Introduction: Developing structured online educational curricula that meet learner needs is challenging. Thrombosis and bleeding are areas of innovation and change in emergency medicine. We aimed to determine the learning needs of the Free Open Access Medical education (FOAM) community with the subsequent goal of developing structured curricula to meet them. Methods: A Massive Online Needs Assessment (MONA) was conducted to determine the perceived and unperceived educational needs in thrombosis and bleeding. The survey was designed by a multidisciplinary team of experts and was open from September 20 to December 10, 2016. The survey requested limited demographic information and contained questions to identify topics of interest. Respondents’ baseline knowledge and unperceived needs were assessed using 5 case scenarios containing 3 questions each. Knowledge gaps were defined a priori as topics where <50% of participants answered correctly. Results: We received 198 complete responses by staff physicians (n=109), residents (n=46), medical students (n=29) and allied health professionals (n=14) from 20 countries. 116/198 responses were from people working in emergency medicine. Topics of interest to participants included choice of anticoagulants, interruption of anticoagulation, management of bleeding and monitoring anticoagulation. Knowledge gaps were identified in 4 main areas including interruption of anticoagulation, management of bleeding (including reversal of anticoagulation and massive transfusion), inherited thrombophilia, and screening for malignancy in acute thrombosis. Conclusion: We have identified six priority topics to cover in our future online Thrombosis and Bleeding curriculum by surveying the online medical community. Although perceived and unperceived needs showed high congruence, two priority topics were only identified by assessing unperceived needs.

Introduction: Choosing Wisely is an innovative approach to address physician and patient attitudes towards low value medical tests; however, a knowledge translation (KT) gap exists. We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC) EM recommendations. We then assessed whether a structured KT initiative affected knowledge and awareness. Methods: Physicians working in urban (tertiary teaching hospital, Saint John, NB) and rural (community teaching hospital, Waterville, NB) emergency departments were asked to participate in a survey assessing awareness and knowledge of the first five CWC EM recommendations before an educational intervention. The intervention consisted of a 1-hour seminar reviewing the recommendations, access to a video cast and departmental posters. Knowledge was assessed by asking respondents to identify 80% or more of the recommendations correctly. Physicians were surveyed again at a 6-month follow up period. The Fisher exact test was used for statistical analyses. A sample size of 36 was required to detect a 30% change with an alpha of 0.05 and a power of 80%. Results: At the urban site, 16 of 25 (64%) physicians responded to the pre- and 14 of 26 (53.8%) responded to the post-intervention survey. Awareness of the EM recommendations did not increase significantly (81.3% pre; 95% CI 56.2-94.2 vs. 92.9% post; 66.4-99.9; p=0.60). There was a weak trend towards improved knowledge with 62.5% (38.5-81.6) of physicians responding correctly initially, and 85.7% (58.8-97.2; p=0.23) after the intervention. At the rural site, 8 of 11 (72.7%) physicians responded to the pre- and post-intervention survey. There was a trend towards improved awareness, (25% pre; 6.3-59.9 vs. 75% post; 40.1-93.7; p=0.13), with 50% (21.5-78.5) responding correctly pre, and 87.5% (50.8-99.9; p=0.28) after the intervention. Conclusion: We have described the current awareness and knowledge of the CWC EM recommendations. Limited by our small sample size, we report a trend towards increased awareness and knowledge at 6 months following our KT initiative in a rural setting where there was a low baseline awareness. At the urban site where baseline knowledge was high, changes seen were less significant. Further work will look at the effectiveness of our initiative on physician practice.

Introduction: Emergency Department (ED) return visits leading to admission (RVs) are a well-recognized quality metric that can potentially signal gaps in patient care. Routine capture, investigation and monitoring of monthly ED RVs provides a better understanding of patient and visit- level factors associated with a return, which can then inform system-level quality improvement (QI) opportunities. The objective of this study is to develop a sustainable database that routinely tracks and analyzes pediatric ED RVs in a large Canadian children’s hospital to understand recurring themes and inform QI initiatives. Methods: Using a computerized record system, all 72-hour RVs are collected and reviewed for patient and visit-level variables. Clinicians receive monthly notification of their RVs and assist with completing root cause analyses. Ongoing cumulative analyses using descriptive statistics and t-test analysis are reviewed to identity trends and predictors of RVs. Targeted solutions are sought to address system-level themes through educational, quality, safety and administrative avenues. Results: The RV database contains almost three years of data analyzing approximately 1,500 cases, equaling 0.75% of our annual ED patient volumes. RVs have higher acuity scores on both their index and return visit (P=0.001) and children under 12 months of age have significantly higher rates of return (24% vs 16%, P<0.001). A consultation service was involved during 31% of the index ED visits, with the top three consultants being Hematology/Oncology (23%), General Surgery (12%), and Neurology (8%). The root cause of the majority of RVs were related to disease progression (65%), while 8% were call-backs for positive blood cultures or discrepant results, and 6% were categorized as a misdiagnoses. Completed quality improvement initiatives to date include the ED Sickle Cell Optimization Program, the Culture Follow-up and Escalation Algorithm, and the Young Infant Fever Pathway and Order Set. Conclusion: Routine monitoring and investigation of ED RVs provides a proactive approach to seeking improvement opportunities. With a better understanding of specific patient and visit-level factors associated with RVs, future system-level quality improvement initiatives can be targeted.

Introduction: Routine auditing of charts of patients with an emergency department (ED) return visit (RV) resulting in hospital admission can uncover quality and safety gaps in care. This feedback can be helpful to clinicians, administrators, and leaders working to improve clinical outcomes, increase patient satisfaction, and promote high-value care. Health Quality Ontario (HQO) has been tasked by Ontario’s Ministry of Health and Long-Term Care (MOHLTC) to manage the newly created ED RV Quality Program (RVQP), which mandates EDs participating in the Pay-for-Results (P4R) program to audit a minimum of 25-50 RVs/year. The goal of the first-ever ED-specific province-wide Quality Improvement (QI) initiative of this kind is to promote a culture of QI that will lead to improved patient care. Methods: Participating hospitals receive quarterly confidential reports from Access to Care (ATC) that show their and other hospitals’ rates of RVs, as well as identifying information for patients meeting RV inclusion criteria at their ED (within 72 hrs of index visit, or within 7 days with specific diagnoses). HQO has partnered with QI experts and ED physician-leaders to develop various guidance materials. These materials have been disseminated through various media. Hospitals are conducting audits to identify underlying quality issues, take steps to address the underlying causes, and submit reports to HQO. A taskforce will then analyze clinical observations, summarize key findings and lessons learned, and share improvements at a provincial level through an annual report. Results: Since its launch in April 2016, 73 P4R and 16 voluntarily enrolled non-P4R hospitals (which collectively receive approximately 90% of ED visits in the province) are participating in the RVQP. ED leaders have engaged their hospital’s leadership to leverage interest and resources to improve patient care in the ED. To date, hospitals have conducted thousands of audits and have identified quality and safety gaps to address, which will be analyzed in February 2017 for reporting shortly thereafter. These will inform QI endeavours locally and provincially, and be the largest source of such data ever created in Ontario. Conclusion: The ED RVQP aims to create a culture of continuous QI in the Ontario health care system, which provides care to over 13.8 million people. Other jurisdictions can replicate this model to promote high-quality care.

Introduction: Patients from all population groups visit the emergency department (ED), with increasing visits by elderly patients. Patient falls in the ED are a significant safety concern, and they can lead to serious injuries and worse outcomes. Toronto Western Hospital’s ED Quality Improvement (QI) team identified as a problem our assessment and management of patients at risk for falls. The aim of this project was to develop a comprehensive and standardized approach to patients at risk of falls in the ED, including implementing timely interventions for fall prevention. Methods: A literature review of existing tools was completed to develop our own reliable and valid fall risk screening tool for ED patients. QI methods were used to devise a comprehensive strategy starting with detection at triage and implementation of action-driven steps at the bedside, through multiple PDSA cycles, randomized audits, surveys, and education. Repeated measurements were undergone throughout the project, as were staff satisfaction surveys. Results: The chart audits showed a five-fold increase in the completion rate of the fall risk screening tool in the ED by the end of the QI initiative (from 10% to 50%). Constructive feedback by an engaged team of nurses was used to iteratively improve the tool, and there was mostly positive feedback on it after various PDSA cycles were completed. The various component of this novel and useful ED-based falls screening tool and bundle will be presented in tables and figures for other leaders to replicate in their EDs. Conclusion: We developed a completely new ED-specific fall risk screening tool through literature review, front-line provider feedback, and iterative PDSA cycles. It was used for the identification, prevention, and management of ED patients with fall risk. We also contributed to a positive change in the culture of a busy ED environment towards the promotion of patient safety. Education and feedback continue to be provided to the ED nurses for reflective practice, and we hope to continue to improve our tool and to share it with other EDs.

Introduction: Analyzing the charts of patients who have a return visit to an emergency department (ED) requiring hospital admission (termed ‘RV’) is an efficient way to identify adverse events (AEs). Investigating these AEs can inform efforts to improve the quality of care provided. The ED RV Quality Program (RVQP) is a new initiative supported by Ontario’s Ministry of Health and Long-Term Care and managed by Health Quality Ontario. It aims to promote a culture of continuous quality improvement through routine audit/investigation of RVs. Methods: The provincial program is mandatory for high-volume EDs and requires auditing of some 72-hour RVs and all 7-day RVs involving ‘sentinel diagnoses’ (subarachnoid hemorrhage [SAH], acute myocardial infarction [AMI], or pediatric sepsis [PS]). A standardized audit template is followed that includes assessment of the type/severity and underlying causes of AEs, and potential actions for improvement. Results: 73 high-volume EDs and 16 smaller EDs (collectively receiving 90% of all ED visits in Ontario) are participating in the program. Nine months’ data have been released to date, comprising 33,956 RVs (1.05% of 3,235,751 ED visits). Of these, 233 RVs (0.69%) were for a sentinel diagnosis (SAH=11, AMI=191, PS=31). The most common presenting complaint on the index visit was abdominal pain (18%). The most common discharge diagnosis following RV admission was acute appendicitis (3.8%). Conclusion: The ED RVQP aims to improve the quality of care provided in Ontario’s EDs by requiring hospitals to conduct audits of RVs and plan actions for improvement when quality gaps are identified. Participating hospitals have completed hundreds of audits to date.

Introduction: Very little is known regarding the emergency department’s (ED) role in the care of paediatric patients with complex chronic and life-limiting illnesses. In fact, the provision of paediatric palliative care (PPC) in the paediatric ED has, of yet, never been explored. This study aims to explore pediatric emergency medicine healthcare professionals’ perspectives regarding their role in PPC and to compare these to other health care professionals’ understandings of the ED’s role in PPC. Methods: Interdisciplinary semi-structured focus groups were held with healthcare providers from pediatric emergency medicine, pediatric palliative care, pediatric complex care and pediatric intensive care. Exploratory open-ended questions introduced naturally occurring discussions and interactions. Data was transcribed in full and analysed using NVivo© software. Data analysis was performed by thematic analysis and theoretical sampling. Results: From January to October 2016, 58 participants were interviewed; most were female nurses and physicians. ED providers seek to maintain continuity of care and uphold pre-established wishes throughout PPC patients’ ED visits by listening and supporting the patient and family, evaluating the clinical situation, communicating with primary care teams and organising rapid admissions to wards. Some ED providers recognized having no choice to provide palliative care approach under certain circumstances despite thinking it might not be part of their culture and role. Each interdisciplinary team demonstrated particular values and cultures, influencing their understandings of the ED’s role in PPC; continuity of care is complicated by these distinct philosophies. Limitations to providing PPC in the ED are related to unsuitable physical environments, lack of uninterrupted time, efficiency expectations, unknown patients, provider lack of knowledge and moral distress. Solutions were directed at improving communication between teams and humanizing care to develop a sensibility to quality PPC in the ED. Conclusion: Although the perspective of pediatric ED’s role in caring for PPC patients is heterogeneous, several barriers to providing high quality emergency PPC can be overcome. Future studies will explore the experiences of PPC families presenting to the ED.

Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been used successfully to increase survival in patients suffering from out-of-hospital cardiac arrest (OHCA). However, few OHCA patients can benefit from E-CPR since this procedure is only performed in dedicated centers. Prehospital triage systems have helped decrease mortality from other acute conditions, by directly transporting patients to dedicated centers, often bypassing primary care centers. Our study aimed to quantify the possible impact of a prehospital triage system on the proportion of E-CPR eligible patients transported to E-CPR centers. Methods: We used a registry of adult OHCA collected between 2010 and 2015 from the city of Montréal, Canada. Included patients were adults with non-traumatic witnessed OHCA refractory to 15 minutes of resuscitation. Using this cohort, we created 3 scenarios in which potential E-CPR candidates could be redirected to E-CPR centers. We used strict eligibility criteria in our first pair (e.g. age <60 years old, initial shockable rhythm), intermediate criteria in our second pair (e.g. age <65 years old, at least one shock given) and inclusive criteria in our third pair (e.g. age <70 years old, initial rhythm ≠ asystole). These 3 scenarios were compared to their counterpart in which patients would be transported to the closest hospital. The proportions of patients who would have been transported to an E-CPR centers were compared using McNemar’s test. To obtain a power of 99%, expecting 1% of discordant pairs and using a unilateral alpha of 0.83% (after Bonferroni correction), we needed to include at least 1000 patients. Results: A total of 3136 patients (2054 men and 982 women) with a mean age of 69 years (standard deviation 15) were included. In each simulation, prehospital redirection would have significantly increased the proportion of patients transported to an E-CPR center (pair 1: 1.3% vs 3.8%, p<0.001; pair 2: 2.6% vs 7.3%, p<0.001; pair 3: 7.6% vs 29.8%, p<0.001). Conclusion: In an urban setting, a prehospital triage system could triple the number of patients with refractory OHCA who would have an access to E-CPR. This implies that centers with E-CPR capability should prepare themselves accordingly for such a system to effectively improve survival following OHCA.

Introduction: Gun related injuries were last reported by the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) in 2005. Since that time, Canadian gun control is less stringent and non-powder guns are increasingly popular. We aim to describe trends in pediatric gun related injuries and deaths since 2005. Methods: This is a retrospective review of CHIRPP data. The dataset included pediatric (age 0-19 years) gun-related injuries and deaths reported by participating CHIRPP emergency departments (ED) from 2005-2013. Variables were tested using Fisher’s exact test and simple linear regression. Results: There were 421 records of gun-related injuries in the database. Three hundred and twenty-nine occurred from use of non-powder guns, 85 occurred from use of powder-guns, and in 7 cases the type of gun was not clear. The number of gun-related injuries per 100 000 ED visits remained stable from 2005-2013 with a male predominance (n=366, 87%). Most injuries resulted from non-powder guns and were unintentional. Injuries most often occurred in the context of recreation (n=181) and sport (n=51). One hundred fifty four eye injuries were reported, 98% of which were from a non-powder gun. Forty-six individuals required admission to hospital and 2 died in the ED. Nine of 10 intentional self-harm injuries were inflicted with a powder gun. Conclusion: This study describes the injuries and circumstances in which pediatric gun-related injury and death occur in Canada. Unintentional injuries caused by non-powder guns were most common. Though less fatal than powder guns, non-powder guns can still cause life-altering eye injuries. This evidence can inform injury prevention programs to target specific circumstances in which the pediatric population is most vulnerable.

Introduction/Innovation Concept: Inter-professional education (IPE) involves ‘occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care’. Current literature has found IPE to increase knowledge and skills, improve attitudes towards other professions, and to promote superior clinical outcomes. Health Canada has collaborated to form accreditation standards to support IPE in Canadian medical schools. The proposed educational innovation termed the ‘nursing shift,’ based out of Kelowna General Hospital’s Department of Emergency Medicine, in partnership with UBC’s Southern and Island Medical Programs, endeavors to enhance IPE in our institution. Methods: This nursing shift was first trialed with third year medical students as a pilot rotation beginning in March of 2016. Based on overwhelmingly positive results obtained from narrative feedback, a formal rotation with the same structure will be implemented in the form of a prospective cohort study with 48 medical students from two UBC sites. One group will attend a nursing shift, while the other group will complete the standard emergency medicine rotation without this nursing shift. Impact will be measured using a mixed-method analysis where students will be asked to provide both quantitative feedback in the form of a questionnaire, and qualitative feedback in the form of a narrative response. The primary outcome will be quantitative score differences between the groups of students, and the secondary outcome will be qualitative results for those who completed the nursing shift. Curriculum, Tool, or Material: The innovative educational concept consists of an 8-hour nursing shift where medical students spend the first 4 hours at triage with a nurse learning about patient intake. The remaining 4 hours are in the emergency department where students collaborate with a nurse on a number of tasks including preparing and administering medications, starting intravenous lines, and inserting Foley catheters. Conclusion: Healthcare systems are shifting to a more collaborative team oriented approach, and IPE has been shown to prepare students for this changing workplace. We seek to understand third year medical students’ experience of the nursing shift, and to evaluate any changes in attitudes towards inter-professional collaboration after engaging in this intervention. Evaluation of this novel implementation will enable us to assess and optimize the nursing shift, and if it is well received, encourage widespread adoption.

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

Introduction: When ventricular fibrillation (VF) cannot be terminated with conventional external defibrillation, it is classified as refractory VF (RVF). There is a paucity of information regarding prehospital or patient factors that may be associated with RVF. The objectives of this study were to determine factors that may be associated with RVF, the initial ED rhythm for patients with prehospital RVF, and the incidence of survival in patients who had RVF and were transported to hospital. Methods: Ambulance Call Records (ACRs) of patients with out of hospital cardiac arrest between Mar. 1 2012 and Apr. 1 2016 were reviewed. Cases of RVF (≥5 consecutive shocks delivered) were determined by manual review of the ACR. ED and hospital records were analyzed to determine outcomes of patients who were in RVF and transported to hospital. Descriptive statistics were calculated and all variables were tested for an association with initial ED rhythm, survival to admission, and survival to discharge. Results: Eighty-five cases of RVF were identified. A history of coronary artery disease (47.10%) and hypertension (50.60%) were the most common comorbidities in patients transported to the ED with RVF. Upon arrival to the ED, 24 (28.2%) remained in RVF, 38 (44.7%) had a non-shockable rhythm, and 23 (27.1%) had return of spontaneous circulation. Thirty-four (40%) survived to admission, while only 18 (21.2%) survived to discharge. Pre-existing comorbidities, time to first shock, time on scene, and transport time were not statistically associated with initial ED rhythm, survival to admission or discharge. Patient age was statistically associated with improved rhythm on ED arrival (p=0.013) and survival to discharge (58.24 yrs vs 67.40 yrs, Δ9.17, 95% CI 1.82 to 16.52, p=0.015). Conclusion: The majority of patients with prehospital RVF have a rhythm deterioration by the time care is transferred to the ED. Of these patients with a rhythm deterioration, few survive to hospital discharge. Younger patients are more likely to remain in RVF and survive to discharge. Further research is required to determine prehospital treatment strategies for RVF, as well as patient populations that may benefit from those treatments.

Introduction: Understanding factors that influence laboratory test ordering in emergency departments (EDs) can help to improve current laboratory test ordering practices. The aim of this study is to compare patterns and influences in laboratory test ordering between emergency physicians and nurses at two ED sites, Halifax Infirmary (HI) and Dartmouth General (DG). Methods: A mixed-methods approach involving administrative data and telephone interviews was employed. Data from 211,279 patients at HI and DG EDs were analyzed. Chi-square analysis and binary logistic regression were used to determine significant factors influencing whether a test was ordered, as well as significant factors predicting likelihood of a nurse or a physician ordering a test. All significant associations had a p-value of <0.0001. Interviews were conducted (n=25) with doctors and nurses in order to explore areas of potential influence in a clinician’s decision-making process, and discuss what makes decision making difficult or inconsistent in the ED. These interviews were analyzed according to the Theoretical Domains Framework. The interviews were coded by two individuals using a consensus methodology in order to ensure accuracy of coding. Results: Overall, laboratory tests were more likely to be ordered at DG than at HI (OR=1.52, 95% CI: [1.48, 1.55]). Laboratory tests were more likely to be ordered by nurses at DG than at HI (OR=1.58, 95% CI: [1.54, 1.62]). Laboratory tests were more likely to be ordered if the ED was not busy, if the patient was over 65, had a high acuity, had a long stay in the ED, required consults, or was admitted to hospital. Doctors were more likely to order a laboratory test in patients over 65, requiring consults or hospital admission, whereas nurses were more likely to order laboratory tests in patients with high acuity or long stays in the ED. Data from the interviews suggested differing influences on decision making between nurses and doctors, especially in the areas of social influence and knowledge. Conclusion: Currently, there is limited research that investigates behaviour of both emergency physicians and nurses. By determining barriers that are most amenable to behaviour change in emergency physicians and nurses, findings from this work may be used to update practice guidelines, ensuring more consistency and efficiency in laboratory test ordering in the ED.

Introduction/Innovation Concept: Estimates suggest that up to eighty-seven percent of human trafficking victims have come into contact with a healthcare provider during their exploitation and yet less than ten percent of emergency medicine (EM) physicians feel confident in identifying a victim. When provided with the relevant tools, medical personnel can aid in the recognition of victims and take the necessary steps in providing appropriate care when they present to the emergency department. Identifying this need for increased awareness in the urgent care setting, a module on human trafficking was implemented into the undergraduate medical education and departmental grand rounds. Methods: After identifying gaps in current medical education regarding screening for victims of human trafficking, a literature review was completed on the topic in medical education and utilized in constructing a list of objectives. These were then reviewed by community organizations that aid victims of trafficking and the Canadian Alliance of Medical Students Against Human Trafficking. Undergraduate medical students completed surveys prior to and following the learning module, in order to evaluate improvement in acquired knowledge. Curriculum, Tool, or Material: A one-hour lecture from ACT Alberta was given to undergraduate medical students as well as to residents and staff in departmental grand rounds. The session met the following objectives: defining human trafficking, recognition of victims, and identification of next steps in providing care. Additionally, an online module from Fraser Health was made available as an additional resource with case studies specific to emergency departments. The surveys consisted of 13 questions evaluating students’ knowledge on human trafficking and its prevalence in emergency medicine. The questions were a combination of a Likert scale, multiple choice, and short answer. There was a large amount of positive feedback from the students and comparison of the surveys showed that their knowledge in identifying victims had significantly improved. Conclusion: Medical students, residents, and staff may come into contact with victims of trafficking in the emergency department and yet less than three percent of emergency physicians have had training on how to recognize a victim. Implementing human trafficking awareness will impact EM medical education by providing victims a greater chance of being recognized and offered help when they present to the emergency room.

Introduction: A cricothyroidotomy is a life-saving procedure and essential skill for EM physicians. The bougie-assisted cricothyroidotomy (BAC) is a newly describe technique that is both simple and reliable. There remains no consensus for the essential steps and ideal training strategy for the procedure. Using a modified Delphi process, we created an expert-derived checklist as a transferable educational tool for BAC instruction. Methods: A literature search was conducted to identify relevant articles describing the steps for BAC performance. These steps formed the first-iteration checklist for the modified Delphi process. Fourteen experts from general surgery, emergency medicine, otolaryngology, and anesthesia were recruited as participants for the Delphi process which consisted of three iterations. In the first two rounds, experts ranked each checklist step on a scale of 1-7, suggested additions, and provided comments. After each round the comments and rankings were integrated and steps with an average ranking of ≤3.0 were removed from the checklist for the next round. In the final round, consensus was sought by asking experts to indicate if this checklist was acceptable for teaching BAC to a novice learner. Results: A 22-item checklist was developed from a literature review. Following a modified Delphi methodology, the final BAC checklist contained 17 items. Internal consistency of the checklist was very good (α=0.855). In the third and final round, 86% of the participants agreed that the final iteration of the checklist. There was disagreement regarding “bougie hold up” as an appropriate method to confirm bougie position within the tracheal lumen. The checklist was modified, replacing “hold up” with digital palpation in the trachea as confirmation of successful bougie placement. With these modifications, consensus was achieved. Conclusion: Using a modified Delphi process, derived from existing literature and expert opinion, a 17-item BAC checklist was developed for novice instruction. This BAC checklist represents the first consensus-based set of steps for the procedure which may serve as a useful tool for trainee instruction and evaluation. Future research is required to test the validity of this checklist in training for a BAC and its applicability within competency-based medical education.

Introduction: The acute onset of flashes and floaters is a common presentation to the emergency department (ED). The most emergent etiology is retinal detachment (RD), which requires prompt ophthalmologic assessment. Previous studies of point of care ultrasound (POCUS) have reported high sensitivity and specificity for RD, but are limited by small sample size, use of highly trained and experienced sonographers, and referral bias. Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. Methods: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of ED patients presenting with the complaint of flashes or floaters in one or both eyes. Participating EPs completed a one hour didactic lecture and were expected to demonstrate appropriate performance of one practice scan before enrolling patients. After standard ED assessment, patients underwent an ocular POCUS scan targeted to detect RD. EPs recorded the presence or absence of RD on the data collection instrument based on their POCUS scan. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CI) using the retina specialist’s determination of the final diagnosis as the criterion standard. Results: A total of 30 EPs, consisting of 21 staff physicians and 9 residents, participated in this study. These EPs performed a total of 128 POCUS scans. Of these scans, 13 were excluded. Of the remaining 115 enrolled patients, median age was 60 years, and 64% were female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD was 75% (95% CI 48% to 93%) and 94% (95% CI 87% to 98%), respectively. The positive likelihood ratio was 12.4 (95% CI 5.4 to 28.3), and negative likelihood ratio was 0.27 (95% CI 0.11 to 0.62). Conclusion: In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.

Introduction: Emergency physicians (EP) often work at undesirable hours. In response to deleterious effects on quality of life for EPs, traditional 2300-0700 night shifts have been replaced at some centres with staggered 6-hour casino shifts (22:00-04:00 and 04:00-10:00). Though purported to allow for better sleep and recovery patterns, no evidence exists to support the benefits on sleep or quality of life that is used to justify a casino shift model. Using a before and after survey model, this study examines the impact of overhauling night work from a traditional 8-hour shift to casino shifts on the quality of life and job satisfaction of EPs working in an academic emergency department (ED). Methods: In 2010, an initial online, 37-item survey, was sent to all EPs working in the ED, just prior to the transition to casino shifts. 6 years following the transition, a slightly modified 37-item survey was again distributed to all current EPs working at that same centre. Participants rated their level of agreement on a 7-point Likert scale regarding questions related to night work. Results from the two surveys were compared. Results: 43 2010- and 47 2016-surveys were completed. In 2016, recovery to baseline function after a single early shift (22:00-04:00) was most common after 1 day at 52.4%, and after multiple early shifts was ≥2 days at 66.7%. Recovery after a single late shift (04:00-10:00) was most common at 1 day at 54.8%, and after multiple late shifts was ≥2 days at 59.5%. This was in contrast to 2010, when 55.8% recovered from a single traditional night shift after 1 day, and 95.3% required ≥2 days to recover from multiple traditional night shifts. In relation to casino shifts, 40.5% of respondents stated that night shifts are the greatest drawback of their job, compared to 79.1% previously. A minority of respondents felt that teaching (36.5%), diagnostic test interpretation (23.2%), and quality of handover (33.5%) were inferior on early and late night shifts compared to other shifts (74.4%, 58.1%, and 60.5% for traditional night shifts respectively).95.0% of respondents preferred casino over traditional night shifts. Conclusion: There were self-reported improvements in all domains following the implementation of casino shifts.

Introduction: Most current cricothyroidotomy simulation models are either expensive or low fidelity and limit the learner to an unrealistic simulation experience. The goal of this project is to innovate current simulation techniques by 3D printing anatomically accurate trachea models. By doing so emergency cricothyroidotomy simulation can be accessible, high fidelity, cost effective and replicable. Methods: 3D modelling software was used in conjunction with a desktop 3D printer to design and manufacture an anatomically accurate model of the cartilage within the trachea (thyroid cartilage, cricoid cartilage, and the tracheal rings). The initial design was based on dimensions found in studies measuring the dimensions of tracheal anatomy. This ensured an appropriate anatomical landmark design was achieved. Several revisions of the model were designed and qualitatively assessed by medical and simulation professionals to ensure anatomical accuracy that exceeded that of the currently used, low cost, cricothyroidotomy simulation model in St. John’s. Results: Using an entry level desktop 3D printer, a low cost tracheal model was successfully designed that can be printed in under 3 hours. Due to its anatomical accuracy, flexibility and durability, this model is ideal for use in emergency medicine simulation training. Additionally, the model can be assembled in conjunction with a membrane to simulate tracheal ligaments and skin for appearance. Conclusion: The end result is a high fidelity simulation that will provide users with an anatomically correct model to practice important skills used in emergency airway surgery, specifically land marking, incision and intubation. This design is a novel, easy to manufacture, replicable, low fidelity trachea model that can be used by educators with limited resources such as those in rural and remote areas.

Introduction: Atrial fibrillation and flutter (AF/AFL) are the most common arrhythmias encountered in the emergency department (ED); however, little information exists regarding the preventive management of patients with AF/AFL by emergency physicians (EPs). This study explored whether patients with AF/AFL received the recommended thrombo-embolic (TE) prophylaxis at discharge from the ED; patients’ TE risks, bleeding risks, and TE prophylaxis upon discharge from the ED were examined following assessment for symptomatic acute AF/AFL. Methods: Patients ≥18 years of age identified by the EP as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three urban Canadian EDs. Using standardized patient enrollment forms, trained research assistants collected data on the patient’s demographics, TE risk (using the CHADS2 and CHA2DS2-VASc score), bleeding risk (using the HAS-BLED score), and management both in the ED and at discharge. Treating physicians were surveyed on their use of risk scores when making TE prophylaxis decisions as well as their estimate of the patient’s stroke and bleeding risk. Descriptive analyses were performed. Results: From a total of 196 patients, 62% were male and the mean age was 63 years (standard deviation [SD] ±14). Most patients had previous history of AF/AFL (71%); hypertension was documented in 40% of them and ≤10% had other risk factors (e.g., congestive heart failure, vascular disease, diabetes, previous stroke, transient ischemic attack). Based on the CHADS2 score and previous management, there was opportunity for new or revised antiplatelet/anticoagulant treatment by EPs in 19% of the patients. Consultations were requested in 28% of the patients, and the majority (89%) were discharged with anticoagulant or antiplatelet agents. EPs expressed concerns that an increased risk of falls, lack of access to facilities for INR monitoring, and significant cognitive impairment would affect their willingness to prescribe anticoagulation. Conclusion: Most patients in the ED with acute AF/AFL are receiving the recommended TE prophylaxis; however, given the significant morbidity and mortality associated with AF/AFL, improved short-term prescribing practices for anticoagulants would benefit 1 in 5 ED patients. More research on barriers to EPs prescribing anticoagulants is required to improve clinician comfort in treating this high-risk population.

Introduction: The Canadian Computed Tomography Head Rules (CCTHR) is a validated and well-known head injury clinical decision rule that allows Emergency Room Physicians (ERPs) to determine which patients are most likely to benefit from a diagnostic CT. However, this clinical decision rule is not uniformly adhered to and a number of preventable CT scans are ordered. Choosing Wisely Canada has ranked decreasing unnecessary head CT scans as the number one priority for Emergency Departments (ED). As such, the purpose of this study was to investigate if an educational intervention for ERPs would increase adherence to the CCTHR. Methods: In September 2015 the CCTHR were presented and discussed at three ED departmental meetings at Kelowna General Hospital (KGH) a large tertiary hospital in the interior of British Columbia, Canada. Educational materials were distributed to the ERPS and a CTTHR checklist was made available throughout the ED. Rates of adherence to the CCTHR criteria were calculated from MHI patients that were seen in the four years prior to the educational intervention and were compared to rates of adherence for patients 12 months post educational intervention. Only patients that agreed to participate in the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were included in this analysis. Differences in adherence rates were tested using the chi-squared test. Results: 477 patients were included in the analysis for the pre-education cohort (control) and 257 for the post-education cohort(intervention). In the control cohort, 348 of the 477 (73%) of the patients were managed in accordance to the CCTHR compared to 194 of the 257 (75%) in the intervention cohort. There was no statistically significant difference in rates of adherence (p=0.457).In the control cohort, 44 of the 321 (14%) of patients received a CT that did not meet any CCTHR criteria compared to 15 of the 163 (9%) in the intervention cohort. The overall CT imaging rate was 24% in each patient cohort. Conclusion: Although adherence rates between the two cohorts were not statistically different, a greater proportion of patients had a CTAS of 2 or 3 and met criteria in the intervention cohort suggesting a higher level of acuity. Imaging rates remained constant at 24%, which was lower than expected if there was full adherence to the CCTHR. Further study is required to determine if educational interventions can improve adherence to the CCTHR.