Introduction: Emergency physicians can use B-mode Point-of-Care Ultrasound (POCUS) to identify a patient’s carotid vasculature including the common carotid artery (CCA), and carotid bulb (CB) as well as carotid bifurcation into the internal carotid artery (ICA) and external carotid artery (ECA). Radiology performed carotid ultrasound (RPCU) is performed using both B-mode and spectral Doppler ultrasound, a combination termed “duplex” ultrasound where first arteries are evaluated for stenosis using B-mode ultrasound, which is followed by flow measurements using Doppler. Performing flow measurements using Doppler may add a significant amount of time to the ultrasound, which makes it impractical for an emergency physician in a busy emergency department. Some institutional practices include arranging for outpatient RPCU to assess patients with Transient Ischemic Attack (TIA) and have them follow up in an outpatient TIA clinic. This study explored whether B-mode POCUS without Doppler may help identify Stroke or TIA patients in the emergency department with significant carotid stenosis (CS) by measuring the CCA, CB, and ICA lumen. Methods: Adult patients with an emergency physician diagnosis of stroke or TIA who were sent for RPCU were included in this study. An emergency medicine resident in their POCUS fellowship training performed a B-mode POCUS of the patient’s right and left CCA, CB and ICA with the patient sitting 90 degrees. Three measurements of each of the 3 sections were obtained and the mean calculated. This was then compared to the results from the RPCU as CS >50% or CS <50%. Results: 38 patients were included in the study between February and June 2013. We observed a correlation between absolute differences in comparing the right side of the carotid vasculature to the left side of the carotid vasculature with CS >50%. Also, in one case, the absolute lumen diameter with B-mode POCUS without Doppler predicted near complete CS which was confirmed on the RPCU. Conclusion: B-mode POCUS without Doppler may be useful in identifying patients with CS above and below 50% and may help identify patients who need expedited referrals for CS. However, further research is required before this method can be recommended.

Introduction: Early warning scores (EWS) use vital signs to identify patients at risk of critical events as defined by unplanned intensive care unit (ICU) admission, cardiopulmonary resuscitation (CPR), or death. Systems that combine an EWS with a ICU outreach team can improve hospital survival and cardiac arrest rates. Although initially developed for use in ward patients, evidence suggests that EWS are useful in emergency department (ED) patients and may aid in the earlier identification of sepsis. The Hamilton Early Warning Score (HEWS) was recently developed as part of quality improvement process in our health system. The current study examined HEWS at ED triage among a cohort of patients who experienced a critical event during their hospitalization. HEWS were also evaluated as a predictor of sepsis. Methods: Patient were selected from a database of patients admitted to a medical or surgical ward at two tertiary care hospitals over a six-month period. Cases were patients who experienced a critical event during admission and were admitted via the ED. Controls were randomly selected from the database in a two-to-one ratio using an algorithm to match cases based upon burden of comorbid illness. Receiver operator curves (ROC) and likelihood ratios were used to evaluate HEWS at ED triage as a predictor of likelihood of critical deterioration and sepsis. Results: The sample included 845 patients of whom 267 experienced a critical event. The median time to occurrence of critical event from admission was 124 hours. ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting likelihood of experiencing a critical event 0.63 [95%CI: 0.58-0.67]. HEWS had fair discriminative ability for predicting likelihood of meeting criteria for sepsis 0.75 [95%CI: 0.71-0.80], and good discriminative ability for predicting likelihood of experiencing a critical event among patients meeting criteria for sepsis 0.80 [95%CI: 0.74-0.86]. Conclusion: This retrospective study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. This may be because deterioration commonly occurred days after admission. However, HEWS may have utility as tool for aiding earlier identification of critically ill septic patients. Prospective studies are needed to further delineate the utility of the HEWS in the ED.

Introduction: Optimising teaching techniques when introducing learners to new skills such as ultrasound guided peripheral IV insertion (UGPIV) is essential due to the time and resource intense nature of skills learning. The testing effect has been demonstrated to be effective in improving learner retention, however there is little research evaluating the testing effect on the acquisition of technical skills in medicine. This study aims to determine whether test-enhanced learning improves learner performance of UGPIV. Methods: A prospective randomized control trial is ongoing with medical students on rotation at Sunnybrook Health Sciences Centre. Participants are randomized to one of two study groups, the control group (CG) and the test-enhanced learning group (TEG). Each group receives a teaching session lasting 1.5 hours surrounding ultrasound guidance for peripheral IV insertion. The TEG receives a formal evaluation of the skill during the last 15 minutes of that session, whereas the CG has continued practice time. Subjects in both groups are being evaluated two weeks later to compare skill performance using an objective structured assessment of technical skills. Results: Data collection is ongoing and is expected to be completed with an recruitment of 40 by March 31st. Conclusion: Given the importance and resource intensive nature of technical skill training it is important to have an understanding of the most efficient ways to teach new techniques. The results from this study will help provide evidence on the testing effect as a method of improving competency and retention for ultrasound guided procedures.

Introduction: The Prehospital Canadian Triage and Acuity Scale (Pre-CTAS) is based upon, and is consistent with, the CTAS (Canadian Triage and Acuity Scale). Paramedic-assigned Pre-CTAS scores using memory compared to Triage Nurse CTAS scores have previously demonstrated moderate inter-rater reliability. This is the first study to measure the effect of two different point-of-care decision support tools on the inter-rater reliability of paramedic assigned Pre-CTAS and Triage nurse CTAS scores. Methods: Paramedics were randomized to Pre-CTAS booklet or CTAS smartphone app during the one-year study period. Pre-CTAS scores assigned on arrival at hospital (AH) were compared with Triage Nurse CTAS scores and analyzed using Cohen’s Kappa. Paramedics were then surveyed to assess the perceived utility and satisfaction with the decision support tools. Results: For 1663 patient transports, the weighted kappa score for Paramedic AH vs. Triage Nurse CTAS was fair at 0.38 (95% CI 0.35-0.41). For patients whose initial on-scene and AH Pre-CTAS scores did not change (n= 1405, 85%), Paramedic-Triage Nurse agreement was moderate at 0.43 (95% CI 0.39-0.46). The survey revealed that tools, when employed, helped assign scores; however accessing the additional resource was cumbersome or time consuming, and scores were occasionally assigned post clinical encounter. Conclusion: Point-of-care external decision support tools did not affect Pre-CTAS and ED CTAS agreement. These tools may add complexity or be perceived to add time to documentation within the delivery of clinical care if not implemented with adequate support. Future research needs to evaluate the impact of clinical decision support embedded within an electronic patient care record consistent with many ED information systems.

Introduction: About 3-8% of fractures are missed in the adult emergency department (ED). No study has examined this in a pediatric ED. Such data is essential to quality improvement. We sought to determine the proportion of missed fractures on x-rays in a pediatric ED, the location of missed fractures and associated factors, and if missed fractures were clinically significant. Methods: We did a retrospective cohort study from Jan 1 to Dec 31, 2013 of 1000 pediatric patients with a fracture on x-ray in our academic pediatric ED. We randomly reviewed radiologist reports to find new fractures. A fracture was missed if identified by the radiologist but not the ED physician. Data was collected on patient, fracture, department and physician characteristics and change in management or complications. Descriptive statistics were used for clinical characteristics. The proportion of missed fractures was computed using the Wilson score method. Factors associated with missed fractures were investigated using chi-squared test. Results: Of 1000 x-rays, 19.4% (95% CI 17.0-22.0%) had at least one fracture missed. However, when possible fractures were removed for further analysis, 13.9% (95% CI 11.7-16.5%) were missed. The bones most associated with missed fractures were pelvis (60%,) carpal (50%,) vertebra (42.9%,) and patella (33.3%) (p<0.001.) However, these accounted for only 12.5% of missed fractures whereas ulna (31.3%,) metatarsal (14.1%,) phalynx of the hand (9.4%,) and fibula (7.8%) accounted for the greatest number of missed fractures. The fracture types most associated with a missed fracture were styloid, Salter-Harris IV, Salter-Harris I, compression, avulsion and buckle (p<0.001.) The presence of multiple fractures was associated with missed fractures (35.0% vs 7.2%, p<0.001) as was older age (11.2 vs 9.5 years, p=0.001). Most missed fractures were not clinically significant (71.9%) but some required splinting or limitation of activities. One had decreased function at 2 months. Conclusion: Overall, the proportion of missed fractures is higher than in adults, stressing difficulties with reading pediatric x-rays. Most missed fractures were not of clinical significance. Carpal, patella, vertebra and pelvis fractures were particularly challenging but were also rare. Ulna, metatarsal, phalynx of the hand and fibula accounted for the greatest number of missed fractures. More education may help improve physician skills in recognizing these fractures.

Introduction: Reducing the number of patients requiring cardiac monitoring would increase system capacity and improve emergency department (ED) patient flow. The Ottawa Chest Pain Rule helps physicians identify chest pain patients who do not require cardiac monitoring and is based on a ‘normal or non-specific’ ECG and being pain-free on initial physician assessment. Our objective was to measure the impact that the implementation of this decision rule would have on cardiac monitoring bed utilization in adult EDs in Calgary. Methods: A convenience sample of patients was prospectively obtained at each of the four Calgary adult emergency sites. All patients presenting with the Canadian Triage Acuity Scale chief complaint of “cardiac pain”, or “chest pain with cardiac features” were captured for inclusion in the study. Real time interviews and survey assessments were conducted with the primary nurse and physician involved in each patient’s care. Results: A total of 61 patients were captured by the study. Physicians identified cardiac as the primary rule-out pathology in 51% of these patients. The average Heart Score of all study patients was 4.2, and 30% of patients were ultimately admitted. Physicians believed that 39% of the 61 patients needed cardiac monitoring, while primary nurses believed that 59% needed monitoring. Of the 61 patients, 59% were triaged to areas providing cardiac monitoring. The application of the Ottawa Rule would have allowed 47% of patients triaged to cardiac monitoring to be taken off cardiac monitoring. This would translate to a total of greater than 74 hours saved or a reduction of 30% of the total cardiac monitored patient time. Conclusion: The Ottawa rule appears to be a low-risk emergency department flow intervention that has the potential to help reduce resource utilization in emergency departments. This change may result in increased emergency department capacity and improved overall patient flow. This simple rule based only on ECG findings and absence of chest pain can easily be applied and implemented without increasing physician workload or increasing risk to patients.

Introduction: Pain is a common presenting complaint amongst emergency department (ED) patients. Evidence suggests that pain is often inadequately and inconsistently treated resulting in oligoanalgesia. Patients that do not have their pain timeously recognised and treated end up with an inferior patient experience in the ED. It was speculated that pain management in Panorama Mediclinic ED was not optimal and an in-depth analysis of pain management trends was performed in order to lead to a targeted intervention which would result in better care in the ED. Methods: A convenience sample of 100 random folders was collected from May-July 2015. Folders with presenting complaints excluding pain and children under 10 years of age were excluded. The data were collected onto a password protected Excel database and analysed using basic descriptive analysis. Results: 44% of patients included were green triage category, 30% yellow, 23% orange and 1% red. 82% of patients presented with verbal pain scores greater than 5/10. The average time to receive analgesia was 60.26 minutes. 33.3% of patients only received analgesia after being in the ED for >60 minutes. Of those patients receiving delayed analgesia, the majority of their pain scores were between 6-8/10. Abdominal and extremity pain together consisted of 51% of the anatomical pain distribution. 29% of the patients sampled received no analgesia during their visit to the EC and the majority of their pain scores were between 3-6/10. Intravenous acetaminophen, intravenous opioids and intramuscular opioids are by far the most common pharmaceutical agents to treat acute pain in this ED. Conclusion: This study demonstrated that acute pain is not well managed in the ED of Panorama Mediclinic. Subsequently an acute pain management protocol was implemented in which all patients with pain scores greater than 5/10 are offered early analgesia on initial presentation to the ED by the triage nurse.

Introduction: Diagnosing the undifferentiated dyspneic emergency department (ED) patient remains a challenge for clinicians; in order to rule in or out acute heart failure (AHF) natriuretic peptide biomarker testing has evolved and is recommended by cardiology international guidelines to be utilized in these presentations. However there is equipoise in the emergency community for its use, largely due to perceived modest test specificity. We sought to analyze this apparent clinical dichotomy as part of a multicenter trial of undifferentiated dyspneic ED patients. Methods: Patients with dyspnea presenting between October 2010 and October 2013 to one of four ED sites -2 Canadian, 1 American, 1 New Zealand- were assessed by certified staff emergency physicians (EPs) and their chest Xray reviewed. Those patients with undifferentiated dyspnea with a potential for AHF (ie further investigated or treated for AHF but investigated and/or treated for another cause) were consented and enrolled. Two of the sites (American, New Zealand) had NT-proBNP assay ordered as a standard of care for these patients; the other 2 sites did not. At the end of Emergency care, the EP recorded the primary diagnosis of the dypnea-either “AHF” or “Not AHF.” Blinded adjudication was carried out by 2 cardiologists after reviewing sequential records: first, with index ED records but no NT-proBNP result; second, with the NT-proBNP result and lastly, with follow up 60 day records (deemed the gold standard diagnosis). EP accuracy between NT-proBNP and no NT-proBNP sites and NT-proBNP accuracy using standard cutpoints were calculated, as were the number of adjudicated cases influenced by exposure to NT-proBNP. Results: 197 patients were enrolled, 107 at NTproBNP sites and 90 at the other 2 sites. EP accuracy was 76% for either site. NT-proBNP used as a binary test with recommended age-stratified cutoffs had 80% accuracy, applied to 70% of patients (30% remained in “gray zone”).Cardiology adjudicators reversed 16% of initial diagnoses upon exposure to NT-proBNP result, ultimately diagnosing 41% of patients with AHF. Conclusion: This study supports the clinical equipoise amongst emergency physicians compared to cardiologists for the use of NT-proBNP in diagnosing acute heart failure in the undifferentiated dyspneic Emergency patient.

Introduction: Maintenance of public pedestrian walkways to ensure safety can be onerous during Canadian winters. The costs of maintenance should be weighed against the potential for reducing injuries related to falls. Ice and snow covered surfaces can increase the chance of falling by 3.5 times compared to normal concrete surfaces. The objectiveof this study is to examine patterns of injury occurrence in persons injured when falling due to snow or ice in public areas. Methods: We identified persons presenting to emergency departments in Kingston, ON for treatment of injuries related to falls on ice or snow for a 5 year period ending in March 2015 using data from the Canadian Hospital Injury Reporting and Prevention Program(CHIRPP). Within CHIRPP, there is a series of variables that describes the injury event, location and circumstances. Hospital medical records were reviewed for additional information on anatomic injuries sustained and subsequent use of hospital based resources.Variables were managed and assessed in Excel. A descriptive analysis examined distributions of variables by subgroups of injury occurrence. Results: 674 injury cases of falls on snow and ice were identified. 316 cases (46.9% of cases/ about 60 per year) occurred in public pedestrian areas, the group of primary interest. Of these: 88 cases (27.8%) resulted in fractures; 68 (21.5%) were soft tissue injuries; 46 (14.6%) were head injuries, concussions or intracranial injuries; and 40 (12.7%) were sprains or strains. Of the fractures, 37 (42.0%) involved the upper limb and 33 (37.5%) involved the lower limb. 72 (81.8%) of fractures were managed in the emergency department with orthopedics referral or follow up. The large majority of sprains or strains (85.0%), soft tissue injuries (80.9%) and head injuries (82.6%) were managed in the emergency department without plans for hospital based follow up. Conclusion: Falls on snow and ice frequently occur on public pedestrian areas. The resulting injury can be significant, leading to fractures in upper and lower limbs. These fractures require more use of hospital based resources than other injury types. It is hoped that providing municipal decision makers with information on the frequency and severity of these injuries will lead to improved snow and ice removal in public pedestrian areas.

Introduction / Innovation Concept: There are numerous research studies in the medical literature, which demonstrate how the experience of a medical residency can contribute towards burnout. The escalating performance pressures and expectations during residency training have the potential to negatively impact upon physician health and clinical performance. The purpose of this prospective cohort study was to test the effectiveness of the High Performance Physician (HPP) program among General Surgery residents at the University of Manitoba with regard to burnout and clinical performance. Methods: This program was delivered over a 9-week period. All 26 residents were asked to complete the Maslach Burnout Inventory - Human Services Survey (MBI-HSS). Each resident then participated as the team leader for a 15-minute trauma resuscitation simulation. Three attending physicians from Surgery & Emergency Medicine assessed resident performance and ability to manage work-based stressors. Following the simulation, each resident received a debrief interview. Once the HPP curriculum had been completed, residents took part in a second high fidelity simulation session and again completed the MBI-HSS. Curriculum, Tool, or Material: The HPP program offered through the Department of Emergency Medicine (EM), is a performance enhancement based curriculum. It is designed to equip physicians with mental skills to help optimize focus, arousal control, stress management, communication, and teamwork. Further, to utilize these skills to cope and respond more effectively to the inherent performance pressures that may present within one’s area of specialization. Conclusion: The Emotional Exhaustion domain of the MBI-HSS demonstrated a statistically significant decrease. The other domain scores were not statistically significant. Simulation domain scores did not demonstrate a statistically significant difference in performance between the pre- and post-HPP curriculum simulation sessions. A summative content analysis of the interview data demonstrated that residents believed internal barriers to situational awareness were the most significant impact on performance. Further study is required to determine if differences are seen in long-term follow-up.

Introduction:Background: Ischemic ventricular fibrillation (VF) is highly related to ST elevation myocardial infarction (STEMI). Pre-hospital STEMI patients have been shown to also develop VF during ambulance transport. However, there is limited literature exploring the characteristics of this specific population of VF. Objective: To determine the incidence of pre-hospital VF, and evaluate some demographic and electrocardiogram (ECG) characteristics of STEMI patients having VF while transported by ambulance in a Quebec suburban pre-hospital setting. Methods: A retrospective study from 8th August 2006 to 6th December 2015 of 937 STEMI patients transported by ambulance in the Chaudiere-Appalaches region, south of Quebec City. Destination for treatment was either Catherization Laboratory (CL) or the nearest Emergency Department (ED) for reperfusion treatment and was mainly based upon a maximum transport time of 60 minutes, from the first confirmed STEMI-ECG to the CL. Demographics and ECG characteristics were extracted from the patients care records. SPSS-20 was used for descriptive statistics. Results: 937 patients (259 women & 678 men) diagnosed with STEMI were included in the study. Patients were regrouped in V1-V4 leads STEMI (336; 35.9%) and in other leads STEMI (651; 64.1%). 52 (5.55%) of all STEMI patients had FV during ambulance transport. There were 10 women (27,4%) and 42 men (72,6%). Of these, 28 had V1-V4 STEMI (28/336; 8.33%) while 24 had other leads STEMI (24/651; 3.69%). Relative risk of FV is higher (225%) with V1-V4 STEMI compared to other leads STEMI. Regarding age groups, patients from 60 to 70 years old represent 38.4% (20/52) of FV for 25.7% (241/937) of STEMI patients while those over 80 years old had 3.85% (2/52) of FV, but were 17% (159/937) of all STEMI patients. Men seem also more at risk for FV (16/20) especially between 60 and 70 years old compare to other age group. Conclusion: In this suburban area, VF occurred in 5.55% of STEMI patient’s transported by ambulance. STEMI patients over 80 years old had a low rate of FV. Being a man, 60 to 70 years old, with a STEMI located in V1-V4, seems to be associated with a higher risk of VF. More studies are needed to confirm these results and explore other characteristics associated to pre-hospital VF.

Introduction: Emergency Department (ED) fall risk screening has been newly implemented in Alberta based on Accreditation Canada requirements. Two existing inpatient tools failed to include certain ED risk conditions. One tool graded unconsciousness as no risk for falling, and neither considered intoxication or sedation. This led to the development of a new fall risk management screening tool, the FRM (Tool1). This study compared Tool1 with inpatient utilized Schmid Fall Risk Assessment Tool (Tool2) and the validated Hendrich II Fall Risk Model (Tool3). Methods: Patients (≥17 years old) in a tertiary care adult ED with any of the following; history of falling in the last 12 months, elderly/frail, incontinence, impaired gait, mobility assist device, confusion/disorientation, procedural sedation, intoxication/sedated, or unconscious were included. Forms were randomized to score patients using different paired screening tools: Tool1 paired with either Tool2 or Tool3. Percent agreement (PA) between the tools based on identification of a patient at either risk/no risk for falling; higher PA indicating more tool homogeneity. Results: A total of 928 screening forms were completed within our 8-week study period; 452 and 443 comparing Tool1 to Tool2 and Tool1 to Tool3, respectively. Thirty-two forms included only Tool1 scores, excluding them from comparative analysis. The average patient age (n=895) was 64.8±21.4 years. Tool1 identified 66.4% of patients at risk, whereas Tool2 and Tool3 identified only 19.2% and 31.4%, respectively. Tool1 and 2 had a PA of 50.2%, whereas Tool1 and Tool3 had a PA of 65.9%. Conclusion: The FRM tool had higher agreement with the validated assessment tool, identifying patients at risk for falling but better identified patients presenting with intoxication, need for procedural sedation and unconsciousness. The other tools generally miss these common ED conditions, putting these patients at risk. Validation and reliability assessments of the FRM tool are warranted.

Introduction / Innovation Concept: With aging, increasing complexity, and prolonged emergency department (ED) stays, patient falls are an increasing problem. Accreditation Canada recently listed falls risk management (FRM) as a required operational practice (ROP). The University of Alberta ED had no screening tool or education program specific to falls. Gaps in identifying patients with altered consciousness, intoxication, or are undergoing procedural sedation were noted in the Alberta Health Services (AHS) recommended tool. This gap led to the development piloting of an ED specific FRM screening tool. Methods: A literature review was completed to assess current fall assessment tools and their applicability to the ED. No ED specific tools were identified leading to the development of the FRM tool. Prior to the FRM tool being piloted, nursing staff were asked to respond to a voluntary survey on their perceived knowledge of falls management followed by a survey testing their actual knowledge. They were then educated on the FRM and protocol through in-services, power point presentations, and fact sheets. A post education knowledge survey was then sent out. Multidisciplinary working groups provided feedback throughout the pilot, resulting in modifications prior to final implementation. Curriculum, Tool, or Material: The FRM tool consists of 10 variables with a maximum score of 20. Variables included are: falls in the last 12 months? Mechanical (1), Physiological (2), Multiple (3); age ≥70 or frail (2); mobility assist device (1) confusion or disorientation (5); impaired gait (1); incontinence (1); intoxicated (3); procedural sedation (3); and unconscious (5). All except for the last 3 variables were adapted from inpatient risk tools. Patients were categorized as low (1-2 points), moderate (3-4 points), or high risk (5+ points) and those scoring ≥3 had a safety protocol implemented. The survey regarding perceived knowledge for management of falls led to an average score of 86.6% (n=46). When tested on their actual knowledge they scored 48.8% (n=29). Following training on the FRM tool and protocol, the actual knowledge of 18 respondents averaged 83%. Conclusion: The FRM screening tool has been implemented and a comparative study looking at ED risk predictability matched to existing falls risk scores. Based on research findings the FRM will be considered for a provincial implementation.

Introduction: In light of recent local initiatives aimed at improving emergency department (ED) patient flow, we sought to characterize how patients aged 65 and older who reside in long term care (LTC) facilities utilize the services of the EDs in Regina, Saskatchewan as compared to an age-matched comparison of community dwelling individuals. Methods: A retrospective chart review was performed with a convenience sample of the first 50 patients who presented to each ED at both hospitals in Regina starting January 1, 2012 for each population. Two separate patient populations were included: those who reside in the health region run LTC facilities and those who live in the community. We abstracted data from a variety of different clinical, demographic and administrative parameters. Results: The charts of 100 patients were reviewed for the LTC population (54 females, mean age 82.6) and 99 patients for the community dwelling population (55 females, mean age 77.3). The CTAS distribution for the LTC patients was found to be CTAS 1: 5%, CTAS 2: 9%, CTAS 3: 43%, CTAS 4: 33% and CTAS 5: 10%. For the community dwelling individuals, the distribution was CTAS 1: 1%, CTAS 2: 21%, CTAS 3: 44%, CTAS 4: 22%, CTAS 5: 10%. This is a significantly different distribution (p = 0.047). From the LTC population, we found that 50% of patients were admitted, with 46% being discharged and 4% leaving without being seen. Furthermore, we also noted that 75% of patients were brought to the ED by EMS. From the community dwelling population, we noted that 43% of patients were admitted, with 55% being discharged and 1% leaving without being seen. This population used EMS services 41% of the time. With respect to length of stay, LTC patients had a mean duration of 5.7 (±4.3 hours) compared to 4.8 (±4.0) hours for the non-LTC population (p=0.111). Conclusion: Our findings suggest that the highest volume of acuity for the LTC patients falls within the CTAS 3 or 4 categories whereas there is a higher proportion of CTAS 2 acuity patients in the community dwelling population. Exactly half of our LTC sample was admitted as compared to 43% of the community population. The LTC population also required EMS services for a considerably higher proportion of their presentations to the ED (75% compared to 41%). It is our intent that the findings of this study will help guide future quality improvement initiatives.

Introduction: Clinical decision rules for computed tomography (CT) ordering in pulmonary embolism and mild traumatic brain injury have been shown to be under-used in clinical practice. Current literature does not explain why these validated decision rules continue to be under-used despite evidence of inappropriate use and increased costs. To better evaluate potential barriers to their use, qualitative methods involving focused interviews were conducted amongst emergency department (ED) physicians. Methods: Physicians were recruited via a brief presentation at Calgary Zone ED rounds. Ten attending and resident physicians (4 female, 6 male) were interviewed. Questions were designed to evaluate potential barriers to the integration of decision rules into the computerized order entry system. Interviews were audio-recorded and transcribed manually. A high-level thematic analysis was conducted to draw primary themes from open-ended questions, and responses were totaled for closed-ended questions. Results: Emerging themes suggest concerns surrounding timing of rule application in relation to test ordering, patient influences on ordering, and overuse reporting. All 10 physicians believed decision rules for CT ordering play a large role in the ED, and 8 were in favor of integration into the order entry system. However, over half expressed concern, noting that their thought process begins before order entry. A majority prioritized shared decision-making with patients. However, 8 indicated that patient expectations influence their ordering. A majority agreed that there is CT overuse in the ED, but many were hesitant in concluding that overuse was primarily physician dependent. Conclusion: Primary barriers to decision rule integration are timing of application, hesitation surrounding patient input, and uncertainty over data. Physicians often make decisions prior to order entry. Mobile copies of decision rules should be available to better facilitate compliance. Concerns over patient influence on ordering are common. Patient-friendly materials on clinical decision rules should be available to better facilitate shared decision making while still promoting decision rules. While overuse is agreed upon, many prefer to see and track their own ordering data before supporting a physician-targeted intervention. Data reports to physicians may help affirm physician-associated overuse, and reinforce their role in responsible resource utilization.

Introduction: Emergency Physicians (EPs) face growing numbers of palliative care patients presenting to the emergency department (ED). Formal training for EM residents across Canada in this area is not well described. We sought to describe the training Canadian emergency medicine (EM) residents receive in end of life care issues, their attitudes toward it, self-reported knowledge and skills, and the importance they place on further training in this domain. Methods: We conducted an electronic survey across Canada. We collected demographic data, previous education in palliative care, attitudes toward end of life care, and a self-assessment of competency and desires for further training in the main components of palliative care pertinent to EM. We used simple descriptive statistics, a Mann-Whitney test to assess whether previous formal training in palliative care affected current comfort level, and a combination of self-reported knowledge and importance levels placed on key areas. Results: We received 112 responses from 17 different Universities in Canada, with 42% from the CCFP training stream, and 58% from the FRCP stream. Fifty-four percent of respondents had not completed a palliative care rotation during residency or fellowship, which was overwhelming accounted for by FRCP residents (13%, vs. 82% among CCFPs). Having completed formal training in palliative care was significantly associated with general comfort in managing terminally ill patients (p<0.0001). Sixty percent of subjects felt a lack of knowledge and skills was their main limiting factor in providing ideal care for terminally ill patients in the ED. The skills deemed highest priority with lowest comfort level among residents included discussing withdrawing and withholding care, prognosticating, pharmacology and other symptom control. Preferred methods of receiving palliative care teaching included simulation, bedside teaching and small groups. Conclusion: The care of acute illness among palliative care patients is substantially underrepresented in the Canadian EM curriculum, particularly for FRCP trainees. Formal training is associated with increased comfort in caring for patients at the end of their life. High yield teaching interventions could be directed toward knowledge of withdrawing, prognosticating and symptom control. Simulation, bedside teaching and small groups are the preferred method for receiving such teaching.

Introduction: Venous thromboembolism (VTE) is a common diagnostic consideration among patients presenting to the emergency department (ED) and often requires the use of diagnostic testing. A normal d-dimer (DD) blood test can exclude VTE and eliminate the need for costly imaging and the associated contrast medium and radiation exposure. The purpose of this quality improvement initiative was to increase the use of DD testing for patients with a low and intermediate clinical pretest probability of VTE, increase the use of ventilation perfusion scans (VQ) as an alternative to CT pulmonary angiogram (CTPA) and decrease the use of CTPA and venous doppler ultrasound (VDUS) at St. Michael’s hospital. Methods: A multispecialty team developed an ED specific algorithm set for appropriate VTE testing that were posted on the ED online portal along with a poster in each zone of the ED after an ED launch campaign with request for feedback. A run chart was used to track DD, CTPA, VQ and VDUS utilization. Two-sided T-test comparison was conducted to compare pre- and post-implementation utilization. Results: Physician feedback was positive regarding the use of: DD in VTE intermediate risk patients and the VTE algorithm set. Feedback was negative for DD turnaround time. We found a significant increase in DD use (77 tests per month to 93; p=0.013), but no significant change in the use of CTPA (27.3 per month to 30; p=0.38), VDUS, or VQ. Number of monthly ED visits remained constant. Conclusion: This intervention increased DD utilization, but measuring appropriateness will require prospective collection of clinical pre-test probability. Integrated risk stratification and decision aids into computer physician order entry may be necessary to track and improve appropriateness.

Introduction / Innovation Concept: Effective communication between health providers and patients is central to patient safety, health education and patient empowerment. Previous studies in the Calgary Zone demonstrated that less than fifty percent of emergency department patients thought discharge handouts communicated health information well and even fewer thought the handout information would aid them in care at home. A partnership between the Department of Information Design, Mount Royal University and the Department of Emergency Medicine, University of Calgary, seeks to provide an innovative solution to this problem. Methods: The Calgary Zone Department of Emergency Medicine has partnered with the Mount Royal University Department of Information Design community service learning course. Information design students will work to develop infographics based on the “Choosing Wisely Alberta” Campaign Topics, with content expertise provided by the Department of Emergency Medicine. Curriculum, Tool, or Material: The five “Choosing Wisely Alberta” topics are: CT scans for adults with head injuries, CT scans to find Blood Clots in the lung, Imaging Tests for Headaches, Imaging tests for lower back pain, Treating Sinusitis. The target audience for the project will involve staff physicians, patients, public and government. Student involvement will direct their individual projects to these target audiences and will consider important issues such as non-English speaking patients, patients with low health-literacy (marginalized populations) and “super-users” of emergency departments, health policy (government and not-for-profit), physicians (emergency and primary care) and other health care workers. Infographics will be available for presentation at CAEP 2016. Conclusion: Information graphics will be used to facilitate clinician-patient discussions for empowered decision making, facilitate clinician-learner decisions based on evidence based guidelines, and improve knowledge translation for health system administrators and policy makers regarding appropriate emergency department resource allocation.

Introduction / Innovation Concept: In Canada, family physicians (FPs) provide the majority of 1st trimester pregnancy care and are often first to evaluate complications, including threatened and spontaneous abortion and ectopic pregnancy. To receive a same day urgent US, most patients will be sent to the emergency department (ED). With increasing availability and affordability of point of care ultrasound (PoCUS), FPs are starting to use US in their offices, potentially diverting some ED visits for patients with reassuring US findings. To date, no formal certification process exists for FPs who wish to use PoCUS for 1st trimester indications. Methods: The objective of this educational initiative was to implement and evaluate a novel, 2-day didactic and hands-on certification process for FPs utilizing office-based PoCUS to identify intrauterine pregnancy and fetal cardiac activity. The FaMOUS course was modeled after the Canadian Emergency Ultrasound Society Emergency Department Echo (CEUS EDE) curriculum and adapted with permission for FPs. Curriculum, Tool, or Material: The curriculum consisted of a deliberate practice mastery model utilizing on-line materials, seminars and hands-on training. Prior to the 2-day course, FPs completed an e-learning module comprised of core competency material specific to obstetrical practice. Learners were required to score 100% on a post-module exam to participate in the 2-day course. Attendees participated in a 4-hour training session to learn US image generation and interpretation. This was followed by 10 hours of hands-on training with CEUS instructor supervision to complete the certification process (50 determinate scans). Thirteen FPs from 3 family practice units successfully completed the certification process. Cumulative knowledge and skill levels were assessed throughout the 2-day workshop through feedback from CEUS supervisors to confirm key concepts were learned. All 13 participants agreed to utilize PoCUS in their clinical assessments of patients with 1st trimester complaints using handheld PoCUS equipment provided to the sites. FPs will be surveyed at 3 month intervals for 12 months following the FaMOUS course to assess provider confidence, satisfaction and perceived impact on clinical decision-making. Conclusion: The FaMOUS certification course is a standardized curriculum by which FPs can learn PoCUS safely to improve quality and timeliness of care for patients experiencing 1st trimester complaints. If PoCUS is adopted by FPs, lengthy ED visits may be decreased for this patient population.

Introduction: Acute upper gastrointestinal (UGI) bleeding is a relatively common emergency resulting in death in 6 to 8% of cases. UGI endoscopy is the intervention of choice which requires procedural sedation and analgesia (PSA). The Halifax Infirmary emergency department (ED) performs 1000 PSAs annually, performed by advanced care paramedics (ACPs). This has been shown safe for other indications for PSA, such as orthopedic procedures. Considering that UGI endoscopy involves upper airway manipulation, and patients are at an increased risk of massive bleeding, this procedure would be expected to be more complex and have an increased risk of adverse events (AEs). This study aims to compare PSA for UGI endoscopy performed by ACPs to that for orthopedic procedures for AEs, airway intervention and medication use. Methods: This study is a retrospective review of an ACP-performed ED PSA quality control database. A dataset was built matching 64 UGI endoscopy PSAs to 192 orthopedic PSAs by propensity scores calculated using age, gender and ASA classification. Outcomes assessed were hypotension (SBP < 100, or 15% decrease from baseline), hypoxia (SaO2 < 90), apnea (> 30sec), vomiting, arrhythmias and death in the ED. The need for airway intervention and medication use was assessed. Results: The UGI endoscopy group was 4.60 times more likely to suffer hypotension than the orthopedic group (OR=4.6, CI:2.2-9.6), and a fifth as likely to require airway repositioning (OR=0.2, CI:0.1-0.5). One endoscopy patient required endotracheal intubation. No patient died in either group. Compared to the orthopedic group, the UGI endoscopy group was one-third as likely to receive fentanyl (OR=0.3, CI:0.2-0.6). When fentanyl was administered, endoscopy patients received an average 26.7 mcg less than orthopedic patients. The endoscopy group was 15.4 times more likely to receive ketamine (OR=15.4, CI:4.7-66.5), and received 34.4 mg less on average. Four endoscopy patients received phenylephrine compared to none in the orthopedic group. There were no other differences. Conclusion: ED PSA for UGI endoscopy appears to differ significantly from that performed for orthopedic procedures. It was associated with more frequent hypotension and increased use of ketamine as a sedative. Patients undergoing UGI endoscopy were less likely to receive fentanyl and require airway repositioning. Only patients in the endoscopy group required intubation or a vasopressor agent.