days. 85 (68.0%) saw another healthcare provider within a 14 day period, 45 (36.0%) saw their family physician, and 34 (27.2%) saw an internist or endocrinologist. 9 (7.2%) were seen again in the ED, 5 of these patients required admission to hospital. There was one death that occurred within the follow-up period. Conclusion: This prospective study builds on our previous retrospective work and demonstrates that visits for hyperglycemia carry a significant burden of disease beyond what may be seen in a single ED encounter. Further research will attempt to identify the factors that may be predictive of adverse outcomes in hyperglycemic patients presenting to the ED.

Introduction: Methanol intoxication is a well-recognized toxicological emergency. While most cases of significant methanol poisoning occur via ingestion, there are reports in the literature of poisoning resulting from the inhalational route. We report a series of methanol intoxications secondary to inhalational abuse of a methanol containing lacquer thinner presenting to an inner city Emergency Department. Methods: A laboratory database was searched for methanol levels > 5 mmol/L. (16mg/dL). from January 1, 2010 to December 31, 2015. A chart review was completed to determine mode of poisoning, clinical presentation, treatment, and disposition. Results: We found 35 patients who made a total of 83 emergency department (ED) visits with a methanol level > 5mmol/L. (16mg/dL). The methanol levels ranged from 5.3-39.6 mmol/L. (16.96 -126.72 mg/dL) . 73% of poisonings were secondary to inhalation of a methanol-containing lacquer thinner. The median age of these patients was 43 years, and 49% were male. The majority of patients (96%) resided in the core area. The most frequent chief complaints were substance abuse/intoxication, gastrointestinal complaints, and chest pain. 18% of patients described visual symptoms. Treatments were fomepizole only (59%), fomepizole plus hemodialysis (26%), and hemodialysis alone (2%). 49% of patients were discharged from the ED, while 28% and 23% were admitted to an intensive care unit (ICU) and an internal medicine ward respectively. There were no cases of blindness. We describe a cohort of patients who developed methanol poisoning from inhalation of a methanol containing lacquer thinner that required treatment with fomepizole and hemodialysis. While almost 1/3 of these patients were admitted to ICU, 49% were discharged from the emergency department after a course of fomepizole. The etiology of this outbreak was found to be a change in the formulation of the lacquer thinner, substituting a higher concentration of methanol for toluene. The manufacturer and a number of local retail outlets were contacted. This resulted in the product being taken off the shelves by the retail outlets, and eventually, a change in the product formulation by the manufacturer, with a resultant decrease in the methanol content. After these actions, we have not seen any additional presentations of inhalational methanol intoxication. Conclusion: We report the largest case series to date of patients who presented with methanol intoxication, requiring fomepizole and/or hemodialysis, secondary to inhalation of a methanol containing lacquer thinner. Physician advocacy regarding the etiology of this outbreak resulted in collaboration with retail outlets and subsequent action by the manufacturer. This ended the outbreak.

Introduction: Intubation is one of the highest-risk procedures performed in the ED. Few Canadian centres monitor intubation frequency, indications, methods used, success, and/or complication rates. An airway registry that tracks patient outcomes and variation in practice would be a valuable quality improvement (QI) tool. We describe the development of the BC-Airway Registry for Emergencies (BCARE) network, an emergency intubation database at two tertiary-care and one community hospital. Methods: Respiratory Therapists (RTs) are present at every intubation outside of the OR and complete a standardized post-intubation form. The airway forms were developed collaboratively with input from RTs, emergency physicians, intensivists, and anesthetists. Completed forms are collected from participating sites and data is entered into a secure online database where patient outcomes are analyzed in real-time. Results: We collected data from 737 unique intubations over 19 months with ongoing enrolment at the time of abstract submission. Mean age was 59.4 (Range 17-95, SD 17.6), Male 66.2%, intubation locations were ED (396, 53.7%), ICU (221, 30.0%), Ward (120, 16.3%). The most common indications for ED intubation were ICH/stroke (14.6%), seizure (10.9%), and sepsis (9.5%). Intubations are done by attending physicians more frequently in the ED (48.0%) compared to in the ICU (11.8%), and ward (8.6%). ED intubations were more commonly performed using video laryngoscopy (57.7%) with a smaller proportion using direct laryngoscopy (39.0%). First-pass success was 81.8% in the ED, 79.2% in the ICU, and 77.5% on the wards. Of ED intubations, 56 (14.1%) had complications and 73 (18.4%) were considered to be a difficult airway. Conclusion: The BCARE network tracks intubation performance across hospitals and is a valuable QI tool. BCARE can be used to ensure that all centres are meeting a benchmark success rate, for assessing the impact of practice changes such as pre-intubation checklists, and for implementing systematic methods to identify patients who previously had a “difficult airway.”

Introduction: Mentorship is an essential component of professional development and benefits include increased career satisfaction, scholarship, and efficiency of academic promotion. The Mastermind group, a collaborative, network-based model for mentorship has gained popularity in the business world. It comprises of a group of colleagues that provide mentorship and career advice for each other through regularly scheduled meetings. The group benefits from the combined intelligence and accumulated experience of the participants, who may be at different career stages. Methods: Academic Life in Emergency Medicine (ALiEM; www.aliem.com), a digital health professions education organization, conducted two Mastermind groups for 14 team members in 2017. The groups included all levels of academic rank from full professor to instructors, and represented 14 different medical schools in North America. Each Mastermind group completed a self-assessment summarizing their professional strengths and weaknesses, two homework assignments, and two 90-minute videoconference meetings, using a structured, moderator-facilitated format. Meetings were conducted on Google Hangouts on Air© (Google Inc.). In the initial group meeting, participants discussed their self-assessments, current projects, and career challenges. The second meeting allowed discussion of suggested professional development resources for each participant, actionable next steps, and an accountability timeline for each participant. The free, cloud-based platforms and voluntary basis for the Mastermind groups resulted in a zero-cost innovation. Results: In a post-intervention survey, the 14 participants rated the experience as 9.4/10 (response rate 100%) using a Likert scale. In a quasi-experimental analysis participants cited the need for career advice or assistance with a project as their reason for participating. Participants received specific resource recommendations during the sessions, including books, training courses, or conferences. Contacts outside the group for additional mentorship were made possible given the breadth of networks among the participants. All participants had at least one identifiable next step with accountability to the group. Overall, the participants described a synergy of energy, commitment to one anothers longitudinal success, and benefit from the diverse range of talent and expertise in the group. Many of the members discussed plans to replicate this mentorship model at their own institutions. Conclusion: Our experiences suggest that the Mastermind conceptual framework is an easily replicated, feasible, zero-cost, and effective model for professional development. Though the model was originally proposed as a method for in-person discussions, we report a more modern, online experience for professional development in our diverse, globally-distributed team.

Introduction: The Emergency Medicine Chief Resident Incubator is a year-long curriculum for chief residents that aims to provide participants with a virtual community of practice, formal administrative training, mentorship, and opportunities for scholarship. Methods: The Chief Resident Incubator was designed by Academic Life in Emergency Medicine (ALiEM; www.aliem.com) a digital health professions education organization in 2015, following a needs assessment in emergency medicine. A 12-month curriculum was created using constructivist social learning theory, with specific learning objectives that reflected 11 key administrative or professional development domains deemed important to chief residents. The topics covered included interviewing skills, contract negotiations, leadership, coaching, branding, conflict resolution, and ended with a focus on wellness and career longevity. A Core Leadership Team and Virtual Mentors were recruited to lead each annual iteration of the curriculum. The Incubator was implemented as a virtual community of practice using Slack©, a messaging and digital communication platform. Ancillary technology such as Google Hangout on Air© and Mailchimp© were used to facilitate learner engagement with the curriculum. Three in person networking events were hosted at three large emergency medicine and education conferences with special medical education guests. Outcomes include chief resident participation rates, Slack© activity, Google Hangout© web analytics, newsletter email engagement, and scholarship. We also incorporated a hidden curriculum throughout the year with multiple online publications, competitions for guest grand round presentations, and incorporation of digital technologies in medical education. Results: A total of 584 chief residents have participated over the first 3 years of the Chief Resident Incubator; this includes chief residents from over 212 residency programs across North America. Over 27,000 messages have been shared on Slack© (median 214 per week). A total of 32 Google Hangouts© have occurred over the course of the inaugural Incubator including faculty mentorship from Dr. Rob Rogers, Dr. Dara Kass and Dr. Amal Mattu. A monthly newsletter was distributed to the participants with an opening rate of 59%. Scholarship included 26 published academic blog posts, 2 open access In-Training exam prepbooks, a senior level online curriculum with 9 published modules and 3 book club reviews. Conclusion: The Chief Resident Incubator is a virtual community of practice that provides longitudinal training and mentorship for chief residents. This Incubator framework may be used to design similar professional development curricula across various health professions using an online digital platform.

Introduction: Fine art education increases the quality and quantity of observations that medical students make in both art and clinical reports. However, there are few free and accessible resources that teach art and observational skills to healthcare learners and providers. CanadiEM.org, a medical education blog, developed a new series called Spot the Diagnosis! to address this gap. The goals of the Spot the Diagnosis! series are to: 1) use art to explain medical concepts, 2) tie medical concepts to visual art, 3) hone observational skills, and 4) expose healthcare providers to art. Methods: Each piece of art for the Spot the Diagnosis! Series is selected based upon the author’s art history knowledge, resources found using an online search, and/or suggestions made by other healthcare professionals. The accompanying blog post is researched and written by a medical student in a question-and-answer style and peer-reviewed by another medical student and physician. Posts are uploaded monthly to CanadiEM.org and accessible to anyone with an internet connection. Promotion occurs on site, via email, word-of-mouth, and social media. Viewership is tracked using Google Analytics (GA). A survey for readers is planned to assess who, how, and why readers use the series, but results were not available prior to abstract submission. Results: Six Spot the Diagnosis! posts have been published, each of which begins with the selection of a piece of fine arts that showcases a potential medical diagnosis and a blog post outlining an interpretation of the work informed by observations, historical reports, and medical evidence. Each was published as a blog post on a Saturday and added to a page containing a list of all posts in the broader Arts PRN section on CanadiEM. All contained a single piece of art as the focus, 6 ± 2 (median ± IQR) questions, 638 ± 250 words, and 6 ± 3 references. The answers to questions are hidden under drop-down formatting to allow viewers to arrive at their own answers first. In the first 30 days of publication, each post in the series was viewed 1582 ± 401 times. Conclusion: The Spot the Diagnosis! series is an online educational resource published on CanadiEM.org that aims to improve learners medical knowledge and observational skills by featuring fine arts pieces with relevant question-and-answer style posts. This series fills the gap between art and medicine and has been well received by CanadiEM viewers. We look forward to analyzing responses in our survey to further understand how, why, and who uses this new and innovative resource.

Introduction: Emergency Department (ED) staff burnout correlates with psychological coping strategies used by Emergency department health professionals (EDHPs). Staff at two urban referral EDs in New Brunswick took part in a survey of burnout and coping strategies after one ED experienced an influx of new physicians and a newly renovated ED in 2011. Six years later, ED crowding and EDHP staffing problems became prevalent at both EDs. We compared levels of burnout at two urban referral EDs to determine if burnout and coping worsened over time. Methods: An anonymous survey of all EDHPs at 2 urban referral EDs was performed in 2011 and in 2017. A demographics questionnaire, the Maslach Burnout Inventory (MBI, measuring emotional exhaustion, depersonalization and personal accomplishment), and the Coping Inventory for Stressful Situations (CISS, measuring task-oriented, emotion-oriented, and avoidance-oriented coping styles) were collected. Descriptive statistics and linear regression models examined relationships over time and between the two hospitals. Results: Burnout scores were similar both at the two facilities and in 2011 (n=153) and 2017 (n=127). There were no differences between samples or EDs for important factors. Emotion-oriented coping was associated with higher levels of burnout, while task-oriented coping was inversely correlated with burnout. Experiencing professional stress was a significant predictor of emotional exhaustion, while those working longer years in their current department had higher emotional exhaustion and depersonalization. By 2017, both EDs had experienced significant nursing staff turnover (50%) compared to 2011. Conclusion: Burnout scores remained consistent after 6 years at these two urban referral EDs. Given the evidence that increased years of service is associated with increased burnout, high staff turnover rate at both EDs could explain how scores remained constant. Staff turnover may represent a way these ED systems cope in a challenging environment. In 2017, task-oriented copers continued to score lower while emotionally-oriented copers showed higher burnout risk, and experiencing professional stress remains a strong predictor of burnout.