Introduction / Innovation Concept: Skillful performance is central to the provision of quality healthcare. Well-organized, deliberate practice with instruction and feedback leads to the best learning and patient outcomes. Professionals in rural/remote locations often face significant challenges in maintaining procedural proficiency and delivering acute care medical services. This is especially important with low-frequency high-stakes procedures. Simulation can play an important role in skills maintenance but limited access to simulation labs and resources in rural areas due to time, cost and distance are often prohibitive. Mobile telesimulation has the potential to facilitate high-quality instruction and overcome these barriers. Our goal is to develop a mobile simulation unit (MSU) that uses acute-care telemedicine mentoring techniques to meet the needs of rural physicians. Methods: The MSU design process is a prototype development series with qualitative results from each prototype (A and B) informing design and development of the next. This serves as an assessment of the functionality and set-up of the MSU for housing the simulation equipment/mannequin and providing an acceptable learning environment. The final design (C) will be evaluated for educational effectiveness. Medical students will be taught endotracheal intubation on a mannequin in the MSU under one of 2 conditions. The experimental group will receive instruction, demonstration and feedback from an expert in the telesimulation lab at Memorial University. The control group will receive the same instructions and feedback face-to-face from an expert located in the MSU. Participants will complete a retention test 1 week after the intervention. Performance between the 2 groups will be compared and user satisfaction will be assessed. Curriculum, Tool, or Material: The MSU will be a portable, inflatable structure equipped with telecommunication equipment to provide efficient interaction between the rural/remote learner and their instructor at a different site. The design and components of the MSU will facilitate easy transport and deployment for telesimulation in rural/remote areas. A combination of fixed and wearable cameras will facilitate instruction, demonstration and feedback to the learner. Conclusion: Mobile telesimulation may play an important role in overcoming the barriers of geography, cost and access to expert instruction. Implications of this research are far reaching and extend beyond healthcare education and training.

Introduction / Innovation Concept: Simulation-based medical education (SBME) has seen increased application in medical education. Emergency medicine (EM) trainees must develop a diverse skill set to smoothly transition to clinical practice and ensure optimal patient outcomes. The competency-based medical education (CBME) framework helps ensure residents develop the required expertise relevant to each of the CanMEDs roles. Simulation is a valuable supplement to hands-on clinical experience and allows skill development in a low-risk setting. The EM Simulation book serves to facilitate the effective application of simulation in our curriculum. Methods: A number of resources were compiled to meet the needs of our simulation program within Memorial University of Newfoundland. Personal knowledge/experience of the author and local contacts provide site relevant content. Prior training helped in review and selection of materials on simulation theory and debriefing. Core EM resources were sourced for information on procedural training. Literature review on simulation was used to compile a list of resources and materials for further reading. The development and revision of the manual continues as an iterative process with sequential edits based on review and feedback. Qualitative evaluation of the design and value of this document is planned to get feedback from key stakeholders including learners, faculty and simulation lab staff. Curriculum, Tool, or Material: The final product is a 94-page document provided in print and electronic format to the EM residents and several faculty involved in simulation. It introduces residents to our simulation program, provides relevant background information and orients them to this modality of curriculum delivery. Theory and rationale behind SBME is included. Information on the key role of debriefing is highlighted. Several core EM procedural topics are covered with tips on practice station set up. Additional learning resources are noted, including information on case development for potential teachers. Conclusion: The simulation book brings together key information to optimize the simulation-based medical education experience for EM residents at Memorial University.

Introduction: Travel-based continuing medical education (CME) has become a popular format for physicians looking to combine education with travel. However these programs do not usually include shared group activities and when they do, they are often social, sedentary events. Emergency Medicine Update (EMU) Europe is a unique biennial accredited CME program which combines high quality Emergency Medicine focused education with organized group physical and social activities in European locales. Methods: We undertook a participant observation-based ethnographic study of the EMU Europe program in Provence, France in 2015. Participant interviews and in-depth observation methods were used to understand (1) the impact of shared group activities on learning and (2) the ethos that is created during this type of program. Results: We describe three phenomena from the data that we feel are highly influential in the success of the program and impact on learning. The first is “social engagement and a sense of community”. Involvement in group physical and social activities supports more interactive learning and people affiliate with this as a group that they enjoy and feel good learning with. The second is “a stimulating escape”. This is the opportunity for high quality education and stimulating travel to be provided in an efficient package. The third is “the ‘flat’ faculty-learner relationships”. This is created through accessibility and innovative teaching and is a key component of the quality of the education. Conclusion: While each trip in and of itself might be unique, there appears to be some common elements - building a sense of community, providing a stimulating escape and choosing faculty with specific teaching styles - that contribute to the educational success of this model. We will discuss how this relates to medical education theory and how it is generalizable to other groups considering this type of program. To our knowledge this is the first empirical research in this area and improves our understanding of how to leverage this approach for more effective continuing medical education.

Introduction: Procedural sedation and analgesia (PSA) is a common practice for non-anaesthesiologists. While complication rates for PSA are low, many of them are preventable. Professional regulatory body requirements state that practitioners should have adequate knowledge and skills to safely administer PSA. However, no certification process currently exists to develop and maintain these competencies. A standardized PSA training course would help close the gap between the best evidence for safe administration of PSA and its implementation in everyday practice. Therefore, we conducted a needs assessment to guide the development of such a PSA training course. Methods: Using modified Dillman methodology, an electronic survey was sent to a convenience sample of 50 potential learners and two groups of stakeholders: 20 hospital administrators and 35 experts in PSA. Questions assessed practice demographics, experience as well as support and interest in the development and attendance of a PSA training course. Prior to distribution, the questionnaire was peer reviewed and pilot-tested for feasibility and comprehension. Responses were stratified based on clinical role. Results: 35 potential learners completed the needs assessment (70% response rate): 15 emergency physicians, 19 registered nurses and 1 nurse practitioner. 48% have been in practice for over 10 years and over 90% participate in PSA at least weekly. 38% received informal training in PSA while 16% obtained no training at all. 86% strongly supported the development of a PSA certification course and were in favour of an inter-professional format. 13 experts responded to the questionnaire within the departments of anesthesia, emergency medicine (EM) and respiratory therapy (37% response rate). 80% supported the need for a PSA training course. 6 hospital administrators responded to the questionnaire within the departments of anesthesia, EM, gastroenterology and respirology (30% response rate). All agreed that standardization of PSA is an important part of patient safety and 80% stated certification in PSA should be a prerequisite for granting privileges to health care professionals to participate in PSA. 60% believed the course should be developed and supported by hospital funds. Conclusion: There is strong support from potential learners and stakeholders for the development of a formal PSA training course.

Introduction / Innovation Concept: Adverse events due to medical error are a significant source of preventable morbidity and mortality in Canada’s emergency departments. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was introduced in 2006 as a strategy to minimize these errors. Although these strategies have been available and widely implemented in hospitals over the last decade, the optimal method of teaching these tools and strategies has not been elucidated. Methods: We endeavoured to introduce a twelve month longitudinal TeamSTEPPS program to physicians, nurses, and allied health care professionals in a busy tertiary care hospital via a multi-pronged approach consisting of group huddles, props in the department, and several social media strategies. Dedicated observers in the emergency department recorded the use of the strategies by staff members to identify improved and sustained use of TeamSTEPPS behaviours after they were introduced. Curriculum, Tool, or Material: The program that consists of five modules to improve patient safety outcomes: Team structure; Leadership; Situation Monitoring; Mutual support; and Communication. Each module consisted of educational tools including posters in the department explaining the concepts, twice weekly department huddles to discuss the importance of the monthly topic and promote team sharing with real life examples, as well as stimulating and generating discussions around the monthly theme on social media (Facebook, Twitter, and an on-line blog). For several modules, extra prompts, such as I PASS the BATON handover cards were also provided to act as reminder visual cues. The first two modules were rolled out with on-line music videos rewritten to promote the significance of the modules. A team performance observation tool was adopted from the TeamSTEPPS program, and behaviors were evaluated and recorded under the five domains. Conclusion: Although unable to detect a meaningful difference in our pre and post-implementation observations, we present a novel approach to educating a multi-disciplinary team about TeamSTEPPS in a busy emergency department, along with the challenges encountered in this unique area of research, and recommendations for further study to interested parties. The TeamSTEPPS program likely could offer as much to the emergency department as similar programs have to the aviation industry yet it requires extensive investigation within this health care venue.

Introduction: Practicing emergency medicine (EM) involves rapid decision-making in an acute setting, broad knowledge and a strong ability to multi-task. Some medical students find these characteristics attractive, while others find them a deterrent. Previous studies have indicated the range of characteristics that interest undergraduate students. No studies have followed students to assess how attitudes towards EM careers evolve over their schooling. Methods: An open-ended survey of medical students’ career interests was distributed at five data-collection points over the four years of undergraduate training from 1999-2006 at Memorial University. Guided by principles of grounded theory the qualitative data was coded to identify key themes and sentinel quotes. Semi-structured interviews with academic emergency physicians at Dalhousie University were then conducted to assess the relevance of these findings to postgraduate training (in progress). These transcripts were analyzed in the same manner as the longitudinal surveys. Results: 1281 surveys were completed by 540 students, with 758 comments about EM. The biggest drawbacks of EM included lack of patient follow-up and lack of experience in EM; the biggest benefits included variety of cases and patients, congruence with previous life experiences, and elective experiences. One major theme was the Certificant of the College of Family Physicians (CCFP) EM training, as it meant a shorter residency that was more transferrable to rural settings. Lifestyle was a prominent theme, seen as positive by some and negative by others. Emergency physicians commented on students’ naivety, especially relating to media and the nature of the work early in their training. Conclusion: Medical students’ opinions of EM tend to shift throughout their schooling, in particular, the perception of the work. Medical students’ perceptions differ significantly from that of experienced emergency physicians, highlighting the need for a greater degree of mentoring. Perceptions of lifestyle in EM are highly variable amongst students, acting as both a benefit and a drawback. Medical schools may be able to improve clinical exposure and provide more informed career counselling with respect to emergency medicine. Residency program directors can consider these findings during recruitment and interviewing to determine whether students have a realistic view of the specialty and career trajectory.

Introduction: Trauma is the leading cause of death among people under 40. With more than 7 million Canadians living over one hour’s travel from a level 1 or 2 trauma center, access to quality trauma care in Canada is a major concern. We recently reported that more than 40% of rural EDs across Canada were more than 300 km from levels 1 and 2 trauma centers. Direct transportation to trauma centers is therefore unusual and most trauma cases are initially managed in rural EDs. Assistance from trauma centers via telemedicine could thus be valuable in optimizing initial stabilization and inter-facility transfers. Objective: Is telemedicine a potentially effective intervention for improving rural trauma care? Methods: We conducted a literature review to examine the potential impact (number of transfers, transfer times, length of hospital stays and mortality) of telemedicine on rural trauma care. Two reviewers independently searched PubMed, Embase and Cochrane databases with key words / concept combinations: telemedicine, trauma and rural. Articles included in the final review had to address the question with specific methodologies. After duplicate removal, 312 articles were found relevant. After independent review of titles and abstracts, only 25 articles pertained to the specific question. Only three studies met inclusion criteria. Results: These studies reported 187 successful teleconsultations in the context of rural trauma care, 29 of which involved significant interventions (8 interventions potentially lifesaving). Some unnecessary inter-facility transfers were avoided. However, transfer times to trauma centers and length of hospital stays appeared slightly longer with telemedicine. Conclusion: The literature on the efficacy of telemedicine in trauma care is scarce, with only three studies addressing the question. Conclusions generally favor telemedicine, but additional research must should determine its impact and better understand the barriers/facilitators to the implementation of telemedicine for rural trauma care.

Introduction: Emergency medicine (EM) is characterized by one time patient encounters where the end diagnosis is often unknown. Seeking patient outcome feedback, (POF) which is defined as following a patient’s clinical course once they leave your care, is crucial as it can highlight a discord between an intended verses actual result, thus spurring clinical change. This study seeks to determine whether EM staff and residents currently seek POF, the types of patients followed and the barriers faced. Methods: An online survey was administered to all EM staff and residents (CCFP-EM and FRCP) working at a tertiary academic hospital to determine their current practices and attitudes towards POF. Results: A total of 72 responses were received, of which 41 were residents and 31 were staff, for an overall response rate of 95%. If feedback was sought, the most commonly used tools were looking up imaging results (52%) and talking to EM colleagues (42%). The patients most frequently followed were those with a poor outcome during their ED admission, sick patients with unclear final diagnosis or unplanned returns within 48 hours (55%, 58%, 34% respectively). However, up to 30% of respondents never or rarely sought out POF even in these situations (16%, 19% and 30% respectively). Patients least commonly followed were those where the diagnosis was more certain. Respondents identified many barriers, primarily being time (83%), not being notified about bouncebacks (79%) and remembering which patients to follow (70%). Barriers were amplified for residents as they had a harder time accessing or automatically receiving POF. The most useful tools not currently available, would be being able to easily create electronic tracking lists, being automatically sent discrepant imaging reports and automatic notification of patients who return to the ED within 48hrs. Also, automatic follow up information on patients who experienced a negative outcome or on sick patients with unclear diagnosis is desired. Conclusion: POF is a useful and crucial practice for clinical care, but is currently not often performed. The most commonly used tools are those that are easiest to access, and POF was mainly performed on patients with either negative results or unclear diagnoses. Thus, identifying the types of patients deemed most relevant for receiving POF and addressing the major barriers faced by clinicians can help improve the frequency with which POF is sought, potentially improving patient care.

Introduction: Substance use and unstable housing are associated with heavy use of the Emergency Department (ED). This study examined the impact of substance use and unstable housing on the probability of future ED use. Methods: Case-control study of patients presenting to an urban ED. Patients were eligible if they were unstably housed for the past 30 days, and/or if their chief complaint was related to substance use. Following written informed consent, patients completed a baseline survey and health care use was tracked via electronic medical records for the next six months. Controls were enrolled in a 1:4 ratio. More than 2 ED visits during the follow-up was pre-specified as a measure of excess ED use. Descriptive analyses included proportions and medians with interquartile ranges (IQR). Binomial logistic regression models were used to estimate the impact of housing status, high-risk alcohol use (AUDIT) and drug use (DUDIT), and combinations of these factors on subsequent acute care system contacts (ED visits + admissions). We controlled for age, gender, comorbidities at baseline, and baseline presenting acuity. Results: 41 controls, 46 substance using, 91 unstably housed, and 31 both unstably housed and substance using patients were enrolled (n = 209). Median ED visits during follow up were 0 (IQR: 0-1.0) for controls, 1.0 (IQR: 0-3.3) for substance using, 1.0 (IQR: 0-4.0) for unstably housed and 4 (IQR: 2-12.3) for unstably housed and substance using patients. The median acute care system contacts over the same period was 1.0 (IQR 0-2.0) for controls, 1.0 (IQR: 0-4.0) for substance using, 1.0 (IQR: 0-5.0) for unstably housed and 4.5 (IQR: 2.8-14.3) for unstably housed and substance using patients. Being unstably housed was the factor most strongly associated with having > 2 ED visits (b=3.288, p<0.005) followed by high-risk alcohol and drug use (b=2.149, p<0.08); high risk alcohol use alone was not significantly associated with ED visits (b=1.939, p<0.1). The number of comorbidities present at baseline was a small but statistically significant additional risk factor (b=0.478, p<0.05). The model correctly predicted 70.1% of patients’ ED utilization status. Conclusion: Unstable housing is a substantial risk factor for ED use; high-risk alcohol and drug use, and comorbidities at baseline increased this risk. The intensity of excess ED use was greatest in patients who were unstably housed and substance using.

Introduction: The use of point of care ultrasound (POCUS) has increased rapidly in the emergency department (ED) over the last 10 years. This study seeks to determine whether the use of POCUS to identify intrauterine pregnancy in the ED shortens the length of stay of patients presenting with first trimester pregnancy-related complaints at The Scarborough Hospital (TSH). Methods: A prospective chart review of women seen at TSH ED for first trimester pregnancy-related complaints was conducted from March 1, 2014 to December 30, 2014. ED physicians were asked to record the names of patients assessed using POCUS in the ED along with their findings during the study period (experimental group). Health Records data was used to find all patients seen in the emergency department during the study period with the chief triage complaint of “Pregnancy Issues < 20 weeks” (control group). Results: A total of 378 patients were identified in the control group and 61 patients were recorded in the experimental group. The outliers were removed from both groups. The POCUS identified an intra-uterine pregnancy (POS IUP) in 47.5% and no definite intrauterine pregnancy (NDIUP) in 52.5%.In the control group, 82.0% proceeded to obtain a formal ultrasound (FUS) after the POCUS. Patients found to have a POS IUP on the POCUS spent 141.48±100.95 minutes in hospital, while patients found to have NDIUP spent 197.10±132.48 minutes in hospital (p=0.07). The POS IUP group spent statistically significantly less time in hospital when compared to the control group (p=0.001). In the POCUS group, patients seen between 1700 and 0800 (i.e. when FUS is not available) spent significantly less time (p=0.02) in hospital (113.13±118.07 minutes, n=24) when compared to patients seen between 0800 and 1700 (208.28±106.35 minutes, n=36). Conclusion: For first-trimester pregnancy-related complaints, POCUS has been shown to be effective in reducing the time that patients spend in hospital at TSH. This difference was especially apparent when POCUS was used at times when FUS was not available. Despite the apparent reluctance of many ED physicians to discharge patients without a FUS, even after identifying a POS IUP on the POCUS, it was evident that this technology was saving time for both physicians and patients.

Introduction: Emergency physician-initiated Extracorporeal Membrane Oxygenation (ECMO/ECPR/ECLS) is gaining critical mass as a successful rescue strategy for patients requiring resuscitation. Wang et al. (2014), Bellezzo et al. (2012) and others have demonstrated promising results of survival to discharge with good neurological function in patients who were resistant to existing treatment protocols after out-of-hospital cardiac arrest. As Saskatchewan does not yet utilize ECMO for cardiac arrest, the objective of this study was to examine the number of adult cardiac arrest patients in the urban emergency departments (EDs) of Saskatchewan who may benefit from the use of ECMO. Methods: Using a retrospective review, we identified 401 patients who died after presenting with cardiac arrest between January 1st, 2013 and December 31st, 2014. Of the original 401, 136 were female and 264 were male, with a mean age of 60.1±20.2 years. The charts of 22 (5.5%) trauma patients were excluded because the suitability of ECMO in these patients is uncertain. Results: For the 379 non-trauma patients, the mean resuscitation length was 41.6±32.8 minutes (median=42 minutes) and 125 of these patients received prehospital mechanical CPR. We applied Bellezzo et al.’s (2012) inclusion and exclusion criteria to identify prospective candidates for ECMO. In total, 53 patients (14.0%) with a mean age of 57.1±13.4 years old, represent suitable candidates for ECMO. 260 (68.6%) were deemed unsuitable either because they failed the inclusion criteria or met explicit exclusion criteria. The remainder (66 [17.4%]) were unsuitable because of age. Conclusion: With 1 in 7 patients potentially representing suitable candidates for ECMO, this is a technique that warrants consideration for implementation in the EDs of Saskatchewan.

Introduction: Despite the provision of evidence-based care, approximately 15% of patients discharged from the emergency department (ED) after being treated for asthma exacerbations will relapse within two weeks. This study summarizes the evidence regarding relapses and factors associated with increased relapse in patients discharged from EDs after being treated for asthma exacerbations. Methods: Comprehensive literature searches were conducted in seven electronic databases; manual and grey literature searches were performed. Studies tracking outcomes for adults after ED management and discharge were included. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Risk of Bias (RoB) tools. Studies were summarized using medians and interquartile ranges (IQR) or mean and standard deviation (±SD), as appropriate. Results: From 793 potentially relevant citations, 178 articles underwent full text review and 10 studies involving 32,923 patients were included. The majority of the studies were of high quality according to NOS and RoB tools. Relapse proportions were 8±3%, 12±4%, and 14±6% at one, two, and four weeks, respectively. Female sex was the most common statistically significant reported factor associated with an increased risk of relapse within 4 weeks of ED discharge for acute asthma. Other factors significantly associated with relapse were past healthcare utilization and symptom duration. Conclusion: After ED management and discharge of acute asthma, a considerable proportion of patients will relapse within the first four weeks. Factors such as female sex, past healthcare utilization, and symptom duration were commonly and significantly associated with relapse occurrence. Identifying patients with these features could provide guidance to clinicians during the ED-discharge decision-making.

Introduction: Diabetes mellitus (DM) is a major chronic disease. Prevalence of diabetes was 9% globally in 2014 and 9.3% in Canada and 7.2% in Alberta in 2015. Complications of the disease are numerous and frequent. Hypoglycemia is one complication of diabetes treatment. The objective of this study was to quantify and characterize presentations by adults to Alberta emergency departments (EDs) for hypoglycemia associated with type 1 (T1DM) or type 2 (T2DM) diabetes. Methods: A retrospective cohort study was conducted using data for Alberta for a five-year period (fiscal years 2010/11-2014/15). Data were sourced from an administrative database: National Ambulatory Care Reporting System (NACRS). Records of interest were those with an ICD-10-CA diagnosis of DM-associated hypoglycemia (i.e., E10.63, E11.63, E13.63, or E14.63). A descriptive analysis was conducted. Results: Data extraction yielded 7,835 presentations by 5,884 patients. The majority of presentations were by males (56.2%) and median patient age was 62. These episodes constituted 0.08% of presentations to Alberta EDs and they occurred at an event rate of 0.67 episodes per 100 patient-years (95% CI: 0.66-0.69). The annual rate of presentations decreased by 11.8% during the five-year period. Most presentations (63.4%) involved transportation to the ED via ambulance. Relative to LOS for ED presentations for all reasons, average length-of-stay (LOS) was 3.2x longer and 1.4x longer for discharged and admitted patients, respectively. For 27.5% of presentations, an X-ray was obtained. Most hypoglycemic episodes (65.2%) were considered to be of moderate severity while 34.3% were considered to be severe. None were mild because all involved access to an ED. The condition mainly (absolute terms) afflicted people with T2DM and urban areas; however, it disproportionately afflicted people with T1DM and rural areas. Conclusion: For a condition that is largely preventable with effective blood glucose management, DM-associated hypoglycemia incurs significant healthcare resource use. People with DM would be better served with more effective and safer euglycemic agents.

Introduction: Diabetes mellitus (DM) is a major chronic disease. Many patients with DM suffer hypoglycemic episodes that may be mild, moderate or severe, requiring ambulance and emergency department (ED) services. The cost of these DM-associated hypoglycemic episodes in the ED is not well understood. This study identified literature on DM-associated hypoglycemia costs that were incurred in acute care settings, with particular interest in the ED setting. Methods: The methods of this systematic review were based on an a priori protocol. The literature searches involved 12 databases. Study selection and quality assessment were conducted independently by two reviewers. Costs from included studies were standardized to year 2014 Canadian dollars. Mean with standard deviation (SD) and median costs with interquartile range (IQR) were calculated whenever possible. Results: The systematic search yielded 1,164 studies and 62 were included. The largest proportion of studies (45%) originated from USA data. Quality of included studies varied widely. Although none of the studies were purely a cost analysis of DM-associated hypoglycemia in the ED, 15 studies reported some ED costs. Median DM-associated hypoglycemic episode costs were $1,187.15 in the ED and $1,288.92 irrespective of setting. More severe episodes were more costly; costs were 8.5 times higher in the inpatient setting than in the ED. Episode costs were 18-45% higher for patients with Type 2 DM than Type 1. Direct costs comprised 80% of total costs. Conclusion: Acute episodes of DM-associated hypoglycemia are costly. These episodes also often require hospitalization; the highest costs are incurred by admitted patients with Type 2 DM. More studies are needed to better understand the costs associated with ED use by patients with DM-associated hypoglycemia.

Introduction: Diabetes mellitus (DM) is a common chronic disease. The Canadian Diabetes Association (CDA) estimated that the national direct cost of DM accounts for approximately 3.5% of public healthcare spending. The economic burden has been estimated to be $12.2 billion in 2010 and projected to increase by $4.7 billion (38%) by 2020. For the province of Alberta, the estimated cost was $1.3 billion in 2015 and $1.7 billion for 2025. The cost of lesser complications of DM like hypoglycemia is not as well understood. The objective of this study was to estimate the health system cost of presentations by adults to Alberta emergency departments (ED) for hypoglycemia associated with type 1 (T1DM) or type 2 (T2DM) diabetes. Methods: A retrospective cohort study was conducted using administrative data for Alberta for a five-year period (fiscal years 2010/11-2014/15). Data were sourced from an administrative database: National Ambulatory Care Reporting System (NACRS). Records of interest were those for ED patients with an ICD-10-CA diagnosis of DM-associated hypoglycemia. A top-down approach was used to estimate costs, excluding physician and ambulance fees. This involved resource intensity weight (RIW), cost of a standard hospital stay (CSHS), and adjustment for inflation (to average value of Canadian dollar for Alberta for January-September 2015). A descriptive analysis was conducted. Results: Data extraction yielded 7,835 presentations by 5,884 patients. The median RIW was 0.0547. RIWs are centered at 1, thus the resource-use/cost of these presentations is well below that of the “average” case. Estimated costs per episode ranged from $108.63 to $4,136.59 with median of $431.11 (IQR: 369.40-639.50). Median episodic subgrouped costs were as follows: sex: $427.72 for males, $439.20 for females; DM type: $411.61 for T1DM, $511.63 for T2DM; date period: $835,862.09/year, $69,655.17/month, $16,030.23/week, and $2,288.78/day. Conclusion: Using population-based administrative data, we identified median costs for DM-associated hypoglycemia of approximately $430/case. Given the frequency, this condition incurs significant healthcare resource use and costs; continued efforts to reduce these ED visits seem worthwhile.

Introduction: Educational interventions driven by the needs of users can help move evidence into practice. This study considered the perceptions of patients and knowledge users in the design of an educational intervention in acute asthma directed from Emergency Departments (EDs). Methods: A mixed methods design with two phases was used. In phase I, convenience samples of asthmatics presenting to the University of Alberta Hospital ED and primary care providers (PCPs) from Edmonton were invited to participate in a survey. Perceptions with respect to: a) an ideal local opinion leader (OL) in ambulatory asthma care; and b) content, style and delivery methods of OL educational interventions in acute asthma were collected. In phase II, focus-group discussions were conducted to further explore preferences and expectations for such interventions; self-perceived barriers and facilitators for implementation were assessed. Results: Overall, 54 patients completed the survey; 39% preferred receiving guidance from a Respirologist, 44% during their ED visit and 56% through individual discussions. In addition, 55% expressed interest in having PCP follow-up within a week of discharge. A Respirologist was identified as an OL in ambulatory asthma by 59% of the 39 responding PCPs. All expressed interest in receiving notification of their patients’ ED presentation, most within a week and including diagnosis and ED/post ED-treatment. Personalized and guideline-based recommendations were considered to be the ideal content by the majority; 39% requested this guidance through an educational pamphlet faxed to their offices. In the focus groups, patients and PCPs recognized the importance of health professional liaisons in the ED to PCP transition of care; patient anxiety and time constraints were identified as potential barriers for ED-educational information uptake and proper post-ED follow-up, respectively. Conclusion: Messages arising from patients and PCPs help tailoring study interventions to meet local needs and expectations. Overall, patients and physicians are seeking ways to mitigate problems with transitions in care. This contact with the practice environment also facilitates the identification of potential determinants to implementation and knowledge uptake.

Introduction: The number of emergency department (ED) visits across Ontario has increased annually over the past two decades leading to overcrowding and longer wait times. ED volume forecasting may provide insight to strategic planners regarding future patient volumes and the effects on health care resources. We investigated the pattern of ED use at the local health integration network (LHIN) level and developed forecasts using historical data. The forecasts were then used to examine the effect on acute care hospital bed requirements and the number of full time equivalent physicians needed. Methods: Aggregated data from the Canadian Institute for Health Information for the period 2003 to 2013 was obtained for each of Ontario’s LHINs. The total number of ED visits per year was first quantified by LHIN and then simple linear regression was used to forecast patient volumes in 2018 and 2023. The rate of hospital admission by LHIN was also calculated. We then used the forecasted volume, admission rate and the total number of acute care hospital beds by LHIN to predict the total number of beds needed by LHIN. Based on the forecasted patient volumes and the hours of coverage model, the total number of full-time equivalent physicians needed was calculated. Results: Over the study period, the number of patients increased from 4 to 37% among LHINs. Admission rates generally decreased from 2003 to 2013. Based on historical trends, all EDs across Ontario are expected to experience increased patient visits in the future but at different rates of growth. Depending on the rate of growth in ED visits, the number of acute care beds needed by LHIN is somewhat variable and affected by the proportion of alternate level of care patients. Given, the forecasted increase in patient volume, the hours of coverage model suggests that approximately 320 additional full-time equivalent ED physicians are needed across the province by 2023. Conclusion: Although all forecasts inherently have a degree of error associated with their estimates, strategic planners require some quantitative prediction of future events to develop initial plans. Through research, these predictions can be focused and refined. The results suggest that many hospitals will experience increased demand for services and will have to do resource allocation planning accordingly to ensure patient demand is met appropriately.

Introduction: The Thunder Bay Regional Health Sciences Centre (TBRHSC) Emergency Department (ED) has experienced an all patient increase in visits ranging from 1.5 to 6% per year since 2004. As a regional referral centre with no dedicated pediatric ED, TBRHSC is the sole emergency provider. Given the rising visits, we have investigated the pattern of pediatric visits, rates of admission to hospital and for a subset of years the investigations completed. Methods: Pediatric visits from 2004 to 2014 were summarized for the TBRHSC ED. The pattern of visits was examined along with the rate of admission to hospital. We also investigated the trend in acuity over the study period. Laboratory and imaging data are purged 1 year after each visit and were not available prior to 2011 but were summarized for the remainder of the years to identify the rates of all investigations completed. Results: From 2004 to 2014 there was a total increase in visits of 7.5% with the average annual admission rate ranging from 5 to 6.3%. The month to month variability in visits over the study period was high with a minimum of 1292 in August 2004 and a maximum of 2488 in October 2009. Nearly all patients were either CTAS II, III or IV, with level III having the highest occurrence. The mean investigation rate was approximately 16, 0.8, 24, and 2.3% of patients having laboratory, CT, x-ray and ultra-sound completed, respectively. Conclusion: Pediatric patients are an important subset of all patients visiting the ED. They often require special resources and at the TBRHSC use specific treatment spaces. In addition, there is a limited number of pediatric inpatient hospital beds. Managers could use the timing of visits, number of visits and admission rates to examine resource use and the probability of exceeding capacity. This study also provides baseline information on the rates of investigations, especially imaging such as CT which can have long-term radiological consequences.

Introduction: The D-dimer assay is a high sensitivity, low specificity test used to rule out pulmonary embolism (PE) in low risk ED patients. Patients with a positive D-dimer result will likely undergo CT imaging to confirm the diagnosis. Given the time, cost, and radiation exposure associated with CT, and the higher false-positive rate in older patients, an age-adjusted D-dimer threshold may be preferred. Our objective was to evaluate the sensitivity and specificity of an age-adjusted D-dimer and approximate the downstream effect on CT imaging utilization. Methods: This was a retrospective cohort study conducted using administrative data from Calgary emergency departments between July 2013 and January 2015. Eligible patients were individuals aged 50 and older who were undergoing PE workup including D-dimer testing. Outcomes were ascertained using CT imaging reports and by searching the regional administrative database for subsequent diagnosis of PE within 30 days of the index visit. These data were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of the D-dimer test using the standard threshold (500 ng/mL) and an age-adjusted threshold (10 ng/mL x patient age as an integer). From this, the potential reduction in CT imaging use and missed PE diagnoses were modeled. Results: Of 6669 patients aged 50 or older who had D-dimer testing for possible PE, 1504 (22.6%) underwent a CT scan, and 217 (14.4% of CT) received a discharge diagnosis of pulmonary embolism, which was confirmed on chart review. When test results were re-interpreted using an age-adjusted threshold, D-dimer specificity increased from 63.9% to 75.4%, while sensitivity decreased from 96.5% to 89.9%. This translates to 888 new true negatives, representing CT scans potentially avoided (a 59% reduction in CT utilization), but with 18 new missed PE diagnoses. Conclusion: The age-adjusted threshold may reduce use of CT imaging among older patients suspected of PE, but at the cost of more missed PE diagnoses.

Introduction: Septic arthritis represents one of the most severe diagnoses for a presentation of an acutely swollen joint, with a high level of morbidity and mortality associated with delayed management. There is continued interest in the utility of serum markers of inflammation in diagnosing this dangerous condition, however there is a lack of clear consensus for cut-offs that optimize diagnostic performance for these tests. The objective of this study was to perform a systematic search of the literature to identify optimal cut-offs for commonly ordered serum markers and to assess how these cut-offs perform in a cohort of patients with a diagnosis of septic arthritis. Methods: We performed a systematic literature search aimed at identifying optimal cut-offs for serum makers (white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) used for diagnosing septic arthritis. We assessed the use of these markers within a retrospective cohort (n=87) of patients diagnosed with septic arthritis (based on positive gram stain, culture, or treatment with a prolonged antibiotic course and/or surgical intervention) that presented to one of four emergency departments in Calgary over a two-year period. We then compared published values to local data. Results: We identified 10 articles that evaluated diagnostic characteristics for serum markers. Although there was variability for cut-offs reported in the literature, classically WBC >11 x 109/L, ESR >30 mm/h, and CRP >100 mg/L were reported to modestly increase the likelihood ratio of diagnosing septic arthritis. In our cohort, a complete blood count was ordered in the emergency department in 97% (n=84) subjects. ESR and CRP were ordered in 66% (n=57) and 85% (n=74) of patients, respectively. When comparing the classic literature based cut-offs to our population group, a WBC <11 x 109/L was found in 38% (n=32), ESR <30 mm/h in 51% (n=38), and CRP <100 mg/L in 30% (n=17). Sensitivity was found to be poor (61% for WBC >11 x 109/L; 70% for ESR >30 mm/h; 48% for CRP >100 mg/L). Conclusion: Data collected from the Calgary Emergency Department supports the published literature suggesting that serum tests are not helpful in the diagnosis of septic arthritis. Future work should evaluate these diagnostic characteristics in relation to patients with non-infectious monoarticular joint pain.