Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a web-based curriculum to teach clinicians how to accurately assess and treat AWS. Methods: This was a three-phase educational program consisting of a series of 3 e-learning modules of core competency material, in-person seminar to orient learners to high fidelity simulation, and summative evaluation in an OSCE setting using a standardized patient. To determine the ED impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the ED pre and post training. ED length of stay, total dose of benzodiazepines administered in the ED, and number of prescriptions and unit benzodiazepine doses given upon discharge were also recorded. Results: 74 nurses from an academic ED completed the AWS curriculum. There were 130 and 126 patients in the pre and post AWS training periods, respectively. Management of AWS was not compliant with CIWA-Ar protocol in 78 (60.0%) and 46 (36.5%) patients pre and post AWS training, respectively ( 23.5%; 95% CI: 11.3%, 34.7%), resulting in administration of benzodiazepine when it was not required, or not giving benzodiazepines with a CIWA-Ar score of 10. There was an average of 4 CIWA-Ar scores per patient in both the pre and post implementation periods. Prior to AWS training, 144/560 (25.5%) CIWA-Ar scores resulted in a breach of protocol, compared to 64/547 (11.7%) following AWS training ( 13.8%; 95% CI: 9.3%, 18.3%). Median total dose of benzodiazepines administered in the ED was lower after the implementation of the AWS curriculum (40mg vs 30mg; 10 mg; 95% CI: 0mg, 20mg). ED length of stay and the amount of benzodiazepines given to patients at discharge were similar between groups. Conclusion: This AWS curriculum appears to be an effective way to train ED clinicians on the proper administration of the CIWA-Ar protocol, and results in improved patient care.

Introduction: Patients with Heart failure (HF) experience frequent decompensation necessitating multiple emergency department (ED) visits and hospitalizations. If patients are able to receive timely interventions and optimize self-management, recurrent ED visits may be reduced. In this feasibility study, we piloted the application of home telemonitoring to support the discharge of HF patients from hospital to home. We hypothesized that TEC4Home would decrease ED revisits and hospital admissions and improve patient health outcomes. Methods: Upon discharge from the ED or hospital, patients with HF received a blood pressure cuff, weight scale, pulse oximeter, and a touchscreen tablet. Participants submitted measurements and answered questions on the tablet about their HF symptoms daily for 60 days. Data were reviewed by a monitoring nurse. From November 2016 to July 2017, 69 participants were recruited from Vancouver General Hospital (VGH), St. Pauls Hospital (SPH) and Kelowna General Hospital (KGH). Participants completed pre-surveys at enrollement and post-surveys 30 days after monitoring finished. Administrative data related to ED visits and hospital admissions were reviewed. Interviews were conducted with the monitoring nurses to assess the impact of monitoring on patient health outcomes. Results: A preliminary analysis was conducted on a subsample of participants (n=22) enrolled across all 3 sites by March 31, 2017. At VGH and SPH (n=14), 25% fewer patients required an ED visit in the post-survey reporting compared to pre-survey. During the monitoring period, the monitoring nurse observed seven likely avoided ED admissions due to early intervention. In total, admissions were reduced by 20% and total hospital length of stay reduced by 69%. At KGH (n=8), 43% fewer patients required an ED visit in the post-survey reporting compared to the pre-survey. Hospital admissions were reduced by 20% and total hospital length of stay reduced by 50%. Overall, TEC4Home participants from all sites showed a significant improvement in health-related quality of life and in self-care behaviour pre- to 90 days post-monitoring. A full analysis of the 69 patients will be complete in February 2018. Conclusion: Preliminary findings indicate that home telemonitoring for HF patients can decrease ED revisits and improve patient experience. The length of stay data may also suggest the potential for early discharge of ED patients with home telemonitoring to avoid or reduce hospitalization. A stepped-wedge randomized controlled trial of TEC4Home in 22 BC communities will be conducted in 2018 to generate evidence and scale up the service in urban, regional and rural communities. This work is submitted on behalf of the TEC4Home Healthcare Innovation Community.

Introduction: Deep vein thrombosis (DVT) can lead to significant morbidity and mortality if not diagnosed and treated promptly. Currently, few methods aside from venous duplex scanning can rule out DVT in patients presenting to the Emergency Department (ED). Current screening tools, including the use of the subjective Wells score, frequently leads to unnecessary investigations and anticoagulation. In this study, we sought to determine whether two-site compression point-of-care ultrasound (POCUS) combined with a negative age-adjusted D-dimer test can accurately rule out DVT in ED patients irrespective of the modified Wells score. Methods: This is a single-center, prospective observational study in the ED of the Jewish General Hospital in Montreal. We are recruiting a convenience sample of patients presenting to the ED with symptoms suggestive of DVT. All enrolled patients are risk-stratified using the modified Wells criteria for DVT, then undergo two-site compression POCUS, and testing for age-adjusted D-dimer. Patients with DVT unlikely according to modified Wells score, negative POCUS and negative age-adjusted D-dimer are discharged home and receive a three-month phone follow-up. Patients with DVT likely according to modified Wells score, a positive POCUS or a positive age-adjusted D-dimer, will undergo a venous duplex scan. A true negative DVT is defined as either a negative venous duplex scan or a negative follow-up phone questionnaire for patients who were sent home without a venous duplex scan. Results: Of the 42 patients recruited thus far, the mean age is 56 years old and 42.8% are male. Twelve (28.6%) patients had DVT unlikely as per modified Wells score, negative POCUS and negative age-adjusted D-dimer and were discharged home. None of these patients developed a DVT on three-month follow-up. Thirty patients (71.4%) had either a DVT likely as per modified Wells score, a positive POCUS or a positive age-adjusted D-dimer and underwent a venous duplex scan. Of those, six patients had a confirmed DVT (3 proximal & 3 distal). POCUS detected all proximal DVTs, while combined POCUS and age-adjusted D-dimer detected all proximal and distal DVTs. None of the patients with a negative POCUS and age-adjusted D-dimer were found to have a DVT. Conclusion: Two-site compression POCUS combined with a negative age-adjusted D-dimer test appears to accurately rule out DVT in ED patients without the need for follow-up duplex venous scan. Using this approach would alleviate the need to calculate the Wells score, and also reduce the need for radiology-performed duplex venous scan for many patients.

Introduction: Primary care paramedics (PCPs) have limited options to provide analgesia during transport thus timely pain relief is often significantly delayed. Inhaled nitrous oxide is considered usual care for PCPs, but is limited in effectiveness. Intranasal (IN) ketamine has been shown to provide effective analgesia with no deleterious effects on cardiorespiratory function thus may provide rapid, easily-administered and well-tolerated analgesia in prehospital transports. Methods: This was a randomized double-blind pilot series. Patients with an acute painful condition reporting a pain score of 5 or more on an 11-point verbal numeric rating scale (VNRS) were included. Exclusion criteria were age under 18 years, known intolerance to ketamine, non-traumatic chest pain, altered mental status, pregnancy and nasal occlusion. Patients were randomized to 0.75 mg/kg of IN ketamine or IN saline. All patents received inhaled nitrous oxide. The primary outcome was the proportion of patients experiencing a reduction in VNRS pain score of two points or more (clinically significant pain reduction) at 30 minutes. Secondary outcomes were patient-reported comfort, patient and provider satisfaction, and incidence of adverse events. Results: 40 patients were enrolled, 20 in each group. 80% of IN ketamine patients compared to 60% of placebo patients reported a 2-point reduction in VNRS pain score by 30 minutes. 50% of ketamine vs 25% of placebo patients reported feeling moderately or much better. 85% of ketamine vs 75% of placebo patients reported any improvement in subjective comfort. 80% of ketamine patients reported minor adverse effects compared to 52% of placebo patients. No serious adverse effects were reported. Conclusion: The addition of IN ketamine to usual care with nitrous oxide appears to result in a greater proportion of patients reporting a clinically significant reduction in VNRS pain score and improved subjective comfort, with a greater incidence of minor adverse effects. These findings will be used to power a definitive randomized double-blind trial.

Introduction: The decision as to whether to end resuscitation for pre-hospital cardiac arrest (CA) patients in the field or in the emergency department (ED) is commonly made based upon standard criteria. We studied the reliability of several easily determined criteria as predictors of resuscitation outcomes in a population of adults in CA transported to the ED. Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19. Multiple data were abstracted from charts using a standardized form. Regression analysis was used to compare criteria that predicted return of spontaneous circulation (ROSC) and survival to hospital admission (SHA). Results: 264 patients met the study inclusion criteria. Logistic regression was used to identify predictors of ROSC and SHA. The criteria that emerged as significant predictors for ROSC included; longer ED resuscitation time (Odds ratio 1.11 (1.06- 1.18)), witnessed arrest (Odds ratio 9.43 (2.58- 53.0)) and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 3.23 (1.07-9.811)) over Asystole. Receiving point of care ultrasound (PoCUS; Odds ratio 0.22 (0.07-0.69)); and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 4.10 (1.43-11.88)) were the significant predictors for SHA. Longer times for ED resuscitation was close to reaching significance for predicting SHA Conclusion: Our results suggest that both fixed and adaptable factors, including increasing resuscitation time, and PoCUS use in the ED were important independent predictors of successful resuscitation. Several commonly used criteria were unreliable predictors.

Introduction: There have been an increasing number of studies published since 2011 investigating the benefits of in situ simulation as a quality improvement (QI) modality. We instituted an emergency department (ED) in situ simulation program at Kelowna General Hospital in 2015 with the aims of improving inter-professional collaboration, improving team communication, developing resident resuscitation leadership skills, educating ED professionals on resuscitation medical expertise, and identifying QI action items from each simulation session. Methods: We applied the SMART framework. Our specific, measureable, and attainable goal was to select two QI action items discovered from each simulation session. Realistic and timely follow-up on each action item was conducted by the nurse educator group who reported back to the local ED network, pharmacy, or manager depending on the action item. This ensured sustainability of our model. Results: A total of 65 individuals participated in 2015 at program inception. This increased to 213 individuals in 2017 with an average of 24 participants/session. Attendants included nurses (31%), ED physicians (20%), ED residents (18%), paramedics (10%), and medical students, respiratory therapists, pharmacists, and others (21%). Our QI action items were grouped as (1) team/communication, (2) equipment/resources, and (3) knowledge/tasks. Examples of each category were: (1) Inability to hear paramedic bedside reports resulting in reinforcement of one paramedic speaking while the team remains quiet, (2) Difficulty in looking up medication information in the resuscitation bay resulting in installation of an additional computer in the resuscitation bay, and (3) Uncertainty of local process for initiating extra corporeal membrane oxygenation (ECMO) in the ED resulting in review of team placement, patient transfer, and initiation of ECMO lines in the ED. Inter-professional team members have reported through electronic feedback on the value of these sessions, including improved inter agency cooperation and understanding. Conclusion: This quality improvement initiative used in situ simulation as a QI tool. We were able to identify latent safety threats, test new patient care protocols, find equipment issues, and foster teamwork in a sustainable way to improve the quality of care in our ED. We hope that this serves as encouragement to others who are initiating a similar program. Our main suggestions after reflection include: (1) Engage a multidisciplinary team in the development of an in situ simulation program, (2) Start with aims and objectives, (3) Foster attendance and buy in by making it convenient for people to attend, (4) Celebrate your successes through interdepartmental communication, and (5) Recruit individuals with expertise in simulation based education.

Introduction: Massive Transfusion Protocol (MTP) activation allows for efficient delivery of a balanced transfusion strategy to exsanguinating patients, and should deliver a reasonable ratio of plasma and platelets to red blood cells. MTP activation should facilitate communication between care providers and laboratory services in order to minimize blood product wastage. Unfortunately, it is unclear which activation criteria are best to achieve this. Understanding of acceptable sensitivity and specificity, as well as reasons for blood component wastage, may provide refinement to MTP design. Methods: We surveyed clinicians, who were identified as content experts in their fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 included Emergency Medicine, Anesthesia, Critical Care, and Surgery; Group 2 included Hematology, Hematopathology and Transfusion Medicine. Between-group differences were examined using the Pearsons Chi-Square Test. Statistical significance was set at p<0.05. Results: 50% of physicians in Group 1 considered an MTP under-call rate of 5-10% to be acceptable, whereas the majority (57.1%) of physicians in Group 2 considered an under-call rate of <5% to be acceptable. Both groups agreed on an acceptable over-call rate of 5-10%. A significantly greater proportion of physicians in Group 1 felt that MTP activation criteria including transfusion of an entire blood volume within 24 hours, loss of >50% blood volume within 3 hours and anticipated transfusion of >10U of PRBC in 24 hours were appropriate for MTP activation. Physicians in Group 2 were more likely to consider poor communication a reason for blood component wastage. Conclusion: Similarities in acceptable over- and under-call rates of MTP highlight the similar values in MTP activation between different medical specialties. Collaboration between the resuscitation team and consultants in transfusion medicine is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.

Introduction: Discharge communication in the emergency department occurs frequently and has been identified as an important, underestimated problem. Tools, such as patient or caregiver-held passports have been used in other departments to improve communication and facilitate provider and patient decision making. The objective of this review was to identify what modalities, methods and designs have been used and evaluated when implementing a communication tool or passport type document in the emergency department setting. Methods: This review was conducted following Joanna Briggs Institute methodology. Iterative steps included identifying the research question, identifying relevant studies, data extraction and synthesis. Keywords and indexed terms were used to search PubMed, Cinahl, Embase and Web of Science. The reference list of all identified reports and articles from that search were reviewed for additional studies and a hand search of the last 5 years of Annals of Emergency Medicine and the Canadian Journal of Emergency Medicine was completed. Inclusion criteria were set to select studies investigating either patients, caregivers or health care providers use of passports, communication documents or journals with the goal of improving any aspect of communication in the emergency department setting. Results: Of the 81 potential publications screened, only 4 met inclusion criteria for extraction. 1 reviewed a passport that aimed at pediatric pain management in settings that include the emergency department, 2 of the publications reported on the same project which developed a passport for asthma patients and 1 discussed a passport for patients with learning disabilities. All the included publications were published in and discuss passports that were developed for use in the UK. Descriptions of implementation, evaluation and perception of the passports in these publications was limited. Conclusion: This scoping review has revealed a major gap in the current literature on communication tools in the emergency department, a department where communication, especially about discharge is of utmost importance. The included studies focused on very different patient populations and aim to improve different outcomes and therefore dont allow us to make for passports aimed at helping the general emergency department population.

Introduction: An evidence-based care protocol to treat migraine with low-dose Propofol was implemented in May 2014 at the emergency department (ED) of the CHUL (Québec city). Given potential side effects of Propofol, we aimed to evaluate the safety and effectiveness of this protocol. Methods: We reviewed charts of all patients aged 16 years and older who received Propofol between May 2014 and August 2017 for a migraine headache with or without aura, as defined in the International Headache Society Classification. The care protocol consisted of: 1) administration of intra-venous Propofol 20 mg each 5 to 10 minutes as needed (maximum of 6 doses); 2) sets of vital signs before and after each dose; and 3) continuous cardiac and saturation monitoring. Our primary outcome measures were the incidence (95%CI) of the following side effects: low arterial pressure (< 90 systolic or < 65 mean), desaturation (SaO2<92%), excessive sedation (scores 3 or 4 on the Pasero scale), and any arrhythmia. We also compared the mean reduction (95%CI) of pain pre- and post-treatment (visual analogous scale VAS 0-10) and the proportion (95%CI) of rescue medication among patients who received Propofol as first-line medication to a matched cohort of patients who had Metoclopramide first. The two cohorts were paired for gender, age, triage priority, and month/year of ED visit. Results: Over the 3-year study period, 45 patients with migraine received Propofol through the care protocol, either as a first-line or a rescue therapy. In this cohort, hypotension, bradycardia (<60/min) and desaturation occurred in 17.8% (8.0-32.1), 13.3% (5.1-26.8) and 6.7% (1.4-18.3) of cases respectively; no excessive sedation was reported. An intervention was undertaken in 4 cases [8.9% (2.5-21.2) 3 iv fluid bolus, 1 supplemental oxygen] to palliate the side effects of Propofol. A statistically significant mean reduction of 3.6 points (2.8-4.4) on the VAS scale was observed in patients treated with Propofol as first-line therapy (n=35). However, patients managed with first-line Metoclopramide (n=100) experienced a significantly higher mean reduction of their VAS score [5.3 (4.6-6.0)] than the Propofol group (p=0.003). The proportion of patients requiring the use of rescue medication was higher among patients first treated with Propofol [77.1% (63.2-91.1) vs. 29.0% (20.1-37.9); p<0.001]. Conclusion: Our care protocol to treat migraine with low doses of Propofol appears to be safe and to cause very few side effects prompting corrective interventions. Continuous (as opposed to intermittent) heart and saturation monitoring is probably not indicated. Given the effectiveness of Propofol compared to Metoclopramide, our care protocol will be used as a second-line therapy.

Introduction: Hereditary angioedema (HAE) patients (both diagnosed and undiagnosed) commonly present to the emergency department (ED). Presenting symptoms (swelling and pain) may be erroneously attributed to common allergic and gastrointestinal conditions resulting in major delays in diagnosis and appropriate treatment. No published tools currently exist for HAE screening and management in undiagnosed disease. The overall goal of the study was to develop a HAE-RT tool for ED settings. Methods: A two-phase mixed methods approach was used to develop the HAE-RT Tool including: Phase 1: A Delphi Study [HAE specialists (N=9) and National Patient Advocacy Group Members (N=3)] was conducted to reach consensus (80% agreement) on predictor variables to include. Phase 2: A retrospective chart review was conducted to assess the predictive findings of the predictor variables. A convenient sample of patients presenting with angioedema (with and without HAE) between January 2012 January 2017 were included in the study. Results: Of the 12 experts invited, 9 (75%) participated in the Delphi study. Of 8 HAE-specific predictive variables, 4 reached consensuses including: (1) recurrent angioedema; (2) absence of urticaria; (3) past recurrent abdominal pain/swelling; (4) response to allergic therapy. The retrospective study included 85 patients (N=46 with HAE; N=39 non-HAE; overall 72% female). HAE patients were significantly more likely to have a family history of HAE (72% vs 0%; P<0.0001); previous recurrent angioedema (96%; P<0.009); present with no hives (91%; P<0.036); previous recurrent abdominal pain (80%; P<0.0001); and only 2% responded positively to allergy treatments (P<0.0001). Conclusion: Our study emphasizes the importance of key stakeholder involvement and feedback to facilitate the prioritization of important information that must be included in the design of an HAE-RT tool. The next step is to observe the effect of the HAE-RT tool on patient triage in the ED.

Introduction: Emergency Department (ED) overcrowding has been shown to delay time sensitive tests and therapies. North American guidelines call for Door-to ECG (DTE) times to be <10min in patients presenting with chest pain as delays have been shown to lead to poorer patient outcomes. We hypothesize that increased ED crowding will increase the DTE times. Methods: This was a retrospective cohort study from July 2015-May 2016 at a single tertiary care Canadian ED (53000 visits per year). Data were extracted from the ED information system (EDIS) which contains an organized record of ED activity for each visit. Our selection criteria screened for patients presenting with complaints that included chest pain, chest heaviness, chest tightness and chest burning. The primary outcome of the study was the association between ED occupancy and DTE time, which was measured using a non-parametric Spearman correlation. Multivariable linear regression models controlling for age and sex were developed for both time in minutes, and the log transformed time in minutes. Results: There were 2479 ECGs done on patients presenting with chest pain that met inclusion criteria. The median DTE time was 55.1 minutes. There was a significant positive association between DTE time and ED occupancy (rho=.133, p<0.001). DTE time increased by 0.64 minutes (or approximately 0.4%) for each additional patient in the ED, p<0.001. Additionally, younger age and female sex were also associated with increased DTE time. Conclusion: Increased ED occupancy was correlated with longer DTE times at a single Canadian ED, even after controlling for age and sex. This study provides an example of the negative consequences of ED overcrowding.

Introduction: EMS time factors such as total prehospital, activation, response, scene and transport intervals have been used as a measure of EMS system quality with the assumption that shorter EMS time factors save lives. The objective was to assess in adults and children accessing ground EMS (population), whether operational time factors (intervention and control) were associated with survival at hospital discharge (outcome). Methods: Medline, EMBASE, and CINAHL were searched up to January 2015 for articles reporting original data that associated EMS operational time factors and survival. Conference abstracts and non-English language articles were excluded. Two investigators independently assessed the candidate titles, abstracts, and full text with discrepant reviews resolved by consensus. Risk of bias was assessed using GRADE. Results: A total of 10,151 abstracts were screened for potential inclusion, 199 articles were reviewed in full-text, and 73 met inclusion criteria. Amongst included studies, 49 investigated response time, while 24 investigated other time factors. All articles were observational studies. Amongst the 14 (28.6%) studies where response time was the primary analysis, statistically significant associations between shorter response time and increased survival were found in 5 of 7 cardiac arrest, 1 of 5 general EMS population, and 0 of 2 trauma studies. Other time factors were reported in the primary analysis in 10 (41.7%) studies. One study reported shorter combined scene and transport intervals associated with increased survival in acute heart failure patients. Two studies in trauma patients had somewhat conflicting results with one study reporting shorter prehospital interval associated with increased survival whereas the other reported increased survival associated with longer scene and transport intervals. Study design, analysis, and methodological quality were of considerable variability, and thus, meta-analyses were not possible. Conclusion: There is a substantial body of literature describing the association between EMS time factors and survival, but evidence informing these relationships are heterogeneous and complex. Important details such as patient population, EMS system characteristics, and analytical approach must be taken into consideration to appropriately translate these findings to practice. These results will be important for EMS leaders wishing to create evidence-based time policies.

Introduction: The optimal management of emergency department (ED) patients with alcohol withdrawal syndrome (AWS) includes a symptom driven approach with scheduled reassessments using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treatments according to symptom severity. The subjective nature of the CIWA-Ar, and lack of standardized competency-based education related to alcohol withdrawal results in widely variable treatment. The objective of this study was to perform a summative evaluation of clinical staff during the objective structured clinical examination (OSCE) of a simulated patient (SP) with AWS. Methods: The AWS education curriculum was completed by all staff nurses in our ED (mandatory for full-time, optional to part-time staff). It was based on a real clinical scenario depicting moderate alcohol withdrawal and portrayed by a single SP. Prior to the OSCE, participants attended a seminar orienting them to the simulation. Each participant was asked to do a complete assessment of the SP, and graded for completeness on 37 individual components of history/physical exam, including the 10 domains of the CIWA-Ar. Results: 74 participants completed the educational curriculum over 8 weeks. At least 9/10 domains of the CIWA-Ar assessment were completed by 65 (88%) of participants, and 28 (38%) correctly assessed at least 80% of all summative evaluation components. 63 (85%) participants correctly identified the need for treatment of withdrawal symptoms. Only 13 (18%) participant assessments exactly matched our exact target CIWA-Ar score of 15, however 61% were within 2 points on the CIWA-Ar scale. In only 4 (5%) instances would a participant have inappropriately rated AWS severity below the treatment threshold. 62/72 (86%) participants rated the SP tremor as 2-4 (intended tremor =3). Clinical features most often overlooked were history of other addictions (25 participants, 33%) and history of liver disease (15 participants, 20%). Conclusion: The majority of participants in this OSCE correctly assessed the important elements in the assessment of AWS, and diagnosed the SP as having moderate alcohol withdrawal. Thus our educational intervention resulted in 85% of participants properly identifying the severity of AWS, and developing an appropriate treatment strategy. The impact of this curriculum on actual patient treatment requires further evaluation.

Introduction: As experienced in Emergency Departments (EDs) across Canada, Saskatoon EDs have a percentage of patients that leave before being assessed by a physician. This Left Without Being Seen (LWBS) group is well documented and we follow the numbers closely as a marker of quality, what happens after they leave is not well documented. In Saskatoon EDs, if a CTAS 3 patient that has not been assessed by a physician decides to leave the physician working in the ED is notified. The ED physician will: try to talk to the patient and convince them to stay, can assess the patient immediately if required, or discuss other appropriate care options for the patient. In spite of this plan patients with a CTAS score of 3 or higher (more acute) still leave Saskatoon EDs without ever being seen by a physician. Our desire was to follow up with the LWBS patients and try to understand why they left the ED. Methods: Daily records from one of the three EDs in Saskatoon documenting patients with a CTAS of 3 or more acute who left before being seen by a physician were reviewed over an eight-month period. A nurse used a standardized questionnaire to call patients within a few days of their ED visit to ask why they left. If the patients declined to take part in the quality initiative the interaction ended, but if they agreed a series of questions was asked. These included: how long they waited, reasons why they left, if they went somewhere else for care and suggestions for improvement. Descriptive statistics were obtained and analyzed to answer the above questions. Results: We identified 322 LWBS patients in an eight-month time period as CTAS 3 or more acute. We were able to contact 41.6% of patients. The average wait time was 2 hours and 18 minutes. The shortest wait time was 11 minutes, whereas the longest wait time was 8 hours and 39 minutes. It was found that 49.1% of patients went to another health care option (Medi-Clinic or another ED in Saskatoon) within 24hrs of leaving the ED. Long wait times were cited as the number one reason for leaving. Lack of better communication from triage staff regarding wait time expectations was cited as the top response for perceived roadblocks to care. Reducing wait times was cited as the number one improvement needed to increase the likelihood of staying. Conclusion: The Saskatoon ED LWBS patient population reports long wait times as the main reason for leaving. In order to improve the LWBS rates, improving communication and expectations regarding perceived wait times is necessary. The patient perception of the ED experience is largely intertwined with wait times, their initial interaction with triage staff, and how easily they navigate our very busy departments. Therefore, it is vital that we integrate the patient voice in future initiatives geared towards improving health care processes.

Introduction: Intimate partner violence (IPV) is a serious public health concern with complex medico-legal implications and a wide range of morbidity. While the ED is often the primary access point for these patients, IPV is under-recognized. Our objectives were to describe the characteristics of female IPV patients in the ED and determine the assessment and management patterns of physicians at a tertiary care academic ED. Methods: We conducted a health records review of adult (>18years) female patients seen at a tertiary care hospital ED presenting with evidence of IPV from January to September 2016. A combined search strategy of hospital records and Sexual Assault and Partner Abuse Care Program (SAPACP) patient rosters was used to identify study subjects. Data were collected for patient demographic/presenting characteristics, assault characteristics, and patterns of referral, management and patient disposition/discharge. Descriptive statistics were generated. Results: 100 patients met inclusion criteria with; mean age 35.1, female 100.0%, arrival by ambulance 53.0%, and mean CTAS level of 2.4. Abuse screening was completed at triage only 24.0% of the time. Presenting complaints were varied, with the most common being injury or trauma (32.0%). Most patients were only identified from the SAPACP roster. Patients reported strangulation, a strong predictor of future homicide, in 34.0% of cases. Admission to hospital occurred in 7.0% of cases with 19.0% involving specialist consultation and 7.0% leaving against medical advice or without being seen. Legal interactions including police involvement occurred 72.0% of the time and Childrens Aid Society was involved in 26.0% of cases. The final diagnosis was recorded as IPV or equivalent in only 49.0% of cases; the remainder were discharged with a final diagnosis of injury/trauma (26.0%), sexual assault (6.0%), somatic complaint (6.0%), mental health (8.0%), substance use/abuse (3.0%) or other (2.0%). Conclusion: Our study highlights that IPV is a common and heterogeneous entity with a wide spectrum of presentations and morbidity. Strangulation rates were high and are associated with increased risk of homicide. IPV is currently under-recognized and continues to carry stigma as ER physicians only recorded a discharge diagnosis of IPV or equivalent in half of cases. Educational strategies are required to highlight the importance of IPV to ED staff.

Introduction: Introduction: Paramedics frequently make immediate life-altering decisions with minimal clinical information. This applies to their decision to treat an unconscious patient with naloxone when the history of an opioid overdose cannot be readily established. Among patients treated by paramedics with naloxone, our objective was to compare patient demographics, treatment interventions and clinical response between patients with and without a confirmed history of an opioid overdose. Methods: Methods: This was a retrospective cohort study design of consecutive patients treated with naloxone by paramedics between January 1, 2016, and June 30, 2017. Patients were classified based on whether paramedics did or did not document a history of an opioid overdose. Baseline characteristics, treatment interventions, and response to naloxone were compared between groups. Comparisons were done using a chi-squared or Fishers exact test. Results: Results: We identified 294 patients of whom 113 (38%) did not have a confirmed history of an opioid overdose. The groups were similar in gender, bystander CPR, and bystander administration of naloxone. There were no differences in the presence of pinpoint pupils, initial oxygen saturation, initial Glasgow Coma Score (GCS), respiratory rate, or time on scene. Both patient groups were managed similarly with respect to route of naloxone administration and the use of a bag valve mask. All patients who were intubated were in the no confirmed history group (n=5; p=.003). Post naloxone there were no differences in last recorded vital signs except the no confirmed history group was less likely to achieve a GCS 10 (57% versus 89%; p<.001). The overall post-naloxone development of agitation (9%) was moderate while the need for physical/chemical restraint (2%) was low with no differences between groups. All patients were transported to the hospital. Conclusion: Conclusion: A substantial proportion of patients who received naloxone did not have a confirmed history of an opioid overdose. These patients closely resembled those with a confirmed history with respect to demographics and physical characteristics. The primary difference was a lower proportion of patients with no confirmed history who achieved a post naloxone GCS 10. Despite a moderate development of post naloxone agitation, paramedics were able to manage most of these patients without the use of physical/chemical restraints.

Introduction: Emergency medicine attending physicians perform many essential procedures but some infrequently. Skill proficiency and familiarity declines over time. We intended to identify skills where colleagues felt deficient and create an opportunity to demonstrate and practice in a safe environment. Methods: Sessions began from a review of ultrasound guided central line and pacemaker insertion. Other procedures have been added as a result of critical incidents, needs assessments by attending physicians, acquisition of new technology/equipment and expert consensus. An evaluation and needs assessment is performed after each session to adjust curricula. Results: Since 2011, we have held 2-3 skill sessions per year at the Advanced Trauma Surgical Skills Laboratory at the University of Calgary. Sessions are taught by attending emergency physicians, employ task trainers, simulators, animal and human cadaveric models, ultrasound, and procedural equipment stocked in our local hospitals. We are able to accommodate ~30 participants per session for 3 hours of rotating 7-8 participants through various stations. Every session has been fully attended with a wait list. Physicians register by email with preference given to new participants and those identified during clinical practice review of requiring remediation. Costs of sessions are covered by voluntary contribution to an emergency department physician support fund. Procedures practiced have included airway (basic, adjuncts, bronchoscopy, video laryngoscopy, surgical airway, chest tube), vascular access (ultrasound guided central venous insertion, transvenous pacemaker insertion, nerve blocks, IO insertion), surgical skills (thoracotomy, chest tube, canthotomy, surgical airway) and other percutaneous procedures (paracentesis, thoracentesis, nerve block, lumbar puncture). High fidelity skills videos were created to augment the sessions, available on the department website. Four point scale evaluations from our most recent session yielded 100% excellent rating for overall workshop and relevance to practice. The 6 facilitators performance received 100% excellent or good ratings. Conclusion: We have developed a fun, nonthreatening opportunity for attending physicians to practice infrequent but important ED procedures. The sessions are well received, well attended, foster collegiality, confidence and competence in performance of infrequent ED skills. Our model could be generalized to other centres.

Introduction: Medical education includes a diverse range of topics and disciplines. For junior clinician educators, it may be difficult to get a grasp of pertinent literature. Our study aims to retrospectively identify whether senior clinician educators (SCEs) and junior clinician educators (JCEs) differ in their selection of what they perceive as key medical education articles. Methods: As a part of the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program, we developed a series of primer articles for JCEs over the preceding year, designed to enhance their educational growth by identifying and discussing key articles within specific medical education arenas. Each set of articles within the primer series were selected based on data collected from JCEs and SCEs, who ranked the specific articles with respect to their perceived relevancy to the JCEs. ANOVA analysis was performed for each of the nine primer series to determine whether there was a statistically significant difference between senior and junior CEs ratings of articles. Results: 216 total articles were evaluated within the nine different primer topics. Through a multilevel regression analysis of the data, no statistically significant difference was found between the rankings of papers by SCEs and JCEs (95%CI: -0.27, 0.40). However, a subgroup analysis of the data found that 3 of the 9 primers showed statistically significant divergence based on seniority (p<0.05). Conclusion: Based on this data, involvement of JCEs in the consensus-building process was important in identifying divergence in views between JCEs and SCEs in one-third of cases. To our knowledge, no other group have compared whether junior and senior clinical educators may have divergent opinions about the relevance of medical education literature. Our findings suggest that it may be important to involve JCEs in selecting articles that are worthwhile for their learning, since SCEs may not fully understand their needs.

Introduction: The diagnostic process is wrought with potential sources of error. Psychologists seek to coach physicians to refine their cognition. Researchers try to create cognitive scaffolds to guide decision-making. Physicians however, are caught in middle between their own daily cognitive processes and these external theories that might influence their behaviour. Few attempts have been made to understand how experienced clinicians integrate guidelines or clinical decision rules (CDRs) into their decision-making. We sought to explore experienced clinicians decision-making via a simulated exercise, to develop a model of how physicians integrate CDRs into their diagnostic thinking. Methods: From July 2015-March 2016, 16 practicing emergency physicians (EPs) were interviewed via a think aloud protocol study. Six cases were constructed and video recorded as prompts to spur the clinicians to think aloud and describe their approach to the cases. Cases were designed to be slightly suggestive for pulmonary embolism or deep vein thrombosis, since these conditions are associated with CDRs. Using a constructivist grounded theory analysis, three investigators independently reviewed the transcripts from the interviews, meeting regularly to discuss emergent themes and subthemes until sufficiency was reached. Disagreements about themes were resolved by discussion and consensus. Results: Our analysis suggests that physicians engage in an iterative process when they are faced with undifferentiated chest pain and leg pain cases. After generating an original differential diagnosis, EPs engage in an iterative diagnostic process. They flip between hypothesis-driven data collection (e.g. history, physical exam, tests) and analysis of this data, and use this process to weigh probabilities of various diagnoses. EPs only apply CDRs once they are sufficiently suspicious of a diagnosis requiring guidance from a CDR and when they experience diagnostic uncertainty or wish to bolster their decision with evidence. Conclusion: EP cognition around diagnosis is a dynamic and iterative process, and may only peripherally integrate relevant CDRs if a threshold level of suspicion is met. Our findings may be useful for improving knowledge translation of CDRs and prevent diagnostic error.

Introduction: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application, however the optimal teaching methods have not been determined. Previous studies have demonstrated that random practice (RP), which increases the variability of training, may improve learning of procedural skills compared with blocked practice (BP). We compared RP and BP for teaching a resuscitative TEE protocol to emergency medicine residents using a simulator. Methods: We recruited emergency medicine residents with no prior TEE experience from a university-affiliated hospital. Participants completed a questionnaire and baseline skill assessment on a simulator, then were randomized to one of two groups. The BP group completed 10 repetitions of a fixed 5-view TEE sequence with instructor feedback, while the RP group completed 10 different random 5-view TEE sequences with feedback. Participants completed a simulation-based performance assessment immediately, and a transfer test consisting of a simulated patient encounter 1-2 weeks after training. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. Our primary outcome was the percentage of successful views on the transfer test, and secondary outcomes included participants confidence level, image quality, percentage of correct diagnoses, and efficiency of movement. We compared all scores using two-tailed, independent samples t-tests. Results: 22 participants completed the study (11 in the RP group, 11 in the BP group). There were no significant baseline differences between the groups. The BP group had a higher rate of successful views compared with the RP group on the transfer test (92.7% vs 80.9%, p=0.02). While not statistically significant, the BP group had higher image quality on a 5-point scale (3.2 vs 2.9, p=0.09), and fewer probe accelerations (297 vs 403, p=0.09). The groups did not differ in rate of correct diagnoses (77.3% vs 72.7%, p=0.73), confidence level on a 10-point scale (6.2 vs 6.2, p=1.0), or scan time (173 vs 199 seconds, p=0.28). Conclusion: Emergency medicine residents randomized to BP had a higher success rate on a transfer test, compared to RP when learning resuscitative TEE using a simulator. We consider this pilot work that can inform future studies in both simulation and real clinical settings.