Introduction: The suboptimal management of children’s pain in the emergency department (ED) is well described. Although surveys of physicians show improvements in providing analgesia, institutional audits suggest otherwise. One reason may be patient refusal. Our objectives were to determine the proportion of caregivers that offered analgesia prior to arrival to the ED, accept analgesia in the ED, and identify reasons for withholding analgesia. Our results will inform knowledge translation initiatives to improve analgesic provision to children. Methods: A novel survey was designed to test the hypothesis that a large proportion of caregivers withhold and refuse analgesia. Over a 16-week period across two Canadian paediatric EDs, we surveyed caregivers of children aged 4-17 years with an acutely painful condition (headache, otalgia, sore throat, abdominal pain, or musculoskeletal injury). The primary outcome was the proportion of caregivers who offered analgesia up to 24 hours prior to ED arrival and accepted analgesia in the ED. Results: The response rate was 568/707 (80.3%). The majority of caregivers were female (426/568, 75%), aged 36 years or older (434/568, 76.4%), and had a post-secondary education (448/561, 79.9%). Their children included 320 males and 248 females with a mean age of 10.6 years. Most (514/564, 91.1%) reported being “able to tell when their child was in pain”. On average, children rated their maximal pain at 7.4/10. A total of 382/561 (68.1%) caregivers did not offer any form of analgesia prior to arrival. Common reasons included lack of time (124/561, 22.1%), fear of masking signs and symptoms (74/561, 13.2%) or the seriousness of their child’s condition (72/561, 12.8%), and lack of analgesia at home (71/561, 12.7%). Analgesia was offered to 328/560 (58.6%) children in the ED and 283/328 (72.6%) caregivers accepted. The most common reason for not accepting analgesia was child refusal (20/45, 44.4%). Conclusion: Most caregivers do not offer analgesia to their child prior to arriving in the ED despite high levels of pain and an awareness of it. Despite high rates of acceptance of analgesia in the ED, misconceptions are common. Knowledge translation strategies should dispel caregiver misconceptions, and highlight the impact of pain on children and the importance of analgesia at home.

Introduction: There is a paucity of pediatric literature regarding effective treatment for post-concussion headache. The objective of this study was to assess whether metoclopramide treatment in the Emergency Department (ED) within 48 hours of injury was associated with reduced persistent headache symptoms post-concussion at 1-week and 1-month post-injury. Methods: Children aged 8-18 years with acute concussion were enrolled across 9 EDs of the Pediatric Emergency Research Canada network in a prospective cohort study [Predicting and Preventing Post-concussive Problems in Paediatrics (5P)] from August 2013 to June 2015. Treatments administered in ED (including metoclopramide) were collected using standardized forms. Self-report symptom questionnaires were rated at baseline, at 7 and 28 days follow-up using the validated Post-Concussion Symptom Inventory (PCSI). Propensity scores for treatment with metoclopramide were calculated using a multivariate logistic regression model including confounders. Intervention and control groups were matched 1:4 on the logit of the propensity scores using a greedy algorithm and nearest-neighbour approach. The primary outcome was headache persistence at one-month. Results: 2095 patients met inclusion criteria and completed baseline assessment. At 1 and 4 weeks respectively, 54% (963/1808) and 26% (456/1780) of participants completing follow-up had persistent headache symptoms. 50 metoclopramide treated participants were propensity score matched to 234 controls (1:4 matching). At 4 weeks, no statistically significant difference in persistent headache symptoms was observed between the treatment and propensity score matched control groups (OR: 0.67; 95% CI: 0.33-1.36, p=0.26). There was also no statistically significant difference between the groups at 1-week post-concussion (OR 0.58; 95% CI: 0.32-1.05, p=0.07). Conclusion: This secondary analysis was unable to detect a statistically significant association between acute ED treatment with metoclopramide and reduced medium and long-term headache symptoms post-concussion. Nevertheless, the 1-week results hold promise, but require a well-powered RCT to fully address confounding issues to determine the benefit of metoclopramide post-concussion.

Introduction: In light of escalating health care costs, initiatives such as Choosing Wisely have been advocating the need to “reduce unnecessary or wasteful medical tests, treatments and procedures”. We have identified coagulation studies as one of those low cost, but frequently ordered items, where we can decrease unnecessary testing and costs by leveraging our Computerized Practitioner Order Entry (CPOE). Considerable evidence exists to suggest a low yield of doing coagulation studies (herein defined as PTT AND INR’s) in suspected cardiac chest pain patients (SCCP). Methods: Using administrative data merged with CPOE we extracted data 90 days pre- and 90 post-intervention (Pre-intervention: May 20, 2015 to August 19th 2015, Post-intervention: August 20th, 2015 to November 18th 2015). The setting for the study is a large urban center (4 adult ED’s with an annual census of over 320,000 visits per year). Our CPOE system is fully integrated into the ED patient care. The intervention involved modifying the nursing CPOE to remove the pre-selected coagulation studies in SCCP and providing education around appropriate usage of coagulation studies. Patients were included in the study if the bedside nurse or physician felt 1. the chest pain may be cardiac in nature and 2. Labs were ordered. The primary outcome was to compare the number of coagulation studies ordered pre and post-intervention. Results: Our analysis included 10,776 patients that were included in an SCCP pathway as determined by the CPOE database. Total number of visits in these two phases were similar (73,551 pre and 72, 769 post). In the pre-intervention phase, 5255 coagulation studies were done (4246 ordered by nursing staff and 1009 studies ordered by ED physicians). In the post-intervention phase, 1464 coagulation studies were ordered (1211 by nursing staff and 253 additional tests were ordered by ED physicians). With our intervention, we identified a net reduction of 3791 coagulation studies in our post-intervention phase for a reduction of 72.14% reduction (p=<0.0001) At a cost of 15.00$ (CDN$ at our center), we would realize an estimated cost -savings of 56,865$ for this intervention over a 90 day period. Conclusion: We have implemented a simple, sustainable, evidence based intervention that significantly minimizes the use of unnecessary coagulation studies in patients presenting with SCCP.

Introduction: The standard approach between Emergency Departments (EDs) and Psychiatric Emergency Services is to medically “clear” a stable patient of organic pathology prior to psychiatric consultation. Medical clearance involves neuroimaging, typically in the form of a computed tomography (CT) head scan. This study examines the clinical impact of ordering CT head scans for patients presenting with bizarre behaviour. Methods: A 5-year retrospective chart review was conducted at 3 academic, urban ED sites. Inclusion criteria were patients ≥18 years of age triaged as “mental health - bizarre behavior” (defined as deviating from normal cognitive behaviour with no obvious cause) with a CT head scan ordered while under the care of the ED. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Demographic, administrative, and neuroimaging data were extracted with 10% of charts independently reviewed by a staff Emergency Physician for inter-rater reliability. Results: 270 cases met study criteria. CT results were unavailable in 3, leaving 267 cases studied. The population demographics were: 49% percent female, average age 51 years old, 28% homeless, 59% arrived by police and/or ambulance. CT head results demonstrated 1 (0.4%) case with possible acute findings on CT. 108 (40%) had incidental findings (i.e. cerebral atrophy, small hypodensities), none of which impacted clinical management. Average time to physician assessment was 1 hour 58 minutes (sd 1:17) and time to CT head completion was 6 hours 50 minutes (sd 7:20) leaving an average of 4 hours 52 minutes awaiting these results. Ultimately 86% of patients were referred to a consultant of which 92% were to Psychiatry. Conclusion: This study of CT head scans for bizarre behavior ED presentations showed that the CT results did not change the clinical management of the patient. Furthermore, awaiting these results prolonged ED length of stay and delayed patient disposition. A prospective trial of a clinical decision tool for ordering CT head scans in these patients is warranted.

Introduction: Hydronephrosis is a marker of stone-related ureteral obstruction. Our objective was to assess the diagnostic and prognostic value of hydronephrosis in ED patients with renal colic. Methods: We used an administrative database to identify all renal colic patients seen in Calgary’s four EDs in 2014. Research assistants reviewed imaging reports to identify proven ureteral stones, and to document hydronephrosis and stone size. Surgical interventions, ED and hospital visits within 60-days were collated from all regional hospitals. The primary outcome was sensitivity and specificity of hydronephrosis (moderate or severe) for detecting stones >5mm. We also assessed the association of hydronephrosis with index admission-intervention, and with outcomes at 7 and 60 days. Results: In 2014, 1828 patients had a confirmed ureteral stone plus assessment of hydronephrosis and stone size (1714 CT, 114 US). Hydronephrosis was absent, mild, moderate or severe in 15%, 47%, 34% and 4% of patients respectively. Median stone size was 4.0, 4.0, 5.0 and 7.0mm for patients in these categories. Mild, moderate and severe hydronephrosis were highly associated with admission (OR=2.0, 4.6, 9.8; p<0.001) and index visit surgical intervention (OR=2.1, 3.7, 6.0; p<0.001). The presence of moderate-severe hydronephrosis was 54.7% sensitive and 65.4% specific for stones > 5mm, with positive and negative predictive values of 51% and 74.2%. Of 1828 patients, 748 had an index visit surgical procedure and 1080 were discharged with medical management. In the latter group, hydronephrosis was absent, mild, moderate or severe in 20%, 50%, 27% and 3%. Corresponding median (IQR) stone size was 3.0, 4.0, 4.0 and 5.0mm. Of 1080 medically managed patients, 19% and 25% had an unscheduled ED revisit by 14 and 60 days, 9% and 10% were hospitalized by 7 and 60 days, and 13% had a rescue procedure within 60 days. In the medically managed group, degree of hydronephrosis had no statistical association with any outcomes at 7 or 60 days. Conclusion: Hydronephrosis has poor sensitivity, specificity and predictive value for stones >5mm. Degree of hydronephrosis is highly associated with MD decisions for admission and intervention, but not associated with patient outcomes in the absence of these decisions. Despite poor diagnostic and prognostic performance, hydronephrosis is likely guiding critical early management decisions.

Introduction: Acute aortic dissection (AAD) is a life threatening condition making early diagnosis critical. Although 90% present with acute pain, the myriad of associated symptoms can make investigation and diagnosis a challenge. Our objectives were to assess emergency physician use of CT, yield of CT and ordering variation among physicians in patients presenting with pain for diagnosis of AAD. Methods: This historical cohort study of consecutive adult patients presenting to two tertiary academic care EDs over one calendar year included patients with a primary complaint of non-traumatic chest, back, abdominal or flank pain. Patients were excluded if clear diagnosis was made by basic investigations or exam. Primary outcome was rate of CT Thorax or Thorax/Abdomen ordered to rule out AAD as per clinical indication on diagnostic requisition. Secondary outcome was variation in CT ordering. Variation was measured with; Cochrane q test for homogeneity, proportion of positive CT’s (z-test) and mean CT’s (t test) ordered between high (>5CT/yr) and low (<5CT/yr) test users. Sample size of 6 per group was calculated based on an expected delta in mean CT ordered of 5 and a within group SD of 3. Results: 31,201 patients presented with chest, abdominal, back, flank pain during the study period. 8,472 were excluded based on a diagnosis made by clinical exam or basic investigations. 22,776 were included (Mean 47years SD 18.5yrs 56.2% Female). Most common diagnoses; Chest pain NYD(23.3%), Abdominal pain NYD(20.8%), Lower back pain NYD(10.5%), Renal Colic (5.3%), ACS (2.9%). CT was ordered to rule out AAD in 175 (0.7%) (Mean 62 years SD 16.5, 50.6% Female). Only 4(2.3%) were found to have an AAD. There was significant variation (range 0.6-12% Q test P<0.027) between proportion of CT's ordered by physicians. Between high (Mean 7.9 n=10 AAD=2) and low test users (Mean 2.3 n=41 AAD=2), there was significant difference in mean number of CT’s ordered (p<0.001) but no difference in number of AAD found (p<0.2). No AAD were missed. Conclusion: Current rate of imaging for aortic dissection is appropriately low but inefficient, with 98% of advanced imaging negative. There is significant variation in physician CT ordering (almost 20-fold) without an increase in diagnosis. These findings suggest great potential for more standardized and efficient use of CT for the diagnosis of AAD.

Introduction: Closed reduction of distal radius fractures (CRDRF) is a commonly performed emergency department (ED) procedure. The use of Point-of-care ultrasound (POCUS) to diagnose fractures and guide reduction has previously been described. The primary objective for this study was to determine if the addition of PoCUS to CRDRF changed the perception of successful initial reduction. This was measured by the rate of further reduction attempts based on POCUS following the initial clinical determination of achievement of best possible reduction. Methods: We performed a multicenter prospective cohort study, using a convenience sample of adult ED patients presenting with a distal radius fracture to 5 Canadian EDs. All study physicians underwent standardized PoCUS training for fractures. Standard clinically guided best possible fracture reduction was initially performed. PoCUS was then used to assess the reduction adequacy. Repeat reduction was performed if deemed indicated. A post-reduction radiograph was then performed. Clinician impression of reduction adequacy was scored on a 5 point Likert scale following the initial clinically guided reduction, and following each POCUS scan and the post-reduction radiograph. Results: There were 131 patients with 132 distal radius fractures. Twelve cases were excluded prior to analysis. There was no significant difference in the assessment scores for reduction success by PoCUS vs. clinical assessment (Median scores 4 vs.4; p=0.370;) or in the odds ratio of successful reduction (0.89; 95% CI 0.46 to 1.72; p=0.87). Significantly fewer cases fell in the uncertain category with POCUS than with clinical assessment (12 vs 2; p=0.008). Repeat reduction was performed in 49 patients (41.2%). In this group, the odds ratio for adequate reduction assessment post-PoCUS to pre-PoCUS was 12.5 (95% CI 3.42 to 45.7; p<0.0001). There was no significant difference in the assessment of reduction by PoCUS vs. radiograph. Conclusion: PoCUS guided fracture reduction leads to repeat reduction attempts in approximately 40% of cases, and enhances certainty regarding reduction adequacy when clinical assessment is unclear.

Introduction: Data regarding adverse events (AEs) (unintended harm to a patient related to health care provided) among children treated in the emergency department (ED) have not been collected despite identification of the setting and population as high risk. The objective of our study was to estimate the risk and type of AEs, as well as their preventability and severity, for children seen in a pediatric ED. Methods: This prospective cohort study examined outcomes of patients presenting to a paediatric ED. Research assistants (RA) recruited patients < 18 yrs old during 28 randomized 8-hr shifts (over 1 yr). Exclusion criteria included unavailability for follow-up and insurmountable language barrier. RAs collected demographics, medical history, ED course, and systems level data. A RA administered a structured telephone interview to all patients at day 7, 14, and 21 to identify flagged outcomes (such as repeat ED visits, worsening/new symptoms, etc). Admitted patients' health records were screened with a validated trigger tool. A RA created narrative summaries for patients with flagged outcomes/triggers. Three ED physicians independently reviewed summaries to determine if an AE occurred. Primary outcome was the proportion of patients with an AE within 3 weeks of their ED visit. Results: We enrolled 1367 (70.3%) of 1945 eligible patients. Median age was 4.3 yrs (range 2 months-17.95 yrs); 676 (49.5%) were female. Most (n= 1279; 93.9%) were discharged. Top entrance complaints were fever (n=206,15.1%), cough (n=135, 9.9%), and difficulty breathing (n=108, 7.9%). Eight eighty (6.5%) patients were triaged as CTAS 1 or 2, 689 (50.6%) as CTAS 3, and 585 (42.9%) as CTAS 4 or 5. Only 44 (3.2%) were lost to follow-up. Flagged outcomes/triggers were identified for 498 (36.4%) patients. Thirty three (2.4%) patients suffered at least one AE within 3 weeks of ED visit; 30 (90.9%) AEs were related to ED care. Most AEs (n= 28; 84.8%) were preventable. Management (n=18, 54.5%) and diagnostic issues (n=15, 45.5%) were the most common AE types. The most frequent clinical consequences were need for medical intervention (n=15;45.5%) and another ED visit (n=13,39.4%). In univariate analysis, age (p=0.005) and weekday presentation (p=0.02) were associated with AEs. Conclusion: We found a lower risk of AEs than that reported among inpatient paediatric and adult ED studies utilizing similar methodology. A high proportion of AEs were preventable.

Introduction: Simulation-based medical education (SBME) is an important training strategy in emergency medicine (EM) postgraduate programs yet the extent of its use is variable. This study sought to characterize the use of simulation in FRCP-EM residency programs across Canada. Methods: A national survey was administered to residents (PGY2-5) and program representatives (PR), either a program director or simulation lead at all Canadian FRPC-EM programs. Residents completed either paper or electronic versions of the survey, and PR surveys were conducted by telephone. Results: The resident and PR response rates were 60% (187/310) and 100% (16/16), respectively. All residency programs offer both manikin-based high fidelity and task trainer simulation modalities. Residents reported a median of 20 (range 0-150) hours participating in simulation training annually, spending a mean of 16% of time in situ, 55% in hospital-based simulation laboratories, and 29% in off-site locations. Only 52% of residents indicated that the time dedicated to simulation training met their training needs. All PRs reported having a formal simulation curriculum with a frequency of simulation sessions ranging from weekly to every 6 months. Only 3/16 (19%) of programs linked their simulation curriculum to their core teaching. Only 2/16 programs (13%) used simulation for resident assessment, though 15/16 (93%) PRs indicated they would be comfortable with simulation-based assessment. The most common PR identified barriers to administering simulation by were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Both PRs and residents identified a desire for more simulation training in neonatal resuscitation, pediatric resuscitation, and obstetrical emergencies. Multidisciplinary involvement in simulations was strongly valued by both residents and PRs, with 76% of residents indicating that they would like greater multidisciplinary involvement. Conclusion: Among Canadian FRCP-EM residency programs, SBME is a frequently used training modality, however, there exists considerable variability in the structure, frequency and timing of simulation exposure for residents. Several common barriers were identified that impact SBME implementation. The transition to competency-based medical education will require a national, standardized approach to SBME that includes a unified strategy for training and assessment.

Introduction: Distal forearm fractures are one of the most common injuries presenting to the pediatric emergency department. Procedural sedation (PS) is commonly used to provide analgesia during fracture reduction, but requires a prolonged recovery period and can be associated with adverse respiratory events. Bier block (BB) regional anesthesia is a safe alternative to PS for fracture reduction analgesia. We sought to assess the impact of BB on length of stay (LOS) and adverse events following forearm fracture reduction compared to PS. Methods: We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. The primary outcome measure was emergency department LOS; secondary outcomes included reduction success rates, adverse events and unscheduled return visits. Results: Two-hundred and seventy-four patients were included for analysis; 109 treated with BB, 165 underwent PS. Overall, mean LOS was 82 min shorter for patients treated in the BB group (279 min vs. 361 min, p<0.05). Sub-analysis revealed a reduced LOS among patients treated with BB for fractures involving a single bone (286 min vs. 388 min, p<0.001) and both-bones of the forearm (259 min vs. 321 min, p<0.05). Both BB and PS resulted in comparable rates of successful reduction (98.2% vs. 97.6%, p=0.74). There were no major adverse events in either group. Patients who received BB experienced significantly fewer minor adverse events (2.7% vs. 14.5%, p<0.05). Return visit rates were similar in the BB and PS groups (17.6% vs. 17.1%, p<0.05). Conclusion: Compared to PS, forearm fracture reduction performed with BB was associated with a reduced emergency department LOS and fewer adverse events, with no difference in reduction success or return visits.

Introduction: H1-antihistamines are often used to treat allergic reactions, however, the influence of H1-antihistamines on progression to anaphylaxis remains unclear. Among patients initially presenting with allergic reactions, we investigated whether H1-antihistamines were associated with a lower proportion of patients progressing to anaphylaxis during observation. Methods: This was a retrospective cohort study conducted at two urban EDs from 2007 to 2012. We included adult patients with allergy and excluded those who met criteria of anaphylaxis at first evaluation by medical professionals and/or received antihistamines before the evaluation. Primary outcomes of interest were the number of patients who developed anaphylaxis during observation at ED and/or transportation by EMS. Secondary outcomes were the number of biphasic reactions and severe anaphylaxis (defined as sBP<90; SpO2<92%; and/or confusion, collapse, loss of conscious, or incontinence). Logistic regression was performed comparing primary and secondary outcomes between H1-antihistamine treated and non-treated groups with propensity score adjustment of the baseline covariates. Number needed to treat (NNT) was calculated by adjusted absolute risk reduction of H1-antihistamine compared to non H1-antihistamine use on primary outcome. Results: This study included 1717 patients with allergic reactions, of whom 1228 were treated with H1-antihistamines. In the H1-antihistamine group 1.0% and 0.2% developed anaphylaxis and severe anaphylaxis, respectively; in the non-H1-antihistamine group 2.6% and 0.6% developed anaphylaxis and severe anaphylaxis, respectively. There were no biphasic reactions (0%, 95% confidence interval [CI] 0 to 0.17%). Administration of H1-antihistamines was associated with a lower incidence of subsequent anaphylaxis (adjusted odds ratio [OR] 0.23, 95% CI 0.10 to 0.53; NNT to benefit 49.1, 95% CI 41.6 to 83.3). There were no significant associations between H1-histamines administration and secondary outcomes. Conclusion: Among ED patient with allergic reactions, H1-antihistamine administration was associated with a lower likelihood of progression to anaphylaxis. These findings suggest that H1-antihistamines should be administered early in the care of patients with allergic reactions.

Introduction: The 2011 Canadian Diabetes Association (CDA) Clinical Practice Guidelines were developed in order to help physicians manage hyperglycemic emergencies in the emergency department (ED), including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The goal of this study was to determine physician attitudes towards these guidelines and to identify potential barriers to their implementation in the ED. Methods: We distributed an online, cross sectional survey to 500 randomly selected members of the Canadian Association of Emergency Physicians (CAEP) who were currently practicing physicians. A total of 3 email notifications were distributed on days 1, 7 and 14. The survey consisted of 23 questions relating to physician management of DKA and HHS in the ED. The primary outcome was overall physician familiarity and usage of the guidelines using a 7-point Likert scale. Secondary outcomes included physician attitudes towards the guidelines as well as any perceived barriers to their implementation in the ED. Simple descriptive statistics were used to illustrate the survey results. Results: The survey response rate was 62.2% (311/500) with the following participant characteristics: male (62.6%), CCFP(EM) training (46.1%) and working in major academic centers (50.5%). The overall awareness rate of the CDA guidelines was 22.9% (95% CI = 18.3%, 27.5%). 58.9% (95% CI = 53.3%, 64.3%) reported the CDA guidelines being useful. The most frequently reported barriers to CDA guideline implementation were concerns about education issues (56.0%), lack of time and disruption of flow (23.9%), staffing and human resource issues (26.7%) and poor policy adherence (25.5%). Physician’s ideal changes to optimize the management of these patients included improved coordination for follow-up with family physicians (79.9%), increased diabetes education for patients (73.9%) and increased availability to diabetes specialists (47.5%). Conclusion: In this study, although Canadian ED physicians were generally supportive of the CDA guidelines, many were unaware that these guidelines existed and barriers to their implementation were reported. Future research should focus on strategies to standardize DKA and HHS management by ensuring physician awareness and education to ensure the highest quality of patient care.

Introduction: The Toronto Central Local Health Integration Network released new antimicrobial guidelines for the treatment of community acquired pneumonia (CAP) in August 2013. These deemphasized antimicrobial coverage for atypical organisms and use amoxicillin-clavulanic acid (AMC) as first-line for low risk CAP. The purpose of this study was to assess physician adherence to these guidelines in St. Michael’s Hospital (SMH) Emergency Department (ED). Methods: A retrospective chart review was conducted from April 1 to May 31 in 2013, 2014 and 2015. All adult patients who were discharged home from the ED with a diagnosis of pneumonia were included. Severity of pneumonia was graded based on the CRB-65 score as per the CAP guidelines. Primary outcome was type of antibiotic prescribed by the ED physician. Data was analyzed using simple descriptive statistics. Results: There were a total of 141 patients analyzed during the study period (N=46 in 2013, N=59 in 2014, N=36 in 2015). Demographics and relevant comorbidities were similar across the years: age (2013: median=53 years, range 20-92 years; 2014: 56, 21-83; 2015: 54, 20-81); preexisting lung disease (30%, 27%, 25% respectively); HIV positive status (9%, 7%, 17%). CRB-65 score was: low risk (0 points)=70% in 2013, 66% in 2014, 75% in 2015; intermediate risk (1-2 points)=30%, 34%, 25%; high risk (3-4 points)=0% in all years. Percentage of patients discharged home with a documented prescription was 83%, 85%, and 94% respectively. In 2013, patients received azithromycin (AZM) (n=17, 43% of antibiotic prescriptions that year); levofloxacin (LVX) (n=10, 25%); AMC (n=5, 13%); clarithromycin (CLR) (n=5, 13%); trimethoprim-sulfamethoxazole (SXT) (n=2, 5%); doxycycline (DOX) (n=1, 3%). In 2014: AMC (n=26, 51%); AZM (n=12, 24%); LVX (n=9, 18%); CLR (n=2, 4%); DOX (n=1, 2%); erythromycin (ERY) (n=1, 2%). In 2015: AMC (n=17, 47%); AZM (n=12, 33%); LVX (n=4, 11%); CLR (n=1, 3%); SXT (n=1, 3%); DOX (n=1, 3%). Number of return ED visits within 2 weeks were: n=16 (35%); n=11 (19%); and n=10 (28%) respectively. Conclusion: The results of this study show that there has been a change in antibiotic prescribing practices in the SMH ED since dissemination of the CAP guidelines, with AMC accounting for nearly half of antibiotic prescriptions. Further antimicrobial stewardship efforts will focus on evaluating factors influencing prescribing practices.

Introduction: Pharyngitis is a common presenting complaint at the emergency department (ED). Historically, acute pharyngitis has been overdiagnosed as the result of a bacterial etiology, leading to over-prescription of antibiotics, and overuse of throat culturing. This study attempts to quantify the current management of acute pharyngitis in the ED, and compare to the theoretical management using a modified Centor score. Methods: This was a retrospective chart review of 1640 patients who presented to four EDs in the central zone of the Nova Scotia Health Authority that received a diagnosis of pharyngitis, bacterial pharyngitis or tonsillitis. The primary outcome was the observed rate of each diagnosis in the study population, the rate of antibiotic prescription, and the rate of throat swab cultures performed. The secondary outcomes were the rate of antibiotics and throat swabs ordered using a modified Centor score. Antibiotics as first-line treatment were indicated if the Centor score was three or greater, and throat cultures were indicated if the Centor score was two or greater. Results: A total of 1596 patients were included in the analysis. Antibiotics were given in 893 patients (0.559; 95% CI: {0.535, 0.584}). Cultures were sent on 863 patients (0.541 CI: {0.516, 0.565}). Using the modified Centor thresholds, we would have prescribed antibiotics as the first-line treatment in 77 cases (0.048 CI: {0.038, 0.060}), potentially saving 786 prescriptions, and ordered throat swabs on 502 patients (0.315, CI: {0.292, 0.338}), saving 361 cultures. The most commonly prescribed antibiotic was penicillin, and the least prescribed was metronidazole. Conclusion: Over half of patients that present with acute pharyngitis receive an antibiotic, and over half have a throat swab culture performed. Utilizing a modified Centor score would result in decreased antibiotic prescription rate, and a diminished rate of throat cultures. Incorporation of these Centor criteria could result in diminished antibiotic prescription rates for acute pharyngitis in the ED.

Introduction: Influenza and pneumococcal disease are vaccine preventable diseases that account for significant morbidity and mortality in Canada. Influenza vaccination has been shown to reduce mortality and pneumococcal vaccination reduces invasive pneumococcal disease. Previous studies have shown that emergency department (ED) patients are often at high risk for influenza and pneumococcal disease and willing to be vaccinated during their ED stay. Our study set out to determine what proportion of adult patients in the ED qualify for and are willing to be vaccinated against influenza and pneumococcus during their ED visit. Methods: Our study used a convenience sample of patients presenting to the ED at a large Canadian tertiary care centre (Vancouver General Hospital). Inclusion criteria were: adult patients (19 years or greater); consenting to be screened for immunization status; and able to communicate in English. The exclusion criteria were: critically ill patients and patients in severe pain. The primary outcome was the proportion of patients presenting to the ED that could be immunized for influenza and pneumococcus (member of a high risk group, unvaccinated and willing to be vaccinated). Secondary outcomes included additional demographic characteristics and patient attitudes regarding vaccination. Results: We screened 413 patients of which 55 did not meet inclusion/exclusion criteria and 104 declined participation. A total of 254 patients completed the survey for a response rate of 71%. Our primary outcome was present in 20% of patients for influenza (high risk for complications, unvaccinated and willing to be vaccinated in the ED). For pneumococcus, 15% were at high risk, unvaccinated and willing to be vaccinated in the ED. In our population, 83% were at high risk of complications from influenza and 58% were at high risk of complications from pneumococcus. In total, 53% of patients would accept influenza vaccine and 44% would accept pneumococcal vaccine. Conclusion: Our study demonstrates that there is a significant high-risk population that is otherwise unreached and are willing to be vaccinated for influenza and pneumococcus in the ED. Our patient population has a very high prevalence of risk factors for complications of pneumonia and influenza. This data suggests that ED patients are a high-risk population and could be a target group for vaccination campaigns.

Introduction: Fever in the returning traveller is a common ED presentation; however approaches and level of comfort with tropical diseases vary widely. This project aimed to conduct a systematic review and critical appraisal of existing clinical practice guidelines and approaches, to guide an ED approach, in Canada, to fever in the returning traveller. Methods: A literature review was conducted of peer reviewed papers, national and international practice guidelines, and practice statements presenting approaches to fever in the returning traveller. A literature search was conducted using MEDLINE and Embase (1947-Dec 2014), with librarian assistance to optimize strategy. The databases of guideline clearing houses, CMA, PHAC, WHO, CDC, and the Cochrane library were searched, along with a google scholar search. References of included articles were hand searched. Article titles and abstracts were reviewed by the author for inclusion. Key elements of the guidelines and approaches were identified and grouped by theme and where appropriate, the quality of guidelines were assessed by two reviewers using the AGREEII tool. Results: The search returned 1598 titles. 72 full manuscripts were reviewed based on inclusion from title and abstract, with 24 manuscripts included for final analysis. Common elements suggested by the guidelines or approaches were identified and grouped within three themes (key historical features, physical exam findings, investigations). Most manuscripts presented tables of important clinical information, but limited guidance on how to approach diagnosis in a focused manner. When evaluated by AGREEII, only one guideline (D’Acremont et al) scored > 50% overall quality rating. Unlike other approaches, this guideline proposes a stepwise approach to diagnosis and treatment based on the presence of key exposures, signs/symptoms, and eosinophilia. Conclusion: The guideline by D’Acremont et al was identified as the most rigorous existing practice guideline. This guideline, combined with other elements identified by thematic review, forms the basis of a suggested ED approach to fever in the returning traveller, which will be further refined using the AGREEII model to propose a practice guideline for Canadian EDs.

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to the emergency department. A coordinated ED AFF electronic order-set and management pathway was developed in collaboration with cardiologists at our institution. The primary objective of this study was to compare the ED length of stay pre and post pathway implementation. Secondary objectives included comparison of the following outcomes pre and post-pathway (PRE & POST): AFF Clinic referral rates, ED return rates, and mortality. Methods: This was a retrospective case series of patients presenting to our quarternary care ED with AFF pre and post AFF pathway implementation. Cases were identified using an administrative database covering 120 000 annual ED visits. Trained research assistants and the primary investigator extracted data from the electronic medical record. 20% of all charts were double collected to ensure accuracy (k=0.85). Descriptive variables were described using counts, means, medians and confidence intervals. Chi-square statistics of dependent samples were calculated for the primary outcome. Results: We examined 307 cases of AFF presenting to our ED (n=130 PRE; n=177 POST). Demographic variables were similar PRE and POST: mean age (66.0 [95%CI 63.8-68.3] PRE; 65.0 [63.0-67.0] POST), % male (59.2% PRE; 59.3% POST), presenting rhythm (66.2% A.fib [58.0-74.3] A. flutter 29.2% [21.4-37.0] PRE; 61.0% A.fib [53.8-68.1] A. flutter 17.5% [11.9-23.1] POST), and CHADS2VASC score (2.1 [1.8-2.4] PRE; 1.9 [1.7-2.1] POST). The mean ED LOS decreased by 72.5 minutes (95% CI -22.9 to -122.1; P < 0.001). AFF clinic referral rates increased from 16.9% PRE to 25.4% POST (not significant). ED return rates within 30 days for AFF, CHF, major bleeding and CVA were unchanged. 30 day mortality rates were not statistically different (1.5% PRE vs. 2.8% POST). Conclusion: A coordinated ED AFF pathway was associated with a significant reduction in ED LOS without significant changes in ED return rates or mortality.

Introduction: Dyspnea is a common presenting problem in the emergency department (ED) that frequently creates a diagnostic challenge for physicians. Acute decompensated heart failure (ADHF) represents a common cause that requires prompt diagnosis and management. Recent studies on dyspneic patients have suggested a potential role for point-of-care ultrasound (PoCUS). The objective of this systematic review was to assess the sensitivity and specificity of early bedside lung ultrasound in patients presenting to the ED with dyspnea. Methods: A search of the literature was conducted using PubMed, EMBASE, the Cochrane Library, bibliographies of previous systematic reviews, and abstracts from major emergency medicine conferences. We included prospective studies that assessed the diagnostic accuracy of B-lines from bedside lung ultrasound in the ED patients compared to a clinical diagnosis of ADHF at hospital discharge. The final diagnosis included at least one of CXR, computed tomography, or BNP. Two reviewers independently screened all titles and abstracts for possible inclusions. Two separate content experts full text-reviewed selected studies and performed quality analysis using a modified Critical Appraisal Skills Program (CASP) questionnaire. Extracted data was assessed with summary receiver operator characteristics curve (SROC) analysis with pooled sensitivity and specificity. Heterogenity was tested. Results: The electronic search yielded 3674 articles of which six met the inclusion criteria and fulfilled CASP requirements for methodological quality. The total number of patients in these studies was 1911. Heterogeneity was noted; due to poorer performance by novice users. Meta-analysis of the data showed that in detecting ADHF, bedside lung ultrasound had a pooled sensitivity of 89.6% (95% CI 69.5 to 97.0%) and a pooled specificity of 88.4% (95% CI 75.0 to 95.1%). The positive likelihood ratio was 6.01 (95% CI 2.93 to 12.32) and negative likelihood ratio was 0.13 (95% CI 0.06 to 0.30). Conclusion: This study suggests that in patients presenting to the ED with undifferentiated dyspnea, early point of care lung ultrasound may be used to confirm the diagnosis of ADHF, which may facilitate earlier appropriate management. Test performance may vary according to experience.

Introduction: Acute aortic dissection (AAD) is difficult to diagnose and if missed carries a significant mortality rate. Our aim was to assess the accuracy of history, physical exam and plain radiographs compared to advanced imaging in the diagnosis of AAD in adults presenting to the ED with a clinical suspicion of AAD. Methods: We conducted a librarian assisted systematic review. Databases searched: Pubmed, Medline, Embase and the Cochrane database from 1968 to January 2016. No restrictions for language were imposed. Studies were reviewed and data extracted by two independent reviewers. AAD was defined by CTA, MRI or TEE Prospective and retrospective studies of patients presenting with a clinical suspicion of AAD were included. Case series were excluded. Studies were combined if low clinical and statistical heterogeonity (I2<30%). Study quality was assessed using the QUADAS tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 was performed. Results: We identified 792 records: 61 selected for full text review, 13 included and a further 7 from reference searches. 20 studies with 4721 participants were included (mean QUADAS score 12/14 SD 1.2, Kappa 0.8). Prevalence of AAD ranged from 9.6-76.1% (mean 39.1% SD 17.1%). Mean diagnosis in those without AAD varied between studies with ACS (30.3% SD 30.1%), Anuerysm(12.4% SD 9.8%), Chest wall pain(18.1% SD 13.3%) and PE(7.9% SD 7.85%) being the most common. The clinical findings most suggestive of AAD were, neurological deficit (specificity 94% LR 4.1 [95% CI, 3.1-5.2], I2 0%, n=9), hypotension(specificity 94% LR 2.6 [95% CI 1.6-4.2], I2 0%, n=8), pulse deficit (specificity 92% LR 3.4 [95% CI 1.8-6.4], I2 0%, n=9) and syncope (specificity 92% LR 1.4 [95% CI 1.1-1.8], I2 10%, n=6). The most useful for identifying patients less likely to have AAD were an absence of a widened mediastinum (sensitivity 80% LR 0.3 [95% CI 0.2-0.5], I2 20%, n=13) and an AHA Aortic dissection risk score <1 (n=2 sensitivity 91%,99% LR 0.02,0.22, [95% CI 0.003-0.128, 95%CI 0.2-0.3]). Conclusion: Suspicion for AAD should be raised with syncope, hypotension and pulse or neurological deficit in the appropriate clinical setting. Conversely the absence of a widened mediastinum and a low ADD score decreases likelihood. Clinical exam alone cannot rule out acute aortic dissection but it can help risk stratify for further testing.

Introduction: Remote ischemic conditioning (RIC) is a non-invasive therapeutic strategy that uses brief cycles of inflation and deflation of a blood pressure cuff to reduce ischemia-reperfusion injury during acute ST-elevation myocardial infarction (STEMI). The primary objective of this systematic review was to determine if RIC initiated prior to catheterization increases myocardial salvage index, defined as the proportion of area at risk of the left ventricle salvaged by treatment following emergent percutaneous coronary intervention (PCI) for STEMI. Secondary outcomes included infarct size and major adverse cardiovascular events. Methods: Electronic searches of PubMed, Ovid MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were conducted and reference lists were hand-searched. Randomized controlled trials comparing PCI with and without RIC for patients with STEMI published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as risk ratios (RR) with 95% confidence intervals (CIs). Results: Nine RCTs were included with a combined total of 999 patients (RIC+PCI = 534, PCI = 465). The myocardial salvage index was higher in the RIC+PCI group at 3 and 30 days; mean difference 0.09 (95% CI: 0.04, 0.15) and 0.12 (95% CI: 0.03, 0.21), respectively. Infarct size was reduced in the RIC+PCI group at 3 and 30 days; mean difference -3.82 (95% CI: -8.15, 0.51) and -4.00 (95% CI: -7.07, -0.93), respectively. There was no statistical difference with respect to death and re-infarction, however there was a reduction in heart failure with RIC+PCI at 6 months; RR: 0.43 (95% CI: 0.19, 0.99). Conclusion: RIC is emerging as a promising adjunctive treatment to PCI for the prevention of reperfusion injury in STEMI patients. Ongoing, multicenter clinical trials will help elucidate the effect of RIC on clinical outcomes such a hospitalization, heart failure and mortality.