Introduction: Six Canadian provinces recently made bicycle helmet mandatory and subsequent data concerning hospitalization rates after head injuries in cyclists were controversial. Furthermore, there remains an important proportion of participants who don’t wear a helmet in sporting activity. We thus wanted to estimate the impact of helmet use in sport injuries on the risk of hospitalization. Methods: Study participants were patients of all age presenting at the emergency department of the Hôpital de l’Enfant-Jésus du CHU de Québec for a trauma that occurred in a sport in which it’s possible to wear a helmet. Data were collected from information provided by the patient and from the Canadian Hospitals Injury Reporting and Prevention Program’ (CHIRPP) database. Descriptive and multivariate analyses have been carried out using these data. We performed binomial logistic regression analyzes to estimate the risk adjusted for potentially confounding variables: age, sex and number of injuries. Results: Most patients included in the study (n=169) were males (69.8%) aged between 10 and 30 years (50.3%). Sports most frequently involved in trauma were cycling (31.4%), downhill skiing (18.3%), snowboarding (14.8%), hockey (11.8%), and skateboarding (5.9%). Overall, 70.4% of patients were wearing a helmet at the time of injury. Helmet use in sports was associated with a reduction of 52% of the risk of hospitalization (RR: 0.48 [CI: 95%: 0.25-0.93]) after a trauma. In addition, patients not wearing a helmet had higher proportions of intracranial hemorrhage (10% vs. 1.7%) and skull fracture (8% vs 2.5%). Conclusion: Results suggest that helmet use decreases the risk of hospitalization for trauma sustained in sports in which it’s possible to wear a helmet.

Introduction: Between 1980 and 2008, survival rates following an out-of-hospital cardiac arrest (OHCA) have remained unchanged, averaging 7.6%. Despite the use of new and emerging technologies, new medications, and automated external defibrillators, survival remains low. Recently, a new focus in cardiopulmonary resuscitation (CPR) has shown dramatic improvements in survival post OHCA. This new model, called pit-crew CPR, focuses on minimizing interruptions in chest compressions and has each team member playing a specific role in the resuscitation, akin to the pit-crew of a car race. Certain districts in the United States and Canada have adopted the pit-crew, or a similar, high quality, maximum time-on-chest CPR model, with much success. We aim to determine whether the pit-crew model of CPR improves survival following OHCA in Saskatoon, SK. Methods: In Saskatoon, EMS and Fire crews respond to OHCAs and have been exclusively using the pit-crew model of CPR since Jan 1st, 2015. This study is a before and after retrospective chart analysis, comparing two groups - pre and post implementation of the pit-crew CPR model. The primary outcome is survival to hospital discharge post OHCA. Secondary outcomes include survival to admission and any return of spontaneous circulation (as per the Utstein definition). The inclusion criteria are patients >18 years old with a witnessed OHCA of presumed cardiac origin who receive CPR by EMS/Fire within the Saskatoon Ambulance service (MD Ambulance) catchment area. Patients were excluded if the OHCA was unwitnessed, or if there was a presumed non-cardiac cause for the arrest, e.g. trauma. Results: In the pre-pit-crew model cohort, between Jan 1st, 2011 and Sept 31st, 2014, 455 OHCAs were analyzed. In this cohort 10.5% survived to discharge, 31.9% survived to admission and ROSC was achieved in 39% of cases. The percentage of patients with initial rhythms of VF/VT, asystole or PEA were 28.5% (26%), 41.5% (1%) and 23.6% (10%) respectively, with survival to discharge shown in parentheses. The post-pit-crew cohort is still in the data collection phase. Conclusion: Our pre-pit crew cohort data has been collected and analyzed. With ongoing data acquisition for the post-pit crew cohort, we hope to have the full data set complete by the end of 2018. It will be at that time when we are able to determine whether the pit-crew model of CPR improves survival to discharge following OHCA in Saskatoon.

Introduction: The incidence of delirium following hip fracture is near 60%. The use of regional anesthesia (RA) with ultrasound (U/S) guidance has suggested a decrease in delirium incidence. In this pilot study, we propose to include the use of femoral block with U/S guidance in the management of the elderly population with hip fracture in the emergency department (ED) to lower the risk of delirium. Methods: This paired control case study was conducted from December 2013 to April 2015, and includes patients seen by emergency doctors from the ED of Hospital Enfant Jesus in Quebec City. Patients of the intervention and control groups were paired by age. Inclusion Criteria: Patients with(1) a hip fracture; (2) admitted to the hospital after their ED management; (3) and surgically repaired. Exclusion Criteria: Patients (1) with delirium upon arrival or a known mental/cognitive status (dementia, unconsciousness or severely ill status) (2) less than 60 years old (3) not able to speak English or French. Intervention group: Patients with hip fracture who received femoral blocks by the five emergency doctors who were trained and performed with U/S guidance. Control group: Patients with hip fracture who received standard pain control care by emergency doctors and who did not receive a femoral block. Analysis: Incidence of delirium and blocks performed by EM doctors were tallied. A comparison of absolute pain reduction at 30 minutes was also done. Odd ratios were derived and adjusted for age, sex, total opiates dose, delay before surgery and morbidity scores. Results: A total of 29 femoral blocks were performed through the analysis period. Groups were similar for age, sex and APACHE II and CHARLSON scores. A 30 minutes absolute pain reduction of 3/10 was noted. Two thirds of the blocks were performed by two ED doctors. Need for rescue medication was needed for 7% of patients for pain control at 30 minutes. Adjusted odd ratios for age, sex, morbidity scores, total opiate doses and delay before surgery revealed no decrease in delirium. Conclusion: Ten out of 26 patients hospitalized for hip fracture who received a femoral block under U/S guidance from the ED doctors were diagnosed with delirium. A Canadian prospective study «EDURAPID» is underway to demonstrate more the impact of R/A under U/S guidance on the incidence de delirium in this population.

Background: Intravenous (IV) and Intranasal (IN) route for analgesic administration cannot always be used to provide adequate pain management in pre-hospital setting. Objective: In a rural and suburban pre-hospital setting, studying the feasibility, safety and effectiveness of the subcutaneous (SC) route for fentanyl administration by Basic Life Service-Emergency Medical Technician (BLS-EMT) for pain management, with the support of an online medical control (OLMC) center. Methods: Retrospective study of patients who received subcutaneous fentanyl and were transported by BLS-EMT to an emergency department (ED). Safety and feasibility were characterized by collecting vital signs, Ramsey sedation scores and adverse events following fentanyl administration, and effectiveness was evaluated by changes in pain scores. Parametric and non-parametric tests were used for statistical analyses comparing age groups (<70 & ≥70 years old) regarding transport time. Results: Pain scores ≥7 were found in 288 patients (14-93 years old) who were eligible for analgesia. 249 (86.5%) of the 284 (98.6%) who received subcutaneous fentanyl were included for analysis. At baseline, no difference (p>0.05) in pain scores pre-fentanyl between groups even if patients<70 years old received a significant higher dose of fentanyl than those ≥70 years old (1.4±0.3 v/s 0.8±0.2mcg/kg, p<0.05). Post-administration pain score decreased significantly while proportion of patients achieving a pain relief increased significantly (p<0.05) regarding transport time (15, 30 or 45min) to ED. Adverse events were present in 1.6% of the patients [hypotension (n=2; 0.8%), nausea (n=1; 0.4%), and Ramsey score>3 (n=1; 0.4%)]. Conclusion: Under the supervision of an OLMC center, subcutaneous fentanyl administration by BLS-EMT for pain management seems to be a feasible approach, with a safe and effective route without major adverse event in pre-hospital setting. Pain relief increased with longer transport time. Further studies are needed to determine the benefits of SC route when compared to other administration routes in EMS.

Introduction: Emergency department handover is a high-risk period for patient safety. A recent study showed a decreased rate of preventable adverse events and errors after implementation of a resident hand-off bundle on pediatric inpatient wards. In a 2013 survey by the Canadian Associations of Internes and Residents, only 11% of residents in any discipline stated they received a formal teaching session on handover. Recently, the CanMEDS 2015 Physician Competency Framework has added safe and skillful transfer of patient care as a new proficiency within the collaborator role. We hypothesize that significant variation exists in the current delivery and evaluation of handover education in Canadian EM residencies. Methods: We conducted a descriptive, cross-sectional survey of Canadian residents enrolled in the three main training streams of Emergency Medicine (FRCP CCFP-EM, PEM). The primary outcome was to determine which educational modalities are used to teach and assess handover proficiency. Secondarily, we described current sign-over practices and perceived competency at patient handover. Results: 130 residents completed the survey (73% FRCP, 19% CCFP-EM, 8% PEM). 6% of residents were aware of handover proficiency objectives within their curriculum, while 15% acknowledged formal evaluation in this area. 98% of respondents were taught handover by observation of staff or residents on shift, while 55% had direct teaching on the job. Less than 10% of respondents received formal sessions in didactic lecture, small group or simulation formats. Evaluation of handover skills occurred primarily by on shift observation (100% of respondents), while 3% of residents had received assessment through simulation. Local centre handover practices were variable; less than half of residents used mnemonic tools, written or electronic adjuncts. Conclusion: Canadian EM residents receive variable and sparse formal training and assessment on emergency department handover. The majority of training occurs by on shift observation and few trainees receive instruction on objective tools or explicit patient care standards. There exists potential for further development of standardized objectives, utilization of other educational modalities and formal assessments to better prepare residents to conduct safer patient handoffs.

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. Subtle pathology may exist in those who require LAs and they may benefit from being transported to the Emergency Department for medical evaluation. Given that the majority of LA calls result in no-transport, there may be a bias towards not upholding the same standards of care as patients who are transported to hospital. Objective: To determine if there is a difference in Ambulance Call Record (ACR) documentation of vitals signs between LA calls and non-LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). A control group of randomly selected calls of low acuity (Canadian Triage Acuity Scale 3,4,5) from the same time period was collected for comparison. ACRs from these calls were reviewed for missing vital sign documentation. Results: Of 42, 055 EMS calls, 808 (1.9%) were LA calls. A comparison of 784 randomly-selected non-LA control calls were reviewed. There were significantly more missing vitals (12.08% vs 6.64% p < 0.001) and refused vitals (1.87% vs 0.51% p = 0.013). Conclusion: There is a significant discrepancy in the complete documentation of vital signs in LA calls vs non-LA calls. There were also significantly more patient refusals for obtaining vitals compared to transported patients. Abnormal vital signs may be a clue to a subtle disease process that has resulted in a LA call, thus care should be taken to ensure that these patients are treated with the same standards of care and documentation as those patients calling EMS for overt medical reasons.

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. What places patients at an increased risk for morbidity and mortality is not yet known. Objective: To determine factors that are associated with increased risk of 14 day morbidity, determined by an ED visit or hospital admission, and mortality in LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). These calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days. Logistic regression analyses were run to predict ED visit or hospital admission within 14 days of the LA call from patients’ age, gender, co-morbidities and vital signs at the initial LA call. Results: Of 42,055 EMS calls, 808 (1.9%) were LA calls. There were 169 (20.9%) ED visits, 93 (11.5%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA. Patient age > 61 (p < 0.001) and history of cardiac disease (p = 0.006) significantly predicted ED visit, while patient age >61 (p = 0.001) and an Ambulance Call Record (ACR) missing at least 1 vital sign (p = 0.017) significantly predicted hospital admission. There was a 10% increase in risk of ED visit and hospital admission for every 10 year increase of age after the age of 61. Of the 96 patients with at least 1 missing vital sign, 14 (14.5%) were coded as patient refusals. The sample size was too small to determine predictors for mortality. Conclusion: Patients at risk for morbidity are older than 61 years of age and have co-existing cardiac disease. Patients who are greater than 61 years of age and had at least one missing vital sign on the ACR were more at risk for hospital admission.

Introduction: Antibiotic overuse for acute respiratory infections (ARIs) is a significant problem in Emergency Departments (EDs). DECISION+, a training program on shared decision making (SDM) and a decision aid for antibiotic use in ARIs, reduces patients’ use of antibiotics for ARIs in primary care, but has never been studied in the ED setting. The objectives of this study are to assess the intention of ED physicians to adopt SDM about antibiotic use in ARIs and to identify barriers and facilitators about adopting SDM and a decision aid for antibiotic use in ARIs. Methods: An adapted version of DECISION+ (1-hour seminar) was offered to physicians of two academic EDs (Quebec, Canada) in fall 2015. A validated questionnaire was administered to participants before and after the seminar. This questionnaire contains three items measuring the intention to adopt SDM using a 7-point Likert scale [ranging from 1 (very unlikely) to 7 (very likely)]. We performed descriptive analyses for demographic characteristics and a paired Wilcoxon signed-rank test to compare pre- and post-training intention to adopt SDM (α=.05). A debriefing session with the participants identified potential barriers and facilitators about implementing SDM and using a decision aid regarding antibiotic use for ARIs. Two researchers analysed the recorded audio material. Results: 41% (23/56) of eligible physicians received the intervention. 74 % of participants had already heard of SDM and 40% felt they already used SDM in their practice. The median intention to adopt SDM was 6 (IQR 5-6) before and 6 (IQR 5-6) after the seminar (P = .23). One participant did not answer the questionnaire after the seminar and his results were excluded from the comparative analysis. We identified 20 specific barriers to adopting SDM for deciding about antibiotics use for ARIs in the ED (e.g., lack of time) and 13 facilitators (e.g., public health campaign). Conclusion: ED physicians’ baseline intention to adopt SDM with patients for antibiotic use in ARIs is high. The adapted tutorial of DECISION+ did not change this intention. This could be explained by the social desirability of SDM. Further studies must be conducted to adapt DECISION+ to the ED setting and also to assess the impact of DECISION+ on the actual prescription and use of antibiotics for ARIs.

Introduction: In the Emergency Department (ED), increasing time pressures and acuity require physicians to have access to quick and reliable data to guide patient care decisions. Blood gases (BGs) allow quick access to key information, and are used frequently in the ED. Our objective was to review the literature on reliability and accuracy of electrolyte measurements obtained from BGs in high acuity settings. Methods: A comprehensive literature review was conducted in September of 2015. The search strategy, done in conjunction with a medical librarian, identified studies that assessed the accuracy of BGs when compared to traditional laboratory serum measurements. Prior to the review we determined sodium and potassium would be the area of focus. Eligibility parameters for the studies included samples from acute care areas - the ED and ICU - and a comparison of BG and serum values taken simultaneously from the patient. Results: Our review included 12 studies, 9 in adult and 3 in pediatrics. There were approximately 1,135 patients included, consisting of 851 adult and 284 pediatric cases. The results were mixed; 9 studies agreed that sodium and potassium readings from BGs were accurate enough to guide acute care decisions, 5 did not. Furthermore, important questions were raised regarding the varying accuracy of BGs depending on what physiological level the electrolytes were at during the time of collection, i.e. at critical vs non-critical levels. Conclusion: This is the first literature review to examine the existing evidence on the accuracy of BGs in acute care environments. Given the variability in the results, a larger study needs to be done to determine the validity and reliability of blood gases for electrolytes in acute care settings. Only by ensuring the accuracy of data collected via point-of-care BGs can the most informed decisions be made surrounding patient care in acute care settings.

Introduction: Special Care Home (SCH) residents require supervision for activities of daily living but not regular nursing care. Emergency Department (ED) use by seniors in SCHs is poorly studied. A recent study in Nova Scotia found seniors represented over 20% of ED visits. We studied SCH resident ED visits in a community with a population of 30,000 aged over 65 years and with 785 SCH beds, to define reasons for ED visits to a tertiary ED, and if these could be avoided. Methods: We performed a retrospective chart review of SCH residents’ visits to an ED (SCH-ED) which has 56,000 total ED (TED) visits over one year. Reasons for visit, admission data, and avoidability were collected. A geriatrician and ED physician independently reviewed visits. Initial disagreement on avoidability (27%) was adjudicated through case discussion. Results: Demographic data revealed 344 ED visits by 111 SCH residents over one year; 37% of visits resulted in admission. 13.9% of residents visited the ED on at least one occasion (average 3.1 visits); mean age 78.4 years; female 66.7%; ambulance arrival 91.0%. The three most common chief complaints were shortness of breath, weakness and abdominal pain. Most SCH-ED visits were Canadian Triage and Acuity Scale (CTAS) Level 3 (63.4%, TED 53.3%). Of CTAS Level 3 visits, 35.3% were admitted (TED 12.9%). SCH-ED visits were avoidable in 40.6% of cases. Gastrointestinal (18%), pain (16.5%), falls, functional decline or injury (14%) and respiratory (12%) were the most common avoidable diagnostic groups, accounting for 57% of total SCH visits. Conclusion: ED visits by SCH residents demonstrated increased acuity and admission rates with a high number of repeat visits. Of all SCH-ED visits, 40% were potentially avoidable. Further study may determine if improved community services reduces ED visits or hospital admission. Gastrointestinal, respiratory, falls and pain diagnoses may be important areas of focus.

Introduction: Patient morbidity and mortality are influenced by delay in access to care and lack of continuity of care. Patients frequently present to the emergency department (ED) for care despite being registered with a primary care (PC) provider. Advanced access is an open scheduling system promoted by the College of Family Physicians of Canada that triages primary care (PC) patients to be seen within 24 hours, reducing care delay. We wished to determine the prevalence of formal triage systems in PC appointment allocation. Methods: We performed linked cross sectional surveys to quantify the number of ambulatory patients presenting to a tertiary urban ED (with an annual census of 56,000 visits) who felt unable to access primary care. PC practices were also surveyed to assess use of formal triage methods and measure access using the metric of time to third next available appointment. Descriptive statistics were calculated. Results: In the patient survey, 381 of 580 patients consented to participate. Of those, 324 patients reported reasons for their ED visit. Perception that wait time for PC was “too long” was reported in 73/324 (23%); 86% reported wait times of greater than 48 hours. The PC practice response rate was 63.8% (46/ 72). The mean time to third next available appointment was 7.7 (95% CI 4.9-10.5) days (median 5 days, range 0-50 days). No PC practice reported utilizing a formal triage system when booking appointments. Conclusion: No primary care practices in the surveyed region used a formal triage system to allocate appointments, despite a range of wait times that extended up to 50 days. The safety of primary care appointment allocation may be improved with introduction of a formal triage system, especially if overall wait times cannot be reduced.

Introduction: There was a recognized lack of available system for Emergency Physicians (EPs) to communicate their x-ray interpretations to the reading Radiologist; this resulted in unnecessary flagging of cases with significant findings already seen by the EP or the possibility of incorrectly assuming a finding was seen by the EP. Our aim was to develop an IT-based system that permitted Radiologists to view EPs documented x-ray interpretations real-time. Based on engagement with both groups, it was essential that the system be user friendly and not add significantly to an already busy workload. Methods: An online reporting system was introduced in 2011, but with complaints that interpretations were not readily accessible, nor automatic. A revised system was launched in 2014 with 2 improvements: i) EP entered interpretation onto “sticky note” in PACs directly; and ii) EP interpretation “popped up” when a film was opened by Radiologist. Results: Both systems allowed data collection of the percentage of events EPs entered an interpretation. Prior to 2011, 0% of films had EP interpretations available to Radiologist, 33% with initial, and 53% with PACS. The revised system has enabled EPs to enter their x-ray interpretation which has resulted in improvement both subjectively, based on regular feedback from both EPs and Radiologists, and objectively. Conclusion: From this and other quality improvement initiatives, we have learned the importance of engaging frontline practitioners in process changes, specifically the impact on workflow. Also, utilizing existing IT systems and resources can result in positive change with minimal costs.

Introduction: The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR has been shown to be a reliable rule to exclude fractures in children over 5 years of age. However, there is limited data to support its use by other health care workers in children. Our objective was to determine the sensitivity and specificity of the OAR, to detect clinically significant fractures, when applied by allied health providers (AHPs). Methods: Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Patients assessed by a physician prior to an AHP, presenting for reassessment or >24 hours after the injury, having open, penetrating or neurovascular injury, or multiple injuries were excluded. Patients with metabolic bone disease, a previous x-ray, or the inability to communicate or ambulate before the injury were also excluded. Baseline data on x-ray use was collected in a convenience sample of 100 patients. AHPs then completed an OAR learning module. Then in phase 2, AHPs applied the OAR to a convenience sample of 186 patients. Both AHPs and physicians performed inter-observer assessments. Results: When AHP’s applied the ankle portion of the OAR, the sensitivity was 88% (95% CI 46.7-99.3) and the specificity was 32.5% (95% CI 24.5-41.6) for clinically significant fractures. When AHP’s applied the foot portion of the OAR, the sensitivity was 87.5% (95% CI 46.7-99.3) and the specificity was 15.6% (95% CI 7.0-30.1) for clinically significant fractures. In total, 2 clinically significant fractures (1 foot fracture and 1 ankle fracture) were missed by AHP’s. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.32 for the foot rule. The missed ankle fracture had a positive OAR when performed by a physician as an inter-observer assessment. The missed foot fracture was a distal metatarsal fracture that was outside of the “foot zone” as defined by the OAR. Conclusion: The sensitivity of the OAR when applied by AHP’s was very good. Both clinically significant fractures that were missed by AHP’s would likely have been picked up by a physician assessment. More training and practice using the OAR would likely improve AHP’s inter-observer reliability. Our data suggest the OAR may be a useful tool for AHP’s to apply as a screening tool prior to physician assessment.

Introduction: Low Back Pain (LBP) remains a condition with relatively high incidence and prevalence. It affects 70-85% of people at some point in their lives and causes significant disability. LBP management may be best suited to a primary care setting, yet it is one of the most common reasons for presentation to Emergency Departments (ED). Nationally representative data from the United States found that LBP related disorders are a frequent cause of ED visits, accounting for 2.7 million visits to US EDs annually. There are numerous treatment modalities for LBP, however the task is identifying those that have relevance in an ED setting. Although there is extensive research available on management of LBP in primary care settings, treatment outcomes differ from that in the ED setting. This makes management of LBP a challenge for ED physicians. Few studies and no systematic reviews focus on treatment of LBP in the ED setting. Methods: The objective of our study is to compare effectiveness of treatment modalities relevant for management of LBP in the ED setting. We conducted an Overview of Systematic Reviews following robust methods advocated by Cochrane. We included systematic reviews of randomized controlled trials (RCTs). A medical librarian assisted in completing of an extensive search of the Cochrane Library, PubMed, and EMBASE. We used transparent criteria to select relevant reviews and assess interventions for ED relevance. We collected key data points from the included reviews including pain and functional limitation outcomes. Evidence will be synthesized for important outcome measures following the approach of Jones et al (2012). Results: We screened 4740 citations and identified 346 likely relevant systematic reviews. Comparative effectiveness review synthesis will be completed before the conference. We will report effectiveness of each of the included interventions and as well as make head to head comparisons of said relevant interventions. Conclusion: Currently most LBP patients presenting to the ED are inundated with a variety of potential treatment modalities, all alleging efficacy in LBP management. Physicians may use the evidence from this synthesis, and related knowledge translation tools, to guide decisions in effectively treating patients presenting to the ED with LBP.

Introduction: Understanding physician human resources in British Columbia’s (BC) emergency settings is essential to plan for training, recruitment and professional development programs. In 2014 we conducted an online and phone survey to the site leads for the 95 Emergency Departments (ED) attached to hospitals in BC. Methods: A one-page survey was developed by the authors (JC and JM). Each hospital listed on the BC Ministry of Health’s website was contacted to confirm that they had a functioning ED attached to the hospital and to determine who their site lead was. Each ED site lead was then emailed the questionnaire and up to three more follow-up emails and direct phone requests were performed as needed. Results: 92 of the 95 EDs completed the survey and we discovered that just over 1000 physicians deliver emergency care in BC with approximately half doing so in combination with family practice. There was an estimated shortfall of 199 physicians providing emergency care in 2014 and an anticipated shortfall of 287 by 2017 and 399 by 2019. Slightly more than half had formal certification, with 28% through the Royal College of Canada and 70% with the College of Family Physicians of Canada. Conclusion: More than 1000 physicians care for patients in EDs across BC but there is a significant and growing need for more physicians. There is tremendous variation across health authorities in emergency medicine certification, but approximately half of those who deliver emergency care have formal certification. Despite limitations of a survey method, this provides the most accurate and current estimate of emergency practitioner resources and training in BC and will be important in guiding discussions to address the identified gaps.

Introduction: Substance abuse is strongly correlated with frequent ED use, which is a known risk factor for mortality. This study aimed to examine epidemiologic trends in ED visit frequency, and visit and patient characteristics among all patients presenting to Albertan EDs with visits related to substance abuse over a five-year period. Methods: This is a retrospective analysis of National Ambulatory Care Reporting System (NACRS) administrative ED data for Alberta. All ED visits related to substance abuse made by adults from fiscal year 2010/11 to 2014/15 were included. Using a validated definition enhanced by expert consultation, ED visits were classified as visits related to substance abuse if a set of ICD-10 codes determined a priori were present within the primary or secondary diagnostic fields. Data are reported as means (with SD), medians (with IQR) and proportions. Visit and admission frequencies were compared using Chi square and Chi square trend tests. All analysis was performed using SAS 9.4. Results: Over the study period, 177,287 visits related to substance abuse were made to Alberta EDs. These visits were made by 77,291 unique patients, and annual patient numbers increased consistently from 17,660 in 2010/11 to 24,737 in 2014/15; 62% of patients were male and median age was 38 years (IQR 24, 49). Visits increased from 27,839 in 2010/11 to 42,965 in 2014/15 (p<0.001). 50% arrived by ambulance, and were mostly triaged as CTAS 3 to 5 (32% CTAS 1 or 2, 43% CTAS 3, and 23% CTAS 4 or 5). While most of the patients were discharged, 15.6% of visits resulted in admission; statistical but not clinically meaningful differences were detected in proportions of admitted visits across the study years. Compared to the overall population of patients with substance abuse presentations, frequent presenters (with a visit number greater than the 95th percentile) appeared to be older (median age 40 years [IQR 31, 49]) and had a higher proportion of males (69%). Conclusion: ED presentations for substance abuse increased from 2010 to 2015 in Alberta, and frequent presenters appear to have a different demographic profile. Future study is needed to determine whether patients who present frequently with substance abuse are at increased risk for mortality as this may justify targeted intervention.

Introduction: Many patients leave the Emergency Department (ED) before beginning or completing medical evaluation. Some of these patients may be at higher medical risk depending on their timing of leaving the ED. The objective of this study was to compare patient, hospital, and visit characteristics of patients leaving prior to completing medical care in the ED either before or after evaluation by a medical provider. Methods: This is a retrospective cross-sectional analysis of ED visits using the 2009-2011 National Hospital Ambulatory Medical Care Survey. The target population was identified by coded dispositions corresponding to leaving prior to completing medical care, and two groups were defined based on whether or not they had been evaluated by a medical professional. Data are reported as means (with standard errors) and proportions, and bivariate and multivariate logistic regressions were performed. All analysis was performed using SAS 9.4 and SUDAAN 11.0.1 to account for the complex sample design. Results: 100,962 ED visits were documented from 2009-2011, representing a weighted count of 402,211,907 total ED visits. 2,646 (3%) resulted in a disposition of left without completing medical care. Of these visits, 1,792 (68%) left prior to being seen by a medical provider versus 854 (32%) who left after medical provider evaluation. Patients who left after being assessed by a medical provider were older, had higher acuity visits, were more likely to have visited an ED without nursing triage, more likely to have arrived by ambulance, and more likely to have private insurance than other payment arrangements (e.g. worker’s compensation or charity). Conclusion: When comparing all patients who left the ED prior to completion of care, those who left after versus before medical provider evaluation differed in their patient, hospital, and visit characteristics and may represent a high risk patient group.

Introduction: As part of the multicenter C-CARE (Cross-Canada Anaphylaxis Registry) project, this study aimed to describe the characteristics of anaphylactic reactions and assess if emergency physicians follow treatment guidelines. Methods: A cohort study was conducted in the emergency department of Sacré-Cœur Hospital, a university-affiliated, urban tertiary care hospital. For each anaphylaxis case recruited by the treating physician, a standardised questionnaire was completed. The information for missed cases was collected retrospectively through chart review. Results: Between May 2012 and May 2015, 280 cases (205 prospective and 75 retrospective) of anaphylaxis were identified from a total of 182,408 ED visits. The median age was 36.21 years (IQR 27.8), 61.8% were female, and 12.5% of all patients were children (<18 years old). The majority of reactions were triggered by food [54.3% (95%CI:48.5-60.1%)], followed by medications [18.2% (95%CI:13.7-22.7%)] and venom [5.7% (95%CI:3.0-8.4%)]. Among all cases, 66.8% (95%CI:61.3-72.3%) received epinephrine; 26.1% (95%CI:21.0-31.2%) received it prior to their arrival and 46.8% (95%CI:41.0-52.6%) in-hospital. As for other in-hospital treatments, 85.4% of patients (95%CI:81.3-89.5%) received corticosteroids, 81.1% (95%CI:76.5-85.7%) received H1 antihistamines, and 41.1% (95%CI:35.3-46.9%) received H2 antihistamines. Out of all patients who had anaphylaxis, 86.4% (95%CI:82.4-90.4%) were prescribed an epinephrine auto-injector in-hospital or had already had one prescribed. Conclusion: Our results reveal that food is a major trigger of anaphylaxis and that despite current guidelines, there is under use of epinephrine and preferential use of corticosteroids and antihistamines.

Introduction: Clinical performance feedback is not always well utilized in healthcare, despite its potential in continual professional development to improve provider performance in healthcare settings. In order to more effectively incorporate performance feedback, we must evaluate the strengths and flaws of current feedback systems and determine best practices. With this goal, we sought to explore the perspectives of paramedics on the feedback they want and what they currently receive. Methods: We used a qualitative methodology with semi-structured interviews. A convenience sampling of practicing paramedics in the Niagara region was interviewed. We used an interpretive descriptive technique with continuous recruitment of participants until thematic saturation was achieved. Themes were identified and a coding system was developed by two investigators separately to code themes and sub-themes. These two systems were merged by consensus. We conducted a member check by contacting participants to determine if they agreed with our analysis. Results: 12 paramedics were interviewed. In our analysis we found several themes: positive perception/aspects of feedback and current feedback systems, current barriers, shortcomings of current systems, desire to know patient outcomes, and mental health as it relates to feedback. Positive perception of feedback has included asking for feedback, specific requests for feedback and strengths of current systems. Perceived barriers to feedback included issues around: confidentiality, practical limitations and social barriers. The limitations of current feedback systems noted the lack of feedback, and the questionable value of the feedback received. The desire to know patients’ clinical course/outcomes was also a recurrent theme, with paramedics spontaneously expressing desire for feedback specific to cases, greater insight into the ultimate diagnosis and knowledge of outcomes. The mental health of paramedics was frequently discussed as well, including positive impact on job satisfaction and confidence and potential for negative impact. Conclusion: We have explored and generated a description of the perspectives of paramedics on feedback in general and the clinical performance feedback they currently receive. The information gained will lay the groundwork for improved feedback systems to provide paramedics with the feedback they want to continually improve as healthcare providers.

Introduction: Motor vehicle collisions (MVCs) resulting in injuries and death disproportionately involve impaired drivers. Those under the influence of alcohol also have a much higher rate of presentation and admission to hospital for traumatic injuries. In an attempt to decrease impaired driving and consequently alcohol related MVCs and injuries, the government of Alberta recently introduced more strict legislation in the summer of 2012 for drivers found to be under the influence of alcohol. However, it has yet to be seen what impact the enforcement of this new legislation has had on traumatic injuries secondary to MVCs and alcohol impairment. The objective of this study was to assess the relationship between the implementation of Alberta’s new impaired driving legislation and the number of alcohol-related motor vehicle traumatic injuries presenting to the emergency department of a Level I Trauma Centre. Methods: A retrospective single centre cross-sectional chart review examining all adult patients presenting to the ED of a major trauma centre who: a) require trauma team activation or consultation and b) have a MVC related injury. Of those charts meeting these criteria, the proportion of patients with positive ethanol screens will be compared between the year before and after the new legislation being implemented. Patients will be identified using electronic medical record logs. Results: 938 total MVC related trauma patients were identified during the study period (468 prior to legislation enactment [2010-2012], 470 after [2012-2014]). 33.3% of these MVC trauma patients had positive ethanol screens prior to the legislation enactment and 32.4% after (a non significant decrease). Interestingly, with a secondary analysis on a year by year basis, the trends appear to be more noteworthy. When comparing between 2010 and 2013 there was a statistically significant drop in the number of cases over legal limit by 7.74%. Subgroup analysis also demonstrated a large, statistically significant drop in 16-24 yr old cases between 2010 and 2013, from 29 to 11% (a 62% drop). Conclusion: While an impact was not seen immediately following the enactment of Alberta’s new impaired driving legislation, a year by year analysis demonstrates a statistically significant decrease in MVC related trauma involving alcohol in the years following the new law. Of note, a substantial 62% drop was seen in the 16-24 year old age category.