Introduction: The positive health outcomes of exercise have been well-studied, and exercise prescription has been shown to reduce morbidity in several chronic health conditions. However, patient attitudes around the prescription of exercise in the emergency department (ED) have not been explored. The aim of our pilot study is to explore patients’ willingness and perceptions of exercise being discussed and prescribed in the ED. Methods: This study is a survey of patients who had been previously selected for exercise prescription in a pilot study conducted at a tertiary care ED. This intervention group were given a standardized provincial written prescription to perform moderate exercise for 150 minutes per week. Participants answered a discharge questionnaire and were followed up by a telephone interview 2 months later. A structured interview of opinions around exercise prescription was conducted. Questions included a combination of non-closed style interview questions and Likert scale. Patients rated prescription detail, helpfulness and likelihood on a Likert scale from 1-5 (1 being strongly disagree and 5 being strongly agree). Median values (+/-IQRs) are presented, along with dominant themes. Results: 17 people consented to exercise prescription and follow up surveys. 2 were excluded due to hospital admission. 15 participants were enrolled and completed the discharge survey. Two-month follow up survey response rate was 80%. Patients rated the detail given in their prescription as 5 (+/-1). Helpfulness of prescription was rated as 4 (+/-2). Likelihood to continue exercising based on the prescription was rated as 4 (+/-2). 11/12 participants felt that exercise should be discussed in the Emergency Department either routinely or on a case-by-case basis.1 participant felt it should not be discussed at all. Conclusion: Our study demonstrates that most patients are open to exercise being discussed during their Emergency Department visit, and that the prescription format was well-received by study participants.

Introduction: In the rural setting, Point-of-Care Ultrasound (POCUS) can dramatically impact rural acute care. In Saskatchewan, many rural clinicians have undertaken POCUS training, but widespread integration into rural emergency care remains elusive. We aimed to explore of the obstacles limiting adoption and their possible solutions to inform the development of a robust and innovative rural POCUS program in Saskatchewan. Methods: We conducted a mixed methods Participatory Action Research (PAR) study using surveys and focus groups. Our rural co-investigators identified 4 key realms relating to rural POCUS use: equipment, access to training, quality assurance (QA), and research. These guided the design of an online survey sent out to rural clinicians throughout Saskatchewan. Results of the survey informed the development of three approaches (centralized, hub-and-spoke, and decentralized) to training, QA, and research which were discussed at focus group sessions held at Saskatchewan’s Emergency Medicine Annual Conference (Regina, SK. 2016). The focus groups were facilitated by the study investigators. Responses were analyzed using a simple thematic analysis to identify relevant themes and subthemes. Results: 34 rural clinicians responded to the online survey. There was general agreement that POCUS is valuable in rural acute care, training is difficult to access and should be standardized, and that QA and research are desired but impractical in the current environment. 11 rural clinicians attended the focus groups. Analysis of focus groups yielded seven distinct themes/needs: infrastructure needs, peer networks, common standards, both local and regional training opportunities, academic support, access to resources, and culture change. Seventeen sub-themes were identified and noted as having either a positive or negative and direct or indirect effect on the above themes. Broadly speaking, participants supported a distributed “spoke-hub” model where training, research and QA occurs within distributed, regional hubs with support from academic sites. Conclusion: The adoption of POCUS for emergency care in rural Saskatchewan faces significant opportunities and obstacles. There is interest on the part of rural clinicians to overcome these challenges to improve patient care.

Introduction: Effective communication to develop a shared understanding of patient expectations is critical in establishing a positive medical encounter in the emergency department (ED). However, there is limited research examining patient/caregiver expectations in the ED, and their impact on the beliefs, attitudes and behaviours during and after an ED visit. The objective of this study is to examine patient/caregiver expectations and satisfaction with care in the ED using a patient expectation questionnaire and a follow up survey. Methods: As a part of a larger 3-phase study on patient/caregiver expectations in adult and pediatric EDs, a 7-item, paper-based questionnaire was distributed to all patients and/or caregivers who presented to one of four EDs in Nova Scotia with a Canadian Triage and Acuity Scale (CTAS) score of 2 to 5. A follow-up survey was distributed to all willing participants via email to determine their satisfaction with care received in ED. Descriptive statistics were used to analyze responses. Results: Phase 1 was conducted from January to September 2016. In total, 24,788 expectation questionnaires were distributed to ED patients/caregivers, 11,571 were collected (47% response rate), and 509 patients were contacted for a follow-up survey. Preliminary analysis of 4,533 questionnaires shows the majority of patients (67.1%) made the decision by themselves to present to the ED, while others were advised by a family/friend (22%). Respondents were most worried about an injury (17.8%) followed by illness (15.6%) and expected to talk to a physician (69.9%) and receive an x-ray (39.3%). The majority of physicians (53.3%) reported the expectation tool helped in caring for the patient and 87.5% felt they met patient expectations. There were 147 patient/caregiver responses to a follow-up survey (29% response rate) and 87.1% of responders reported that ED clinicians met their expectations. Conclusion: Patient/caregivers have a variety of concerns, questions, and expectations when presenting to the ED. Obtaining expectations early in the patient encounter may provide opportunities for improved communication between clinicians and patients while enhancing satisfaction with care received. Further analysis is needed to determine the impact of the expectation questionnaire on productivity in the ED.

Introduction: Burnout is well documented in residents and emergency physicians. Wellness initiatives are becoming increasingly prevalent, but there is a lack of data supporting their efficacy. In some populations, a relationship between sleep, exercise and wellness has been documented, but this relationship has not been established in emergency medicine (EM) residents or physicians. We aim to determine whether exercise and sleep quality and quantity as measured by a Fitbit are associated with greater perceived wellness in EM residents. Methods: Fifteen EM residents from two training sites wore a Fitbit during a 4-week EM rotation. The Fitbit recorded data on sleep quantity (minutes sleeping)/quality (sleep disruptions) and exercise quantity (daily step count)/quality (daily active minutes performing activity of 3-6 and >6 metabolic equivalents). Participants completed an end-of-rotation Perceived Wellness Survey (PWS) which provided information on six domains of personal wellness (psychological, emotional, social, physical, spiritual and intellectual). Associations between PWS scores and the Fitbit markers were evaluated using a Mann-Whitney-U statistical analysis. Results: Preliminary results indicate that residents who scored ≥50th percentile for sleep quantity had significantly higher PWS scores than those who scored ≤50th percentile (median PWS 17.0 vs 13.0 respectively, p=0.04). There was no significant correlation between PWS scores, sleep interruptions, daily step count and average daily active minutes. Postgraduate Year PGY1 and PGY2-5 report median PWS scores of 13.9 and 17.2 respectively. Conclusion: To our knowledge, this is the first study to objectively measure the quality and quantity of sleep as well as exercise habits of EM residents using a Fitbit device. Our data indicates a significant relationship between better sleep quantity and higher wellness scores in this population. We aim to enroll 30 residents in order to obtain a more robust data set. A larger sample size will increase statistical power and allow us to more extensively evaluate the use of exercise and sleep monitoring devices in the efficacy assessment of wellness initiatives.

Introduction: Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. Methods: A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by two blinded evaluators using a standardized tool. Thirty 4th year medical students from two graduating classes at the Schulich School of Medicine & Dentistry in London, ON were screened for eligibility. Two students did not complete the study, and were excluded. There were 13 students in the NEJM group, and 15 students in the ATLS group. Results: The NEJM group’s average score was 45.2% (±9.6) on the pre-questionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.7) on the post-questionnaire. The didactic group’s average score was 42.8% (±10.9) on the pre-questionnaire, 73.7% (±9.9) for the procedure, and 46.5% (±7.5) on the post-questionnaire. There was no difference between the groups on the pre-questionnaire (Δ +2.4%; 95% CI: −5.2, 10.0), or the procedure (Δ −6.0%; 95% CI: −14.6, 2.7). The NEJM group had better scores on the post-questionnaire (Δ +11.15%; 95% CI: 3.7, 18.6). Conclusion: The NEJM video was as effective as video-recorded training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. The objective of our study was to assess the diagnostic accuracy of high risk historical, examination and basic investigative features for AAS, in confirmed cases of AAS and a low risk control group in order to address the spectrum bias in previous diagnostic accuracy studies. Methods: We performed a historical matched case-control study: participants were adults >18 years old presenting to two tertiary care emergency departments (ED) or one regional cardiac referral center. Cases: new ED or in-hospital diagnosis of non-traumatic AAS confirmed by computed tomography or echocardiography. Controls: triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 4:1 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2. Results: Data were collected from 2002-2014 yielding 194 cases of AAS and 776 controls (mean age of 65(SD 14.1) and 66.7% male). Of the 194 cases of AAS, 32 (16.5%) were missed on initial assessment. Chest pain unspecified (20.7%), abdominal pain unspecified (9.9%) and acute coronary syndrome (8.7%) were the top diagnoses in the control population. Absence of acute onset pain (Sensitivity 95.9% negative likelihood ratio (LR-) 0.07(0.03-0.14)), and a negative D-dimer (Sensitivity 96.7%, LR- 0.05(0.01-0.18)) can help rule out AAS. Presence of tearing/ripping pain (Specificity 99.7%, LR+42.1 (9.9-177.5), a history of aortic aneurysm (Specificity 97.8%, LR+6.35(3.54-11.42)), hypotension (Specificity 98.7%, LR+ 17.2(8.8-33.6)), pulse deficit (Specificity 99.3, LR+31.1(11.2-86.6)), neurological deficits (Specificity 96.9%, LR+ 5.26(2.9-9.3)), and a new murmur (Specificity 97.8%, LR+ 9.4(5.5-16.2) ) can help rule in the diagnosis of AAS. Conclusion: Patients with one or more high-risk feature should be considered high risk, whereas patients with no high risk and multiple low risk features are at low risk for AAS. Further research should focus on a combination of these factors to guide who warrants further investigation thus reducing miss rate, morbidity and mortality.

Introduction: Emergency department visits related to substance use are becoming more serious and increasingly costly in Canada. Emergency physicians must be able to effectively screen, manage, refer, and advocate for these complex patients. This study sought to describe the current state of addiction medicine training in Canadian emergency medicine (EM) residency programs and to assess the need for a formal curriculum. Methods: All Royal College and College of Family Physicians EM Program Directors (PDs) were asked to participate in a ten-question needs assessment survey on addiction medicine training for residents. Questions were developed through consensus after reviewing the relevant literature and conducting a formal pilot survey with staff physicians experienced in survey methodology. Responses were collected securely using the Research Electronic Data Capture (REDCap) database. Results: 19 out of 31 (62%) eligible PDs completed the survey. The importance of addiction medicine training received a median score of 69.5 (IQR=74.0) on a scale of 1-100. Most programs devoted two hours or less per year of formalized teaching on individual topics (such as opioids, alcohol, harm reduction) over the past two academic years. The two most common teaching modalities used were didactic lectures (15/19, 78.9%) and case-based tutorials (12/19, 63.2%). Case-based tutorials were identified as the most effective teaching method (12/19, 63.2%). Topics highlighted as most important to include in a curriculum were: screening for substance use disorders and referral for further treatment (14/19, 73.7%), social determinants of health (14/19, 73.7%), alcohol, opioid, and stimulant intoxication and/or withdrawal (14/19, 73.7% each), and management of patients on opioid agonist therapy (14/19, 73.7%). The most commonly perceived barriers to implementing such a curriculum were insufficient curriculum time (10/19, 52.6%) and lack of qualified teaching staff (7/19, 36.8%). Conclusion: This needs assessment provides an understanding of the current state of addiction medicine training for EM residents in Canada. A case-based addiction medicine workshop is currently being developed to address identified curriculum gaps. Integrating this curriculum longitudinally into a time-constrained academic schedule is an important next step.

Introduction: The Canadian CT Head Rules (CCTHR) is the gold standard clinical decision rule for minor head injuries (MHIs) & has been shown to have 100% sensitivity in identifying patients that would have an abnormal CT scan. Within the CCTHR age 65+ is considered to be an independent risk factor for abnormal head CT. However, a previously published Italian study indicated that the rate of pathological findings in otherwise low risk MHI patients under the age of 79 was less than 1% & significantly lower than those over the age of 80, which brings to question whether the traditional age cut off of 65 as a factor in the CCTHR is too conservative when considering the appropriateness for imaging. Therefore this study aimed to quantify the extent to which low risk MHI patients between the ages of 65-79 present with abnormal CT findings or require neurosurgical intervention when compared to patients over 80 years of age as one of the criteria used in the CCTHR is the age threshold of 65. A secondary objective of this study was to explore abnormal CT rates across these age groupings for otherwise low risk patients on anticoagulants. Methods: A retrospective chart review was conducted on all patients over the age of 65 that received a head CT for a MHI in the Kelowna General Hospital ED between 2006-2016. The imaging results for all patients that had no other risk criteria of the CCTHR other than age were reviewed & rates of pathological findings were compared between patients ages 65-79 & 80+ for both patients on anticoagulants & those not on anticoagulants. Differences in rates by age were compared for statistical significance using the chi-squared & Fisher’s exact test. Results: To date 248 patients have been reviewed & meet the criteria of being >65 & with no other CCTHR criteria. 65% of patients were female & 30% of patients were on anticoagulants. For the patients that were not on anticoagulants, 6 of the 75 (8%) individuals between 65-79 & 9 of the 94 (10%) of those over 80 had abnormal findings on CT (p=0.128). Conclusion: Preliminary results of this study population indicate that there are a significant number of abnormal CT findings in patients under the age of 80 suggesting that patients ages 65-79 without any other CCTHR criteria may still benefit from a head CT. Chart reviews are ongoing & updated results including findings for anti-coagulated patients will be presented at CAEP 2017.

Introduction/Innovation Concept: Rural and remote practice of emergency medicine presents unique challenges, particularly when faced with infrequently encountered cases and procedures. Simulation-based training is a valuable tool in the acquisition and maintenance of knowledge and skills; however, simulators are often located in larger centers and they are not widely outside these centers due to geographic, cost and time constraints. Mobile tele-simulation has the potential to overcome barriers but challenges such as comfort, technical issues and ability to teach desired content via tele-simulation must be addressed. We are developing a mobile-tele-simulation unit (MTU) prototype that will enable emergency medicine practitioners and trainees to access simulation-based instruction in rural and remote settings. Methods: Through application of a mixed-methods approach with input of a multidisciplinary team we are iteratively developing an MTU prototype to assess key factors in design and function, including: technical issues, environmental features, and human factors. The Delphi method is being used to collect input from experts on key design components and feedback is also being collected from trainees after participating in trial deployments of the MTU in different educational and environmental settings. Curriculum, Tool, or Material: The effective application of the MTU in a variety of learning settings will be optimized through ongoing evaluation in the iterative design cycle. Feedback to ensure a quality learning experience in the MTU will direct features of physical design and technical performance that can be applied in deployment of the unit. In addition, challenges to the delivery of module content and instructional modality/ features of lessons to be executed will be important considerations as we move toward developing content that can effectively be taught using the MTU. Conclusion: To ensure effective use of tele-simulation in the delivery of a meaningful simulation experience to rural and remote trainees a number of important challenges must be overcome. We describe our evolving multidisciplinary mixed-methods approach to develop an effective mobile tele-simulation unit.

Introduction: Following an emergency department (ED) presentation for acute atrial fibrillation and/or flutter (AF/AFL), patients often experience anxiety, depression and impaired health-related quality of life (QoL). Emergency physicians may prescribe appropriate thrombo-embolic (TE) prophylaxis upon discharge; however, the QoL of these patients is unclear. This study measured the QoL of patients with AF/AFL following discharge to determine the factors associated with QoL. Methods: Patients ≥18 years of age identified by the attending physician as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three Edmonton, AB EDs. Using standardized enrollment forms, trained research assistants collected data on patient demographics factors and management both in the ED and at discharge. Patients’ health-related QoL was assessed up to 20 days after their initial ED visit by a telephone interview based on six domains of the short-form 8 health survey. Results: From a total of 196 enrolled patients, 121 (62%) were male and the mean age was 63 years (standard deviation ±14). Most patients had previous history of AF/AFL (71%), and emergency physicians had the opportunity to treat or revise TE prevention therapy in 19% of the patients. The majority (89%) were discharged with prescriptions for antiplatelet or anticoagulant agents, and 188 (96%) were contacted by telephone at a median of 7 days. Most patients rated their overall health between good and excellent (70%); however, 30% assessed their health as fair or very poor. Many also reported having physical limitations (54%), difficulties completing their daily work (42%), bodily pain (32%) and limitations in social activities (32%). Finally, some patients reported having low energy (25%). At follow up, patients receiving adequate TE prevention rated their health to be similar to those without adequate TE prevention (30% vs 23%; p=0.534). Conclusion: Overall, patients with acute, symptomatic AF/AFL seen in the ED have impairments in health-related QoL following discharge from the ED. Many factors contribute to this impairment; however, providing patients with appropriate TE prophylaxis at discharge did not explain these findings. Further research is required to explore the impact of AF/AFL on patient’s health-related QoL after discharge from the ED.

Introduction: Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation in Canada; however, an evidence-practice gap in mTBI management exists among ED physicians, evidenced by significant practice variation. This review aimed to identify mTBI education and training directed at ED physicians and its relationship with practice patterns and physician knowledge. Methods: A comprehensive literature search of four bibliographic databases and the grey literature was performed using the keywords: concussion, mTBI, medical education, and continuing medical education. Included studies were required to report on mTBI education received by practicing ED physicians. Two independent reviewers screened unique citations for relevance and reviewed the full-texts of relevant articles. Two independent reviewers assessed methodological quality using the Methodological Index for Non-Randomized Studies. Data were extracted in duplicated onto standardized forms. Throughout the review process, discrepancies were adjudicated by an independent third party. Results: A total of 409 unique results were retrieved, and five studies were included. None of the included studies were of high methodological quality. Included studies assessed mTBI educational toolkits (n=3), conference presentations and academic journal articles (n=1), and pediatric fellowship training (n=1). Training primarily occurred after residency (i.e., continuing professional development) and focused on awareness and management of mTBI. Three studies measured ED physicians self-reported knowledge uptake and retention, and all three studies reported positive changes in knowledge uptake including self-reported increases in appropriate return-to-school and return-to-play recommendations. An increase in appropriate return-to-school/sports recommendations was reported in one study, measured by surveying parents of children diagnosed with mTBI. Conclusion: After a systematic and comprehensive search, few studies on mTBI education or training targeting ED physicians were identified and focused on process change rather than outcomes, highlighting an evidence-practice gap that needs to be addressed to improve mTBI patient care. Existing mTBI knowledge translation, including EDP education, needs to be optimized to effectively disseminate evidence-based best-practices for mTBI management in the ED.

Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.

Introduction: The following adverse outcomes have been described in patients treated in hospital for opioid overdose: pulmonary edema, cardiac dysrhythmias, neurologic injury secondary to hypoxia, prolonged opioid toxicity, recurrent opioid toxicity. In addition, patients who take an overdose of fentanyl may develop fentanyl induced chest rigidity, a life-threatening complication that appears to be uniquely related to fentanyl. The prevalence of adverse outcomes and the clinical course of patients that develop these complications have been described in patients who have taken an overdose of heroin. However, in British Columbia there has been a dramatic increase in the number of patients who overdose on fentanyl and other ultrapotent opioids. The proportion of illicit drug overdose deaths in British Columbia for which fentanyl was detected was only 5% in 2012 but, by 2016, this proportion had increased to 62%. It is very important to know the prevalence of adverse outcomes and the clinical course of patients that develop these adverse outcomes in patients with an overdose of fentanyl or another ultrapotent opioid. Methods: We are completing a retrospective cohort study to evaluate the prevalence of the following adverse outcomes for patients treated in hospital for an opioid overdose: i) pulmonary edema, ii) cardiac dysrhythmias, iii) fentanyl induced chest rigidity, iv) neurologic injury secondary to hypoxia, v) prolonged opioid toxicity, vi) recurrent opioid toxicity. Health records of patients treated for opioid overdose in the emergency departments of six greater Vancouver hospitals from Jan 1, 2014 to Dec 31, 2016 are being reviewed. Results: All Institutional approvals have been obtained. The dataset of 3600 ED visits for opioid overdose has been obtained and 160 health records have now been reviewed as of January 8, 2017. We will describe the type and prevalence (with 95% confidence intervals) of complications sustained by these patients. Conclusion: The results of this study will guide management of opioid overdose in a setting were ultrapotent opioids are commonly ingested. All health records will have been reviewed and the data analysis completed by May 2017.

Introduction: In 2015, there were 476 apparent illicit drug overdose deaths, prompting BC’s Provincial Health Officer to declare a public health emergency on 14 Apr 2016. Paramedics of BC’s Ambulance Service (BCAS) are on the front lines in this crisis. Here we examine recent trends in the number of suspected overdose events attended by the BCAS and the use of naloxone, an opioid antagonist, by BCAS paramedics. Methods: The BC Centre for Disease Control receives a weekly data feed from BC Emergency Health Services that includes all records from the BCAS Patient Care Record where: naloxone was administered by paramedics; the primary impression code indicates poisoning or overdose; or, the originating call is associated with ingestion poisoning (‘card 23’). Here, we report a descriptive analysis of these data for suspected drug overdose events during the period January 1, 2010 to September 30, 2016. Results: Between January 2010 and September 2016 BCAS paramedics attended 164,227 suspected overdose events; 12% of these events (n=16,944) included naloxone administration by BCAS paramedics. Paralleling the rise in illicit drug overdose deaths in BC, naloxone administration by paramedics has been increasing rapidly, doubling from approximately 180/month in 2014, to 370/month in 2016. When naloxone was administered by paramedics, 90% of these patients were transported, whereas 77% were transported when naloxone was not administered. Administrations occurred most frequently on Friday and Saturday evenings. Almost half (46%) of all naloxone administrations by paramedics were recorded as being in a home or residence; 18% were recorded as occurring on a street or highway. The proportion of naloxone administrations among males has increased yearly. In 2010, 58% of naloxone administrations were in males compared to 69% in 2016. Conclusion: The number of overdose deaths in BC has risen drastically in recent years and the proportion of ambulance calls requiring administration of naloxone by BCAS has climbed correspondingly. The vast majority of overdose cases-especially those requiring naloxone-are transported to the emergency department. With the overdose crisis showing little sign of abating, the administration of naloxone by BC paramedics will continue to be a critical element of the provincial response.

Introduction: Transcutaneous cardiac pacing (TCP), a skill taught in Advanced Cardiovascular Life Support (ACLS) courses, is recommended to treat unstable bradycardia. Training manikins currently available fail to reproduce key features of TCP and might be suboptimal to teach this procedure.The objective of this study was to measure the impact of a modified high-fidelity manikin on junior residents’ TCP competency during an ACLS course. We hypothesized that the use of this high-fidelity manikin improves junior residents’ performances. Methods: This prospective cohort study was conducted at the Université de Montréal in July 2015 and 2016. First-year residents undergoing their mandatory ACLS course were enrolled. The control group (2015) received the traditional curriculum, which includes hands-on teaching on Advanced Life Support manikins. The intervention group (2016) received a similar curriculum, but used a modified high-fidelity manikin that reproduces key features of TCP (e.g. use of multifunction pads, TCP induced patient twitching, ECG artifacts). Cohorts were tested with a simulation scenario requiring TCP. Performances were graded based on six critical tasks: turns on pacer function, applies multifunction pads, recognizes TCP is ineffective, achieves captures, verifies mechanical capture and prescribes sedation. Our primary outcome was successful use of TCP defined as having completed all tasks. Secondary outcomes were the success rates for each task. These were compared using Pearson’s chi-squared test. We anticipated that the success rate of TCP would increase from 20% to 50%. To obtain a power of more than 90%, 48 participants were needed in both cohorts. Results: A total of 50 residents were recruited in both cohorts. No resident that received the traditional curriculum was able to successfully establish TCP while 18 residents trained on the modified high-fidelity manikin succeeded (0 vs 36%, P<0.001). Furthermore, the latter were more likely to recognize when pacing was inefficient (12 vs 86%, P<0.001), obtain ventricular capture (2 vs 48%, P<0.001), and check for a pulse rate to confirm capture (0 vs 48%, P<0.001). Conclusion: Successful use of TCP is a difficult skill to master for junior residents. A modified high-fidelity manikin during ACLS training significantly improves their ability to establish effective pacing.

Introduction: Fast track (FT) implementation in emergency departments (ED) has shown a decrease in patient wait times, length of stay (LOS), left without being seen rates, and has increased patient satisfaction. The objective of this study was to analyze the demographics and presenting complaints of patients presenting to FT in Calgary EDs using local administrative databases to understand the current selection of FT patients, as well as to uncover potential throughput efficiencies through LOS analysis. Methods: Sunrise Clinical Manager data was pulled from the Foothills Medical Center (FMC), Peter Lougheed Center (PLC), and Rockyview General Hospital (RGH) EDs between October 2015 and September 2016. Based on consensus achieved by the Calgary FT-Minor Treatment Sub-committee, data was descriptively analyzed based on the following criteria: (1) triage profiles of the Calgary ED sites; (2) site admission rates by complaint, Canadian Triage and Acuity Scale (CTAS), vitals, and age; (3) LOS for orthopedic patients admitted from FT/Minor; and, (4) LOS in FT for non-admitted back pain patients. Results: A total of 53911 patients were triaged to FT, with 16224 patients triaged to FMC, 18299 to PLC, and 19388 to RGH. 6.9% of FT patients were admitted to hospital at FMC, 4.8% at PLC and 4.8% at RGH. 14.4% of patients at FMC, 18.3% at PLC and 17.6% at RGH were CTAS 2; 40.9% of patients at FMC, 46.2% at PLC and 37.9% at RGH were CTAS 3; 34.0% of patients at FMC, 27.8% at PLC and 33.3% at RGH were CTAS 4; 10.7% of patients at FMC, 7.7% from PLC and 11.2% for RGH were CTAS 5. For FT patients 80 years or older, 10.4% were admitted at FMC, 13.1% at PLC and 9.4% at RGH. The top FT presenting complaints at all sites were lower extremity injury, upper extremity injury, and laceration/puncture. The annual FT bed hours for patients admitted to orthopedic surgery (consultation request to time of orthopedic admission) was 802.3 hours at FMC, 441.1 PLC and 705.1 from RGH. The annual FT bed hours for patients with non-admitted back pain (FT bed to time of discharge) was 2144.3 hours from FMC, 3367.9 from PLC and 1134.9 from RGH. Conclusion: The efficiency of FT is based on streamlining low acuity patients with an expected rapid discharge from hospital. The results of this investigation will be presented to the FT-Minor Treatment Sub-committee in order to utilize current admission rates, patient profiles, and aggregate LOS to potentially improve throughput.

Introduction: Syncope is responsible for up to 5% of emergency department visits. Vasovagal syncope (VVS) is the most common subtype and can have significant quality of life implications as it is often recurrent. Clinicians treating VVS have limited treatment options available to them and often struggle with prognostication. The aim of our study was to identify patient-specific determinants of VVS improvement or cessation. Methods: Patients (pts) from the Prevention of Syncope Trials (POST) 1 and 2 were included in this study. All patients had VVS according to tilt table testing or a diagnostic point score. Patients had fainted ≥1 time in the previous year and all were followed for up to 1 year after enrollment. Data are presented as median (IQR). Complete responders (CR) did not faint in follow-up; partial responders (PR) fainted ≥1/year less than prior year but did not stop; and non-responders (NR) did not improve or stop. Results: There were 392 patients: 126 males, median age 34 (23,50) who had fainted for 10 (3,22) years and followed for a median of 363 (148,376) days. There were 225 CR (57%), 120 PR (31%) and 47 NR (12%). PR subjects were younger: 27 (24,33) years compared to CR (36 (32,42)) years and NR (36 (29,47)) years (p<0.05). Receiver operator characteristic analysis showed age predicted PR (AUC=0.62). Lifetime fainting frequency was 0.67 (0.14,2.00) faints per year, increasing to 4 (2,10) faints in the pre-year and decreasing to 0 (0,1.9) faints in the post-year (p<0.0001). Pts had similar syncope frequency in the distant past (PR, 1.14 faints/year; CR, 0.68 faints/year; NR, 0.58 faints/year) but PR pts worsened markedly prior to enrollment. PR subjects fainted much more in the prior year: 10 (6,18) faints compared CR (3 (2,3) faints, p<0.0001) and NR (2 (2,4) faints, p<0.05). Receiver operator characteristic analysis showed prior year faints predicted PR well (AUC=0.81). There was no significant interaction with treatment (metoprolol in POST 1, fludrocortisone in POST 2). Conclusion: After specialist consultation, 57% of VVS patients stop fainting and 31% improve incompletely without a significant treatment effect. Patients who will improve incompletely can be accurately selected based on younger age and more frequent syncope. Older patients with less frequent syncope are 83% likely to stop fainting. These findings will help counsel pts and select candidates for medical therapy.

Introduction: Acute Mountain Sickness (AMS) is a high-altitude medical emergency that requires prompt treatment. If left untreated AMS can progress to high-altitude cerebral edema or pulmonary edema, both of which can be fatal. As the popularity of high altitude trekking increases in the Himalayas we were interested in determining what rates of AMS are on popular routes in this region. Methods: AMS was diagnosed using a standardized Lake Louise Symptom Score (LLSS) where scores 3-5 denoted mild AMS and >5 denoted severe AMS. Forms were distributed to trekkers prior to departure and symptoms scores were determined daily. Data on medical history and patient demographics were also collected. All data are expressed as mean ±SEM. Results: Preliminary results are reported from N=17 (4 female) participants. Mean age was 43.7±3.9y. Most subjects, 68.8%, had trekked above 2500 m in the past. Only 6.25% reported having no knowledge of AMS, with the others having limited or expert knowledge. 25% of subjects had previously suffered from AMS. Most subjects, 82.4%, took prophylactic AMS medication, acetazolamide; at a dose of 250 mg/d. Subjects trekked at a mean altitude of 3650±85 m and ascended to a maximum altitude of 5012±103 m. The mean LLSS was 1.48±0.31 with a maximal LLSS of 4.76±0.75. Within our sample, 70.86% suffered from AMS at some point during their trek. Of those who suffered from AMS, the mean number of days affected was 3.17±0.61, and of those with severe AMS, mean number of days affected was 2.14±0.7. Conclusion: Over 70% of trekkers to the Himalayas experience AMS for an average of 3d, despite the use of prophylactic medication that most participants take. Almost 95% of trekkers have working knowledge of AMS and most have prior experience trekking at high-altitude. Given the dangers of high altitude trekking, pre-departure education for patients, especially those with chronic diseases, alongside prophylactic medication for AMS may help mitigate the risk.

Introduction: The social determinants of health (SDoH) can play a significant role in a person’s overall wellbeing. This is especially true for adults with mental illness and mental health disorders. In this study, we describe the SDoH of patients presenting to an academic, inner-city emergency department (ED) with an acute mental health complaint (AMHC). Methods: We prospectively identified and enrolled a convenience sample of patients presenting to an ED with an annual census of 85,000 visits. Participants provided informed written consent, and completed a questionnaire package containing questions related to demographics and SDoH. As well, participants were asked to complete four mental health, quality of life, and recovery validated patient-reported outcome measures. Results: A total 108 participants were enrolled in this study, of which 65% were male, aged 37.5 years (IQR 26.7-50.3), 56% Caucasian, and 22% Aboriginal. Depression was the primary diagnosis reported by 55% of participants, with 58.9% meeting the PhQ-9 cutoff for moderate-severe depression. The highest level of educational achievement for 44% of participants was high school or less, with 75% reporting being unemployed. Almost half (45%) reported engaging in less than two hours of structured activity each week. Thirty eight percent of participants reported living in their own apartment, with 25% reporting being homeless and 17% living in a single-room housing unit. The majority of participants (56%) sampled were not satisfied with their housing, and 67% were actively looking for new housing. Sixty percent of participants reported smoking cigarettes daily and 40% reported weekly cannabis use. A total of 11% of the sample reported that they did not have access to clean drinking water; 35% worried that their food would run out, and 47% reported cutting the size of meals due to a lack of money. Conclusion: This study lends evidence towards the circumstances in which patients presenting to the ED with an AMHC live and work. A considerable proportion of patients reported homelessness or being marginally housed, lack access to clean drinking water and sufficient food, and high rates of unemployment. Mitigating the effects of harmful social determinants is critical for optimal health of this population. Future work is needed to clarify the role of the ED in the surveillance, screening, and intervention of SDoH for this vulnerable patient group.

Introduction: Emergency department (ED) over-crowding and increased wait times are a growing problem. Many interventions have been proposed to decrease patient length of stay and increase patient flow. Early disposition planning is one method to accomplish this goal. In this study we developed statistical models to predict patient admission based on ED administrative data. The objective of this study was to predict patient admission early in the visit with goal of preparation of the acute care bed and other resources. Methods: Retrospective administrative ED data from the Thunder Bay Regional Health Sciences Centre was obtained for the period May 2014 to April 2015. Data were divided into training and testing groups with 80% of data used to train the statistical models. Logistic regression models were developed using administrative variables (i.e., age, sex, mode of arrival, and triage level). Model accuracy was evaluated using sensitivity, specificity, and area under the curve measures. To predict hourly bed requirements, the probability of admission was summed to calculate a pooled bed requirement estimate. The estimated hourly bed requirement was then compared to the historical hourly demand. Results: The logistic regression models had a sensitivity of 23%, specificity of 97%, and an area under the curve of 0.78. Although, admission prediction for a particular individual was satisfactory, the hourly pooled probabilities showed better results. The predicted hourly bed requirements were close to historical demand for beds when compared. Conclusion: I have shown that the number of acute care beds required on an hourly basis can be predicted using triage administrative data. Early admission bed planning would allow resources to be managed more effectively. In addition, during periods of hospital over capacity, managers would be able to prioritize transfers and discharges based on early estimates of ED demand for beds.