Introduction: Patients with neurologic chief complaints comprised 12.5% of total visits to the University of Alberta Emergency Department (ED) in 2017. Symptoms are often subjective, transient, or atypical, leading to diagnostic uncertainty. Serious diagnoses require timely intervention to mitigate morbidity and mortality, however the proportion of patients who leave the ED without being seen (LWBS) has increased over time. We sought to analyze the characteristics and outcomes of patients with neurologic complaints who LWBS to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care Reporting System database to select adult patients presenting to the University of Alberta Hospital in 2017 with neurologic complaints as defined by the Canadian Triage Acuity Scale (CTAS). Using standard descriptive statistics we examined demographic and clinical characteristics to compare LWBS patients to all others. Results: Of 8,726 total visits 7.54% patients LWBS. These patients tended to be younger on average (39 vs 55 years), with a larger proportion presenting at night (37.69%) and on Monday. The majority were triaged CTAS 3 (68.69%). Their mean length of stay was shorter than all other visits (3.70 vs 9.51 hours). Headache (22.74%), extremity weakness/symptoms of CVA (20.19%), head injury (14.32%), seizure (8.28%), and sensory loss/paresthesia (8.14%) comprised the top 5 neurologic complaints, and were disproportionately presented in LWBS patients; headache (31.76%), head injury (23.71%), sensory loss/paresthesia (12.01%), seizure (11.25%). Patients who LWBS also re-presented to the ED within 72 hours (21.43%), more often than those discharged by a physician (8.29%). Conclusion: Patients presenting with neurologic complaints who LWBS are younger, tend to arrive at night, with less acute presentations, however they more frequently return to the ED within 72 hours than those seen and discharged. Patients who LWBS may benefit from education, physician assessment or closer nurse reassessment at triage to increase the quality and safety of care in the ED, reduce return visits and ED utilization.

Introduction: Patients with neurologic presenting complaints comprised 12.5% of total University of Alberta Emergency Department (ED) visits in 2017. This group of patients has high rates of EMS utilization, admission, and ED resources including diagnostic imaging and consult services. We sought to analyze the characteristics and outcomes of the patients with neurologic complaints who have an unscheduled return visit (URV) to the ED within 72 hours to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care System databases to select adult patients presenting to the University of Alberta hospital in 2017 with neurologic complaints as defined by the Canadian Triage and Acuity Scale (CTAS). We additionally selected for return visits to Edmonton Zone EDs within 72 hours. Using standard descriptive statistics, we examined demographic and clinical characteristics of patients with 72-hour URV. Results: Of 8,770 total visits, 674 (7.69%) had a 72-hour URV to an Edmonton zone ED. The URV rate was 9.0% in patients seen by a physician and discharged with approval and 23.4-33.3% in patients who left against medical advice (LAMA), prior to completion of treatment (LPCT), or without being seen by a physician (LWBS). The mean age of URV patients was 45.6 years, 56.5% were male, with a mean ED length of stay of 7.37 hours. The top 5 diagnoses for URV patients were headache, migraine, alcohol related disorders, concussion, and transient ischemic attack. 14.7% of URV patients were admitted, 13.5% LWBS, 1.6% LAMA, 1.6% LPCT, and 66.1% were discharged. Conclusion: The majority of neurologic complaint patients with URV within 72 hours are those who LAMA, LPTC, or LWBS at index visit. The admission rate for URV patients (14.7%) is lower than for the index ED visit (55%), however these patients have high LWBS rates. Identifying strategies to limit the LWBS rate for these patients would reduce return visits and improve the quality and safety of patient care.

Introduction: Evidence suggests that prehospital point of care ultrasound (POCUS) may improve outcomes. It serves as an aid in physical examination, triage, diagnosis, and patient disposition. The rate of adoption of POCUS among aeromedical services (AMS) throughout Canada is unknown. The objective of this study was to describe current POCUS use among Canadian AMS providers. Methods: This is a cross-sectional observational study. A survey was emailed to directors of government-funded AMS bases in Canada. Data was analyzed using descriptive statistics. Results: The response rate was 88.2% (15/17 AMS directors) and accounted for 42 out of 46 individual bases. POCUS is used by AMS in British Columbia, Alberta, Saskatchewan, and Manitoba. New Brunswick, Nova Scotia, Prince Edward Island, and Yukon are planning to introduce POCUS within the next year. Ontario, Quebec, and Newfoundland are not utilizing POCUS and are not planning to introduce it. BC is the only province currently using POCUS on fixed-wing aircraft. POCUS is used in <25% of missions, most frequently at sending hospital and in flight. Most useful applications were assessment for pneumothorax, free abdominal fluid, and cardiac standstill. Most common barrier to POCUS use was cost of training and maintenance of competence. Conclusion: Prehospital POCUS is available in Western Canada with one third of the Canadian population having access to AMS utilizing ultrasound. The Maritimes and the Yukon Territory will further extend POCUS use on fixed-wing aircraft. While there are barriers to POCUS use, those bases that have adopted POCUS consider it valuable.

Introduction: For many years, Emergency Medicine (EM) educators have used narrative comments to assess their learners on each shift, either in isolation or combined with some type of Likert scale ranking. Competency based medical education (CBME), soon to be fully implemented throughout Canadian EM educational programs, encourages this type of frequent low-stakes narrative assessment. It is important to understand what information is currently garnered from existing narrative assessments in order to successfully and smoothly transition to the CBME system. The purpose of this study was to explore how one Canadian undergraduate EM program's narrative assessment comments mapped to two competency frameworks: one traditional CanMEDS-based and one competency-based, built on entrustable professional activities (EPAs). Methods: A qualitative and quantitative content analysis of 1925 retrospective, narrative assessments was conducted for the 2015/2016 and 2016/2017 academic years. The unprompted comments were mapped to the Royal College CanMEDS framework and the Association of Faculties of Medicine of Canada EPA Framework. Using an iterative coding process as per accepted qualitative methodologies, additional codes were generated to classify comments and identify themes that were not captured by either framework. Results: 93% and 85% of the unprompted narrative assessments contained comments that mapped to at least one CanMEDS role or EPA competency, respectively. The most common CanMEDS role commented upon was Medical Expert (86%), followed by Communicator, Collaborator and Scholar (all at 23%). The most common EPA competency mentioned related to history and physical findings (62%) followed by management plan (33%), and differential diagnosis (33%). However, 75% of narrative comments contained within the assessments, included ideas that did not fall into either framework but were repeated with frequency to suggest importance. The experiential characteristics of working with a learner were commented upon by 22% of preceptors. Other unmapped themes included contextual information, generalities and platitudes, and directed feedback for next steps to improve. Conclusion: While much of the currently captured data can be mapped to established frameworks, important information for both learner and assessor may be lost by limiting comments to the competencies described within a particular framework, suggesting caution when transitioning to a CBME assessment program.

Introduction: Iron Deficiency Anemia (IDA) is a common presentation to the emergency department (ED) and is often treated with red blood cell transfusions. Choosing Wisely and the American Association of Blood Banks released guidelines in 2016 outlining under what circumstances transfusions should be given for patients with IDA. Few well-powered studies have looked at the impact of these guidelines on transfusions in EDs. The goal of this study was to examine the number of RBC transfusions that were given in EDs in Calgary, Alberta from 2014-2018 and what proportion of these were potentially avoidable (PA). Methods: We analyzed 8651 IDA patient encounters from 2014–2018 at four centers in the Calgary Zone. A transfusion was considered PA if the patient's hemoglobin (hgb) was ≥70 g/L AND if the patient was hemodynamically stable. We performed descriptive statistics to assess the number of transfusions and the number of avoidable transfusions. We used chi-squared tests to determine if there were significant differences between site, time-period, hemoglobin level. Results: In total, 990 (11.4%) of the encounters received transfusions; 711 (71.8%) were indicated while 279 (28.1%) were PA. Out of the transfusions that were indicated, 230 (32.3%) were given to patients with a hgb <70 g/L and 481 (67.7%) were given to patients with a hgb >70 g/L but who were hemodynamically unstable. Out of the transfusions that were PA, the highest number were given to those in the 71-80 g/L hgb group (142) and the lowest number were given to those in the 110-130 g/L hgb group (9), a difference that was statistically significant (p < 0.001). The PA transfusion rates from 2014 to 2018 were 30.8%, 25.6%, 34.5%, 23.6%, 20.7% respectively, which was a statistically significant difference (p = 0.004). Conclusion: Our data suggest that the number of PA transfusions at the hospitals in the Calgary zone is comparable to the rates reported in the existing literature. In addition, the rate of PA transfusions has decreased since the release of the guidelines. A limitation of the present study was that it did not look at the number of units of red blood cells transfused and since many patients receive more than one unit, it is possible that the number of PA transfusions was underestimated. Nevertheless, we intend to use our results to create a safer and more cost-effective approach to managing IDA.

Introduction: Global health partnerships (GHPs) between high income and low income countries are a means of capacity building in education. Literature often focuses on the GHP structure and output, along with retention and experience of local trainees, but neglects the experience of involved faculty. Here, we survey Canadian teaching faculty participating in the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) to describe characteristics of participants and their experience in the program. Methods: EM faculty participating in TAAAC-EM teaching trips from 2011-2016 were invited to complete an online survey in February 2017. Teaching faculty travel for one month and undergo an extensive selection process, pre-departure training and post-trip debriefing. Quantitative and qualitative data were collected and analyzed using basic statistics and inductive thematic analyses respectively. Results: Overall, 19 (N = 30, 63.3%) faculty completed the survey, of which 13 had prior global health experiences (range 1 to > 12 months). On a scale of 1-7, participants rated their mean overall experience as a 5.9 and preparation as a 5.7. Among respondents, 79% would participate in future TAAAC-EM activities, 79% would engage in future global health endeavours, 95% said the experience improved their satisfaction of practicing clinical medicine and 89% said it improved their enjoyment of teaching medicine. However, while 58% stated they would recommend this experience without hesitation to colleagues, the remaining 42% said they would recommend this experience with caveats. This latter group had a lower rated preparedness (MD = 1.398, p = 0.003) and TAAAC-EM experience (MD = 1.545, p = 0.001). Major themes in qualitative responses included that the participants felt that intrinsic motivation and flexible predispositions were necessary to participate. Intrinsic motivation for global health involvement included appreciation and impact for GH, and personal growth. Regarding flexibility, respondents highlighted the importance of having a flexible demeanor to understand, accommodate and ethically address cultural differences and practicing in another context. Conclusion: The type of faculty to recruit for GHPs may require flexible predispositions and intrinsic motivation for GH. These qualities combined with adequate preparation can facilitate overall faculty experiences on global health trips.

Introduction: In July 2018, Emergency Medicine (EM) transitioned to the Royal College of Physicians and Surgeons of Canada's (RCPSC) Competence by Design (CBD) training framework. In anticipation of CBD implementation, we conducted a nation-wide needs assessment of EM faculty and senior residents to understand their attitudes towards CBD, workplace-based assessments (WBA) and overall educational needs. Methods: A multi-site, cross-sectional digital survey was conducted in winter 2018 with a sample of EM faculty and senior residents across RCPSC EM programs in Canada. Recruitment was via program director nomination. Survey domains included baseline perceptions about CBD, attitudes toward implementation, perceived/prompted and unperceived faculty development needs. Microsoft Excel was used to calculate descriptive statistics. This study was reviewed by the Hamilton Integrated Research Ethics Board.A multi-site, cross-sectional digital survey was conducted in winter 2018 with a sample of EM faculty and senior residents across RCPSC EM programs in Canada. Recruitment was via program director nomination. Survey domains included baseline perceptions about CBD, attitudes toward implementation, perceived/prompted and unperceived faculty development needs. Microsoft Excel was used to calculate descriptive statistics. This study was reviewed by the Hamilton Integrated Research Ethics Board. Results: Between February-April 2018, 47 participants (40 faculty, 7 residents) completed the survey (58.8% response rate). Most respondents (89.4%) thought learner feedback should be provided on each shift; 55.3% believed they provided adequate feedback. Time constraints, learner disinterest and fear of assessment repercussions were the top three barriers to providing good feedback. A majority of respondents (78.7%) thought that the ED provided above average opportunities for direct observation and 91.5% were confident of incorporating WBAs into their practice. 44.7% reported that CBD will not impact patient care; 17.0% perceived it may have a negative impact. 55.3% felt that CBD will lead to improved feedback for trainees. The top areas for faculty development were: feedback delivery, completing WBAs, resident promotion decisions, and receiving feedback on teaching. Only 25.5% were interested in learning about CBD, although the average of correct responses on the CBD knowledge test was 44.6%. Conclusion: EM is well-situated to transition to CBD given clinicians’ positive attitudes towards feedback, direct observation, WBAs, and opportunities for direct observation. Threats to CBD implementation are concerns about effects on patient care and trainee education, and skepticism regarding effects on feedback quality. Faculty development should concentrate on further developing clinical teaching and supervision skills, focusing on feedback and WBAs.

Introduction: Today's emergency department sees healthcare system pressures manifest through longer wait times, increased costs, and provider burnout. In the face of questionable sustainability, there is a greater role for training future innovators and entrepreneurs in healthcare. However, there is currently little formal education or mentorship in these areas. The aim of this scoping review was to identify the current and ideal educational practices to foster innovative and entrepreneurial mindsets, with specific interest amongst emergency medicine trainees. Methods: Using a scoping review methodology, the relationship between healthcare and entrepreneurship was explored. OVID, PubMed and Google Scholar were searched using the keywords “entrepreneurship”, “health education” and “health personnel”, on March 8th, 2018. Results were screened by title, abstract and full text by a team of three calibrated researchers, based upon pre-defined exclusion and inclusion criteria. The final list of papers was reviewed using an extraction tool to identify demographics, details of the paper, and its attitudes and perceptions towards entrepreneurship and innovation. Results: After screening, 59 papers were identified for qualitative analysis. These papers ranged from 1970-2018, mainly from the USA (n = 36). Most papers were commentaries/opinions (n = 35); 11 papers described specific innovations. Entrepreneurship was viewed positively in 45 papers, negatively in 2 papers, and mixed in 12 papers. Common specialties discussed were surgery (n = 9), internal medicine (n = 3), and not specified (n = 44). Emergency medicine was described in one paper. Major themes were: entrepreneurial environment (n = 29), funding and capital (n = 12), idea generation (n = 9), and teaching entrepreneurship (n = 6). Of the 11 innovation papers, the discussion was focused on educational (n = 6) or system (n = 5) innovations. These innovations related to surgery (n = 1), public health (n = 1) and palliative care (n = 1). None of these innovations were specific to emergency medicine. Conclusion: This review indicates a small number of programs focused on promoting innovation and entrepreneurship amongst trainees, but no programs specific to the emergency department. There may be benefit for educators in emergency medicine to consider how to foster a greater innovative spirit in our speciality, so our next generation of physicians can help tackle problems affecting patient care.

Introduction: Emergency department (ED) return visits are used for quality monitoring. Health information technology (HIT) has historically supported return visit programs in the same hospital or hospital system. The Emergency Department Return Visit Quality Program (EDRVQP) is a novel population level continuous quality improvement (QI) program connecting EDs across Ontario that leverages HIT. We sought to describe the EDRVQP HIT architecture, experience of participants, enabling program factors and barriers. Methods: The Informatics Stack conceptual framework was used to describe the HIT architecture. A literature review of peer-reviewed background literature, and stakeholder organization reports was conducted. Purposive sampling identified key informants. Semi-structured interviews were conducted until saturation. Common themes were identified by inductive qualitative thematic analysis. Results: Twenty-three participants from 15 organizations were interviewed. The EDRVQP architecture description is presented across the Informatics Stack. The levels from most comprehensive to most basic are world, organization, perspectives/roles, goals/functions, workflow/behaviour/adoption, information systems, modules, data/information/knowledge/algorithms, and technology. Enabling factors were a high rate of EHR adoption, provincial legislative mandate for data collection and program membership, use of functional and data standards, local variability, phased deployment, and QI and patient safety culture. Two main barriers were increased case turnaround time and privacy legislation. Conclusion: The Informatics Stack framework provides a robust approach to thoroughly describe the HIT architecture of this population health programs. The EDRVQP is a population health program that illustrates the pragmatic use of continuous QI methodology across a population (provincial) level.

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a new and poorly understood phenomenon with a subset of patients presenting to emergency departments (ED) for symptomatic control of their refractory nausea and vomiting. Curently, there is a lack of agreement and considerable practice variability on initial treatment modalities for CHS. The objective of this study was to describe the treatment modalities for patients presenting to ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census: 150,000) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations, and utilization of treatment options within the ED. Descriptive statistics are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Sixty-nine (33.4%) received any treatment during their visit with 28 (40.6%) receiving IV fluids, of which 24 (85.7%) received normal saline. Anti-emetics were used in 21 (30.4%) patients with ondansetron being the first-line agent in 11 (52.4%) patients followed by dimenhydrinate in 6 (28.6%) and haloperidol in 2 (9.5%) cases. Six patients required two doses of anti-emetics, favouring ondansetron in 3 cases followed by haloperidol, dimenhydrinate, and metoclopramide each used once. Thirteen (19%) patients required analgesia, with the first-line preference being non-opioid medications in 11 versus opioids in 2 cases. Seven patients required multiple modes of analgesia, favouring opioid medications in 4 patients. Twenty-eight (40.6%) patients required anxiolytics with lorazepam being used primarily in 16 (57.1%) patients followed by lorazepam/haloperidol in 5 (17.9%) cases. Conclusion: This ED-based study demonstrates variability of practice patterns for symptomatic treatment of cannabis related ED presentations. Despite knowledge of haloperidol being useful in patients with suspected CHS, physicians opted for ondansetron as first line anti-emetics. Future research should focus on studying various treatment modalities of patients with suspected CHS in the ED to optimize symptomatic treatment.

Introduction: When presenting to the Emergency Department (ED), the care of elderly patients residing in Long Term Care (LTC) can be complicated by threats to patient safety created by ineffective transitions of care. Though standardized inpatient handover tools exist, there has yet to be a universal tool adopted for transfers to the ED. In this study, we surveyed relevant stakeholders and identified what information is essential in the transitions of care for this vulnerable population. Methods: We performed a descriptive, cross sectional electronic survey that was distributed to physicians and nurses in ED and LTC settings, paramedics, and patient advocates in two Canadian cities. The survey was kept open for a one month period with weekly formal reminders sent. Questions were generated after performing a literature review which sought to assess the current landscape of transitional care in this population. These were either multiple choice or free text entry questions aimed at identifying what information is essential in transitional periods. Results: A total of 191 health care providers (HCP) and 22 patient advocates (PA) responded to the survey. Within the HCPs, 38% were paramedics, 38% worked in the ED, and 24% were in LTC. In this group, only 41% of respondents were aware of existing handover protocols. Of the proposed informational items in transitional care, 100% of the respondents within both groups indicated that items including reason for transfer and advanced care directives were essential. Other areas identified as necessary were past medical history and baseline functional status. Furthermore, the majority of PAs identified that items such as primary language, bowel and bladder incontinence and spiritual beliefs should be included. Conclusion: This survey demonstrated that there is a need for an improved handover culture to be established when caring for LTC patients in the ED. Education needs to be provided surrounding existing protocols to ensure that health care providers are aware of their existence. Furthermore, we identified what information is essential to transitional care of these patients according to HCPs and PAs. These findings will be used to generate a simple, one page handover form. The next iteration of this project will pilot this handover form in an attempt to create safer transitions to the ED in this at-risk population.

Introduction: Prior Canadian Emergency Department (ED) studies have demonstrated variable benefits of initial assessment physician (IAP) to rapidly assess and initiate care of ED patients after triage. These studies have been conducted primarily in academic teaching and large urban hospitals. It is not clear if such an IAP role could be beneficial in an small community hospital. Our pilot study hypothesized that instituting a supported IAP role can reduce physician intial assessment (PIA) time, total ED length of stay (LOS), and left-without-being-seen (LWBS) rates. Methods: This was a pre and post interrupted time series observational study at a community ED in Niagara Health Systems (Welland Ontario, 4 MD shifts, 36hrs total coverage, 30000 annual visits). In July 2017, an IAP ED shift (with separate assessment/treatment area) was re-purposed, with nursing support, to reduce initial time to MD assessment after triage. For lower acuity cases, the IAP MD generally completed full case management & disposition. Higher acuity complex cases were initiated by IAP, and transferred into the main ED care areas for “inside” MD management. Administrative data was accessed for 6 months prior to intervention, and 4 months available post-intervention. Descriptive statistics were calculated for collected data. Results: A modest improvement in different administrative ED performance metrics was observed. The following changes were noted pre and post IAP intervention: PIA time reduced from 3.6hrs to 3.2hrs, total ED LOS reduced from 19.2hrs to 13.8hrs, and daily LWBS rate reduced from 4.2% to 3.7%. This pilot study demonstrated improvement trends in ED performance metrics, although there is insufficient data to show statistical significance. Aggregate data was not subgrouped based on CTAS categories. This pilot was not intended to collect patient or staff satisfaction data, adverse events, nor designed to demonstrate cost-effectiveness Conclusion: Introducing an IAP shift in a small community ED has shown improvement trends for various ED throughput measures pertaining to outcomes such as PIA time, total LOS and LWBS rates. Further research is required to determine statistical significance of time reductions, satisfaction (patients, staff), resource utilization impact and CTAS subgroup performance. This improvement demonstrates potential impact system-wide across Niagara region.

Introduction: Email and text messaging holds the potential to not only contact patients after emergency department (ED) care for clinically important communications such as appointment reminders, but also to solicit feedback for quality improvement and/or participation in research. A necessary first step though is the collection of electronic contact information, but little is known about current practice in Ontario EDs. In this study, we sought to characterize current collection, consent and use of patient email and texting to communicate with ED patients at academic and community hospitals across Ontario. Methods: We developed a questionnaire, with a blend of multiple choice and open-ended questions, targeted at ED registration administrators. The questions focused on if and how EDs collect, store and consent for patient emails, how and what they utilize those emails for and if they text patients. The questionnaire was administered both online and by phone. Participants were recruited through snowball sampling, including facilitated dissemination of the questionnaire via an existing listserv of the Patient Registration Network of Ontario (PRNO). Results: Twenty-two respondents (41% response rate) completed the questionnaire. Seven of the 22 institutions were academic health centres (32%). Nine institutions (41%) collected patient email addresses in the ED and none collected or used text message technology. In all 9, registration staff were tasked with asking, consenting, collecting and storing patient details within their hospital admissions, discharge and transfer system (ADT). For sites with email address collection, respondents estimated 40-60% of ED patients shared an email address. Seven of 9 institutions had a verbal consent process, while 2 used implied consent. Only 2 institutions used email to send patients post-discharge feedback questionnaires and four used email to facilitate access to patient portals. Four institutions were looking at using text messages to direct patients at triage, sometime in the future. Conclusion: Engagement in optimized care and feedback requires communication which is quickly shifting to electronic format. Collection of electronic contact information continues to be slow and uneven in Ontario. There is an immediate need for clearer guidance to accelerate collection, storage, consent and use of email and text messaging technology.

Introduction: Trampoline injuries are frequent complaints of children presenting to paediatric emergency departments (PED) in Canada. The medical community has recognized the danger of recreational trampoline use, with the Canadian Paediatric Society (CPS) formally recommending against their use. A new type of trampoline recreation has recently emerged in the form of trampoline parks. Trampoline parks are dangerous, with similar rates of injury as backyard trampolines, and an increased likelihood of injuries warranting hospital admission. No current Canadian governmental or industry regulations exist for trampoline parks. This study aimed to determine the public perspective of trampoline park safety in order to provide a basis for addressing the current lack of safety recommendations around trampoline parks. Methods: Parents/caregivers of children seeking care in the PED were approached to participate in a survey regarding trampoline safety. Parents/caregivers of patients with severe injury/illness were excluded. Survey questions included demographics, safety perceptions of both home trampolines and trampoline parks, as well as awareness of the CPS statement regarding trampoline use. The survey was completed in the Research Electronic Data Capture System. Results: To date, 68 participants have completed the survey. 66% of participants (45/68) were aware of the new trampoline parks recently opening in the community. 31/68 (46%) of participants had allowed their child to visit a trampoline park. A comparison of the perception of the relative safety of trampoline parks found that 31% of participants (21/67) considered home trampolines “safe/very safe” while 39% of participants (26/66) considered trampoline parks “safe/very safe.” The median [IQR] age at which participants thought children could safely play at trampoline parks was 10 [3-15]. 43% of participants (29/67) thought the current CPS statement about backyard trampolines should apply to trampoline parks, and 93% of participants (62/67) thought the Ontario government should institute mandatory standards for trampoline parks. Conclusion: Trampoline parks are a significant emerging source of paediatric injury. Trends in preliminary data suggest that participants consider trampoline parks to be safer than backyard trampolines, and perceive that young children can safely participate in trampoline park activities. Should final survey data analysis support these trends, a call for adjustment of CPS guidelines and public policy should proceed.

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The objective of this study was to explore the lived experiences and perceptions of care of women treated for early pregnancy complications in the ED and early pregnancy clinic (EPC). Methods: We conducted an interpretive phenomenological qualitative study of women who presented to the ED or EPC of an urban tertiary care hospital with early pregnancy loss or threatened loss. We employed purposive sampling to recruit participants for in-depth, one-on-one telephone interviews conducted approximately 6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Our research team of two qualitative researchers, a clinician, a clinical researcher, and a research student performed a phenomenologically-informed thematic analysis including three phases of coding to identify essential patterns of lived experience and meaning across the sample. Results: Interviews were completed with 30 women between July and August 2018. Participants ranged in age from 22 to 45 years and reflected the diversity of the multicultural city where the study occurred. Four key themes of patient experience were identified: tensions between what is known and unknown by women and ED staff about early pregnancy complications and care in hospital, stigmatization of early pregnancy complications and ED use, normalization of a chaotic experience, and the overwhelm of unexpected outcomes during the ED visit. Conclusion: The perspectives of women attending the ED or EPC for early pregnancy complications highlights the ways in which the current health care system minimizes and medicalizes early pregnancy complications in this setting and fails to adequately support these women. The emotional complexity of this medical situation is often overlooked by ED staff and can produce encounters that are traumatic for patients and families. However, the participants’ negative experiences occurring in the ED were often mitigated with their care in their follow-up with the EPC.

Introduction: The harm that may come to healthcare providers impacted by adverse events has led them to be called “second victims.” Our objective was to characterize the range and context of interventions used to support second victims in acute care settings. Methods: We performed a scoping study using the process described by Arksey and O'Malley. Comprehensive searches of scientific databases and grey literature were conducted in September 2017 and updated in November 2018. A library scientist searched PubMed, CINAHL, EMBASE and CENTRAL. We sought unpublished literature (Canadian Electronic Library, Proquest and Scopus) and searched reference lists of included studies. Stakeholder organizations and authors of included studies were contacted through email, requesting information on relevant programs. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data and appraised methodological quality with the Mixed Methods Appraisal Tool (MMAT). All discrepancies were resolved through consensus. A qualitative approach was used to categorize the context and characteristics of the identified strategies and interventions. Results: Our search strategy yielded 3883 results. After screening titles and abstracts, 173 studies underwent full text screening. Extracted data reflected 21 interventions categorized as providing peer-support (n = 7), proactive education (n = 7) or both (n = 7). Programs came from Canada (n = 2), Spain (n = 2), and United States (n = 17). Specific traumatic events were described as the trigger for development of five programs. While some programs were confined to a standard definition of second victim as a healthcare provider traumatized by an “unanticipated adverse patient event” (n = 6), other programs had a broader scope (n = 12) including situations such as non-accidental trauma, stressful anticipated patient events and complaints/litigation (3 programs were unclear about the definition). Confidentiality was assured in nine peer support programs. Outcome measures were often not reported and were limited in terms of quality. Conclusion: This is a new area of study with little scientific rigour from which to determine whether these programs are effective. Concerns about protecting healthcare providers from potential legal proceedings hinder documentation and study of program effectiveness.

Innovation Concept: Mass Casualty Incidents (MCI) are complex events that most paramedics encounter only a few times in their careers. Triaging and managing multiple patients during an incident requires different skills than typically practiced by prehospital providers. Simulation and drills can provide an opportunity to practice those skills, but are costly and resource intensive while only allowing a few providers to be in a triage or leadership role. It is important to find engaging and less expensive methods for teaching MCI triage and initial scene management. Methods: The authors have developed and are testing a card game based on the previously published GridlockED board game. The game was developed utilizing an iterative process previously described. This game was tested with paramedics as well as other emergency medicine learners to determine usability, engagement, fidelity, as well as usefulness in teaching MCI triage and patient-flow concepts. Curriculum, Tool or Material: The card game provides a focused learning experience to allow providers to practice initial triage of multiple injured patients as well as manage patient flow from the scene to area hospitals when faced with limited prehospital resources and capabilities. Players work together in various simulated scenarios to correctly triage injured patients and send them to the correct healthcare facility. Conclusion: Serious gaming has gained momentum in medical education. Developing novel curriculae around low frequency, high stakes situations using a game like TriagED may hold the key to ensure prehospital care providers are trained for these incidents. In the future, games which integrate an element of Incident Command or receiving hosptials (e.g. full integration with GridlockED game) may help to further explore the relationship between scene management and patient flow within receiving hospitals.

Background: There is growing concern about emergency physicians overuse of computed tomography (CT). In an attempt to ensure appropriate ordering many hospitals implement strict protocols for ordering of CT scans in the emergency department (ED) that include approval of all scans by a board-certified radiologist, and a reduced access to CT overnight. Aim Statement: The aim of this study is to review the impact of RAD ED – direct access to CT ordering by ED physicians, 24hr CT technologist and third-party reporting on CT scans overnight. Our objectives were to assess the effect on; 1) ED length of stay, 2) number of CT scans ordered and 3) admission rates. Measures & Design: We conducted a prospective pilot before & after study at a single tertiary-care emergency department between February 1st, 2018 and July 31st, 2018. Inclusion criteria were adult patients presenting to the emergency department and undergoing CT for any of the following: face, neck, spine, upper and lower extremities, chest, abdomen and pelvis. Exclusion criteria were those undergoing CT head for stroke or trauma. Evaluation/Results: A total of 924 patients met our criteria, 352 before and 568 after implementation. Comparison of the patient populations demonstrate very similar characteristics in both groups; (49% male, average age 56 years, CTAS 2(40%) and 3(47%). Results demonstrate that an additional 216 scans were performed in post-implementation group. This equates to an increase of 61%. ED length of stay averaged 5.6 hours pre-implementation and 4.7 hours post-implementation. This corresponds to a significant reduction in length of stay of approximately 0.9 hours (p < 0.01). Collection is currently ongoing for factors that we will adjust for a multivariate analysis, including admission rates. Discussion/Impact: RAD ED led to a significant increase in CT ordering and decrease in ED length of stay. We believe that this project provides important information to clinicians and patients with regards to overall CT utilization, ED wait times, follow up visits for CT scanning and admission rates. It is also important for administrators to help decide if these new rules are leading to improved efficiency, and to help estimate their financial impact.

Introduction: Emergency department (ED) crowding and increased patient load has been shown to have an impact on physician decision making and patient mortality. As the volumes in Canadian EDs increase, so does the need to effectively prepare new learners for the challenges ahead. This study aims to determine which level of training varying teaching techniques should be employed to educate Emergency Medicine (EM) residents about ED management and flow in the age of competency based medical education. Methods: We designed a survey that contained a previously derived list of ED flow and management teaching strategies. We piloted and edited the survey based on feedback from operations and educational experts. A total of 21 teaching techniques were included in the final survey ranging from didactic teaching sessions to experiential techniques such as residents running the department with supervision. Then, we invited members of the Royal College of Physicians and Surgeons of Canada EM specialty committee, the Canadian Association of Emergency Physicians Education Scholarship Section, and the Canadian EM Simulation Educators Collaborative to participate in our survey. We analysed the results using simple descriptive statistics. Results: A total of 21 EM (38% female, 62% male) educators from 11 programs (78% of Royal College Training sites) responded to the survey, representing 7/10 provinces, with a mean years-in-practice of 15.2 years (SD 9.7). All respondents were involved in resident education; 66% had a current formal educational role, such as Program Director. Results showed a universal trend towards teaching flow and management skills later in residency. Participants endorsed 35.93% of teaching strategies for the “Core of discipline” and 39.65% for the “Transition to practice” stages of training. Didactic and observational techniques were occasionally considered acceptable at earlier training stages, whereas experiential teaching techniques were skewed towards the later stages of residency. Conclusion: EM educators from across Canada believe that most teaching techniques for flow are better suited for the later stages of residency training, with didactic techniques more suitable earlier on. This work will inform faculty development on managerial/leadership skills teaching in the ED.

Introduction: The opioid crisis persists, and in the context of this urgency and new practice guidelines, the practice of buprenorphine (BUP) prescription is expanding across Canadian emergency departments (EDs). The objective of this study was to identify current knowledge, attitudes and behaviours to managing opioid use disorder (OUD) in the ED, including barriers and facilitators to prescribing BUP. Methods: Forty ED staff physicians were randomly invited to participate from an urban Toronto ED which recently received continuing medical education in addictions, and whose hospital established an addictions follow-up clinic. Individual semi-structured interviews with the 19 physicians who self-selected to participate were grounded in phenomenology, allowing for in-depth accounts of participants’ lived experience and viewpoints on their role in addressing OUD. Thematic analysis was achieved through multiple readings; themes were coded using Dedoose software by two researchers. Themes were further organized as facilitators, barriers, and proposed solutions. Results: Opioid withdrawal management in the ED varied significantly between these practitioners in the same practice group. Facilitators to treating withdrawal and initiating BUP in the ED were rooted in three contributors to physician empowerment: knowledge about OUD and BUP, positive patient and provider experience with substitution therapy in the past, and exposure to physician champions to guide their practice. Systems-level facilitators included timely access to follow-up care and an available order set. Barriers included provider inexperience: missing subtle presentations of withdrawal, lacking feedback on treatment effectiveness, and reported uncertainty about the protocol from nursing staff. The ED environment also limits time to counsel effectively and discourages taking up a bed both to wait for withdrawal onset and for BUP induction. Other barriers were concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion: This is the first study describing barriers and facilitators to addressing OUD and prescribing BUP in the ED. These findings suggest a role for home induction, involvement of allied health professionals in BUP counseling, and heightened continuing medical education. Results will inform departmental efforts across Canada to implement BUP prescribing as standard of care for patients in opioid withdrawal.