Introduction: The Ottawa SAH Rule was developed to identify patients at high-risk for subarachnoid hemorrhage (SAH) who require investigations and the 6-Hour CT Rule found that computed tomography (CT) was 100% sensitive for SAH 6 hours of headache onset. Together, they form the Ottawa SAH Strategy. Our objectives were to assess: 1) Safety of the Ottawa SAH Strategy and its 2) Impact on: a) CTs, b) LPs, c) ED length of stay, and d) CT angiography (CTA). Methods: We conducted a multicentre prospective before/after study at 6 tertiary-care EDs January 2010 to December 2016 (implementation July 2013). Consecutive alert, neurologically intact adults with a headache peaking within one hour were included. SAH was defined by subarachnoid blood on head CT (radiologists final report); xanthochromia in the cerebrospinal fluid (CSF); >1x106/L red blood cells in the final tube of CSF with an aneurysm on CTA. Results: We enrolled 3,669 patients, 1,743 before and 1,926 after implementation, including 185 with SAH. The investigation rate before implementation was 89.0% (range 82.9 to 95.6%) versus 88.4% (range 85.2 to 92.3%) after implementation. The proportion who had CT remained stable (88.0% versus 87.4%; p=0.60), while the proportion who had LP decreased from 38.9% to 25.9% (p<0.001), and the proportion investigated with CTA increased from 18.8% to 21.6% (p=0.036). The additional testing rate (i.e. LP or CTA) diminishedfrom 50.1% to 40.8% (p<0.001). The proportion admitted declined from 9.8% to 7.3% (p=0.008), while the mean length of ED stay was stable (6.2 +/− 4.0 to 6.4 +/− 4.1 hours; p=0.45). For the 1,201 patients with CT 6 hours, there was an absolute decrease in additional testing (i.e. LP or CTA) of 15.0% (46.6% versus 31.6%; p<0.001). The sensitivity of the Ottawa SAH Rule was 100% (95%CI: 98-100%), and the 6-Hour CT Rule was 95.3% (95%CI: 88.9-98.3) for SAH. Five patients with early CT had SAH with CT reported as normal: 2 unruptured aneuryms on CTA and presumed traumatic LP (determined by treating neurosurgeon); 1 missed by the radiologist on the initial interpretation; 1 dural vein fistula (i.e. non-aneuyrsmal); and 1 profoundly anemic (Hgb 63g/L). Conclusion: The Ottawa SAH Strategy is highly sensitive and can be used routinely when SAH is being considered in alert and neurologically intact headache patients. Its implementation was associated with a decrease in LPs and admissions to hospital.

Introduction: Gastroenteritis accounts for 1.7 million emergency department visits by children annually in the United States. We conducted a double-blind trial to determine whether twice daily probiotic administration for 5 days, improves outcomes. Methods: 886 children aged 348 months with gastroenteritis were enrolled in six Canadian pediatric emergency departments. Participants were randomly assigned to twice daily Lactobacillus rhamnosus R0011 and Lactobacillus helveticus R0052, 4.0 x 109 CFU, in a 95:5 ratio or placebo. Primary outcome was development of moderate-severe disease within 14 days of randomization defined by a Modified Vesikari Scale score 9. Secondary outcomes included duration of diarrhea and vomiting, subsequent physician visits and adverse events. Results: Moderate-severe disease occurred in 108 (26.1%) participants administered probiotics and 102 (24.7%) participants allocated to placebo (OR 1.06; 95%CI: 0.77, 1.46; P=0.72). After adjustment for site, age, and frequency of vomiting and diarrhea, treatment assignment did not predict moderate-severe disease (OR, 1.11, 95%CI, 0.80 to 1.56; P=0.53). In the probiotic versus placebo groups, there were no differences in the median duration of diarrhea [52.5 (18.3, 95.8) vs. 55.5 (20.2, 102.3) hours; P=0.31], vomiting [17.7 (0, 58.6) vs. 18.7 (0, 51.6) hours; P=0.18], physician visits (30.2% vs. 26.6%; OR 1.19; 95% CI0.87. 1.62; P=0.27), or adverse events (32.9% vs. 36.8%; OR 0.83; 95%CI 0.62. 1.11; P=0.21). Conclusion: In children presenting to an emergency department with gastroenteritis, twice daily administration of 4.0 x 109 CFU of a Lactobacillus rhamnosus/helveticus probiotic does not prevent development of moderate-severe disease or improvements in other outcomes measured.

Introduction: Neuroleptics are commonly used drugs to treat different conditions (e.g. psychosis, migraines) in the acute care setting and the emergency department. Their side effects can be disabling or, worse, fatal. The use of diphenhydramine to prevent those side-effects is widespread, but remains controversial. We performed a systematic review to determine if prophylactic administration of diphenhydramine (PAD) reduces the incidence of neuroleptic side-effects. Methods: Data sources: Medline, Embase, Cochrane Library, PsycInfo and Web of Science were searched. References from reviews that were identified in the search and from included studied were also reviewed for inclusion. Study selection: Randomized controlled trials evaluating any neuroleptic with PAD versus the same neuroleptic alone or with any inactive agent. Primary outcome was incidence of any extra-pyramidal side-effect. Secondary outcomes were akathisia, usage of rescue medication, subjective restlessness, neuroleptic malignant syndrome, sedation and sedation intensity. Data extraction: Independent reviewers scanned identified citations, extracted data and assessed for risk of bias. Data analysis: Meta-analysis was performed using random effect models. Heterogeneity and quality of evidence were assessed using, respectively, I2 and the GRADE approach. Results: Results: Of 1566 identified citations, nine studies (n=1436) met all eligibility criteria. Four studies were specifically designed to assess for neuroleptic side-effects. Four studies were at high risk of bias. In primary analysis, PAD had no effect on the incidence of extra-pyramidal symptoms (7 studies, n=1393 patients, RR 0.70 [0.40-1.22]), akathisia (5 studies, n=1094 patients, RR 0.81 [0.36-1.82]) and sedation (5 studies; n=1079, RR 1,48 [0.90-2.42]). Higher dosage of diphenhydramine was not associated with a greater reduction of extra-pyramidal side-effects. In a sensitivity analysis excluding an outlier study (n=120, RR 6.63 [1.55-28,35]), PAD was associated with a significant decrease in extra-pyramidal side-effects (6 studies, n=1273, RR 0.56 [0,38-0.82]), but not with any of the secondary outcome measures. Conclusion: Conclusion: When excluding an outlier study, PAD was associated with a significant reduction of extra-pyramidal side-effects. However, PAD did not significantly influence the incidence of akathisia. Overall quality of evidence is low. Further studies are warranted. PAD represents an interesting treatment option against neuroleptic side-effects, but its widespread usage whitout strong evidence to support it raises concerns.

Introduction: Overuse of acute care services, particularly emergency department (ED) use, is an important topic for healthcare providers and policy makers within Canada and abroad. Prior work has shown that frail elderly patients with complex medical needs and limited personal and social resources are heavy users of ED services and are often admitted when they present to the ED. Updated information on the most effective strategies to avert ED presentation and hospital admission focused specifically on elderly patients is needed. Methods: This systematic review addressed the question: what interventions have demonstrated effectiveness in decreasing ED use and hospital admissions in elderly patients? Comprehensive literature searches were conducted in databases including Ovid Medline, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials with no language or date restrictions. Citations were limited to interventional studies. Grey literature and reference list searches, as well as communication with experts in the field were performed. Consensus or a third reviewer resolved any disagreements. Original research regarding interventions conducted in populations 65 years or older with acute illness, either living in community or facility-living were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included: mortality, cost, and patient-reported outcomes such as health-related quality of life and functional status. Results: Forty-three relevant studies were identified including 22 randomized controlled trials (RCT), 2 cluster-RCT, 2 trials with non-random allocation, 4 before-after studies, 6 quasi-experimental studies, and 7 cohort studies. Intervention settings included: home visits (22), long-term care (7), outpatient or primary care clinics (8), and ED (3) or inpatient (3). Data characterization revealed that home-based, outpatient and/or primary care-based strategies reduced ED visits and hospitalizations, particularly those which included comprehensive geriatric assessments, home visits or regular face-to-face contact and interdisciplinary teams. Hospital-based models generally showed no difference in ED or inpatient service utilization. There was, however, considerable variability across individual studies with respect to reporting of outcomes, statistical analyses performed, and overall risk of bias. Conclusion: Various interventional strategies have been studied to avert ED presentation and hospital admission for frail elderly patients. More rigorous methodology and standardization of outcome measures is needed to quantitatively assess the effects of these programs.

Introduction: Out-of-hospital cardiac arrest (OHCA) is associated with high mortality, and CPR quality is one of the few modifiable factors associated with improved outcomes. Particularly, bystander CPR has been shown to improve survival and neurological outcomes in OHCA. However, the quality of CPR performed by bystanders in OHCA is unknown. We evaluated bystander CPR quality during OHCA, utilizing data stored within Automated External Defibrillators (AEDs), and matched with cases enrolled in the Resuscitation Outcomes Consortium (ROC) database. Methods: This cohort study included adult OHCA cases from the Ottawa ROC site between 2011-2016, which were of presumed cardiac etiology, not witnessed by EMS, and where an AED was utilized by a bystander with > 1 minute of CPR process data available. AED data from Ottawa Paramedic Services was matched to each case identified by the ROC database. AED data was analyzed using manufacturer software to determine overall measures of bystander CPR quality, changes in bystander CPR quality over time, and bystander adherence to existing 2010 Resuscitation Guidelines. Results: 100 cases met all inclusion criteria. 75.0% of patients were male, with a mean age of 62.3 years. 58.0% of arrests occurred in the home setting, and 24.0% were witnessed arrests. Initial rhythm was ventricular fibrillation/ventricular tachycardia in 36.0% of cases. Overall survival rate was 42.0%, with a modified Rankin Score of 3.7 (95% CI: 2.9-4.5). Bystanders demonstrated high-quality CPR over the course of resuscitation, with a chest compression fraction (CCF) of 75.9% (73.6-78.1), a compression depth of 5.26 cm (5.03-5.49), and a compression rate of 111.2/min (107.7-114.7). Mean peri-shock pause was 26.8 seconds (24.6-29.1). Adherence rates to 2010 Resuscitation Guidelines for compression rate and depth were 66.0% (60.9-71.1) and 54.9% (48.6-61.3), respectively. CPR quality was lowest in the first minute of resuscitation, during which rhythm analysis took place (mean 40.5 sec). In cases involving a shockable rhythm, overall latency from initiation of AED to shock delivery was 59.2 sec (45.5-72.8). Conclusion: We found that bystanders perform high-quality CPR, with strong adherence rates to existing Resuscitation Guidelines. Our findings provide evidence of the quality of bystander CPR performed during OHCA.

Introduction: Within Manitoba, little is known about the current state of pediatric emergency department (ED) use or the state of provincial data collection. This study sought to gain a baseline understanding of pediatric ED use in Manitoba, including child demographics, visit characteristics, variation across the province, drivers of ED use, and data completeness. Methods: A retrospective cohort study was conducted using administrative data from the Manitoba Centre for Health Policy, and included all children aged 0-17 who presented to a Manitoba ED between 2011/12 and 2015/16, as identified from the Emergency Department Information System (EDIS), the National Ambulatory Care Reporting System (NACRS) and physician billing claims. Frequency of use was defined as single, intermediate (2-6 visits) and frequent (7+) and regional trends in child characteristics, ED use, acuity, presenting complaints, and discharge dispositions were observed. Ordinal logistic regression will be used to identify predictors of ED use. Results: Overall, we were able to capture 250,620 ED visits made by 172,306 children; data sources and completeness varied by year. Provincially, children under 5 years of age were the most frequent users of the ED, and use <1 year of age was highest in the North. We observed higher use among low-income children, particularly in rural mid and north, and few differences by sex. By year, the majority of children made single-use of the ED (64.48%), while fewer were classified as intermediate (34.40%) or frequent users (1.11%). Overall, the top presenting complaints were for fever (10.27%), limb complaint/trauma (7.48%), abdominal pain (5.75%), nausea and/or vomiting (4.53%) and shortness of breath (3.68%), with variation by triage level. In rural but not urban areas, mental health assessments were a top presenting complaint and primary reason for transfer to larger centres. Results of predictors of ED use are pending. Conclusion: Results from this study will provide important information about the predictors and variation of ED use by region and top causes for visit, enabling us to better tailor knowledge mobilization efforts and tool development to the local context. Identified gaps in data collection are important to address to advance our knowledge and delivery of pediatric emergency care at the provincial level.

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm (ventricular tachycardia or ventricular fibrillation) have higher odds of survival than those suffering from non-shockable rhythm (asystole or pulseless electrical activity). Because of that prognostic significance, patients with an initial non-shockable rhythm are often not considered for advanced resuscitation therapies such as extracorporeal resuscitation. However, the prognostic significance of the conversion to a shockable rhythm from an initially non-shockable rhythm remains uncertain. This study aimed to determine the degree of association between the conversion (or not) of a non-shockable rhythm to a shockable rhythm and resuscitation outcomes in patients with OHCA. It was hypothesized that such a conversion would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montreal, Canada. Adult patients with non-traumatic OHCA and an initial non-shockable rhythm were included. The primary outcome measure was survival to hospital discharge, and the secondary outcome measure was prehospital return of spontaneous circulation (ROSC). The associations of interest were evaluated with univariate logistic regressions and multivariate models controlling for demographic and clinical variables (e.g. age, gender, type of initial non-shockable rhythm, witnessed arrest, bystander cardiopulmonary resuscitation). Assuming a survival rate of 3% and 25% of the variability explained by the control variables, including more than 4580 patients would allow to detect an absolute difference of 4% in survival between both groups with a power of more than 90%. Results: A total of 4893 patients (2869 men and 2024 women) with a mean age of 70 years (standard deviation 17) were included, of whom 450 (9.2%) experienced a conversion to a shockable rhythm during the course of their prehospital resuscitation. Among all patients, 146 patients (3.0%) survived to discharge and 633 (12.9%) experienced prehospital ROSC. In the univariate models, there was no association between the conversion to a shockable rhythm and survival (odds ratio [OR] 1.14 [95% confidence interval {CI} 0.66-1.95]), but a significant assocation was observed with ROSC (OR 2.00 [95% CI 1.57-2.55], p<0.001). However, there was no independent association between the conversion to a shockable rhythm and survival (adjusted OR [AOR] 0.92 [95% CI 0.51-1.66], p=0.78) and prehospital ROSC (AOR 1.30 [95% CI 0.98-1.72], p=0.073). Conclusion: There is no clinically significant association between the conversion to a shockable rhythm and resuscitation outcomes in patients suffering from OHCA. The initial rhythm remains a much better outcome predictor than subsequent rhythms and should be preferred when evaluating the eligibility for advanced resuscitation procedures.

Introduction: The World Health Organization recommends emergency care training for laypeople in low-resource settings, but the effects of these programs on patient outcomes and community health have not been systematically reviewed. Our objective was to identify the individual and community health effects of educating laypeople to deliver emergency care in low-resource settings. Methods: We conducted a systematic review to address this question: in low-resource populations (P), does emergency care education for laypeople (I) confer any measurable effect on patient morbidity and mortality, or community capacity and resilience for emergency health conditions (O), in comparison with no training or other education(C)? We searched 12 electronic databases and grey literature for quantitative studies. We conducted duplicate and independent title and abstract screening, methodological and outcomes extraction, and study quality assessment using the Effective Public Health Practice Tool. We developed a narrative summary of findings. (PROSPERO: CRD42014009685) Results: We reviewed 16,017 abstracts and 372 full-text papers. 38 met inclusion criteria. Most topically relevant papers were excluded because they assessed educational outcomes. Cardiopulmonary resuscitation training (6 papers) improved cardiac arrest survival and enhanced capacity to respond to cardiac arrest in rural Norway, Denmark and commercial aircraft operations. A public education campaign in remote Denmark improved absolute cardiac arrest survival by 5.4% (95%CI 2-12). Lay trauma training (12 papers) reduced absolute injury mortality and improved community capacity in Iraq, Cambodia, Iran and Indigenous New Zealand communities. A trauma care program in Iraq and Cambodia reduced absolute mortality by 25% (95%CI 17.2-33). Education for mothers on paediatric fevers in Ethiopia was associated with 40% relative reductions in under-5 mortality (95%CI 29.2-50.6). Similar training improved access to care for paediatric malnutrition, malaria, pneumonia, and gastrointestinal disease in Nigeria, Kenya, Senegal, Burkina Faso, Mali, and India (13 papers). Overdose education and naloxone distribution was associated with reductions in opioid overdose deaths (3 papers), including in Massachusetts where high-uptake communities for overdose education had significantly lower overdose fatality rates than no-uptake communities (rate ratio 0.54, 95%CI 0.39-0.76). Community education improved measures of access to emergency care for remote Indigenous populations in Canada, Alaska and Nepal (3 papers) and adolescent mental health capacity in Australia (1 paper). Studies were of low or medium quality. Conclusion: In addition to established interventions for injury and cardiac arrest, emergency care training can improve community capacity in underserviced populations, and save lives in opioid overdose, paediatric infectious disease and malnutrition.

Introduction: Understanding the spatial distribution of opioid abuse at the local level may facilitate community intervention strategies. The purpose of this analysis was to apply spatial analytical methods to determine clustering of opioid-related emergency medical services (EMS) responses in the City of Calgary. Methods: Using opioid-related EMS responses in the City of Calgary between January 1st through October 31st, 2017, we estimated the dissemination area (DA) specific spatial randomness effects by incorporating the spatial autocorrelation using intrinsic Gaussian conditional autoregressive model and generalized linear mixed models (GLMM). Global spatial autocorrelation was evaluated by Morans I index. Both Getis-Ord Gi and the LISA function in Geoda were used to estimate the local spatial autocorrelation. Two models were applied: 1) Poisson regression with DA-specific non-spatial random effects; 2) Poisson regression with DA-specific G-side spatial random effects. A pseudolikelihood approach was used for model comparison. Two types of cluster analysis were used to identify the spatial clustering. Results: There were 1488 opioid-related EMS responses available for analysis. Of the responses, 74% of the individuals were males. The median age was 33 years ( IQR: 26-42 years) with 65% of individuals between 20 and 39 years, and 27% between 40 and 64 years. In 62% of EMS responses, poisoning/overdose was the chief complaint. The global Morans Index implied the presence of global spatial autocorrelation. Comparing the two models applied suggested that the spatial model provided a better fit for the adjusted opioid-related EMS response rate. Calgary Center and East were identified as hot spots by both types of cluster analysis. Conclusion: Spatial modeling has a better predictability to assess potential high risk areas and identify locations for community intervention strategies. The clusters identified in Calgarys Center and East may have implications for future response strategies.

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions partially implemented in two Canadian tertiary care Emergency Departments (ED) between June 2014- July 2016 with the goal to improve patient care by increasing value and reducing waste. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards and a novel initial assessment process. Some interventions have only been partially implemented due to persistent access block. This project was designed to examine the effect of partial EDST implementation on patient experience of emergency department visits. Patient satisfaction has been linked to improved patient outcomes, improved adherence to physician instruction, and improved provider satisfaction. Methods: Semi structured interviews were conducted over three distinct time periods (summer 2015, 2016 and 2017) to encompass progressive levels of EDST implementation. The interviews focused on the patients perceptions in each of 4 stages of their ED visit - Check-in, assessment, reassessment, and disposition. Patients were asked a list of positive (respected, listened to, supported, safe) and negative (in pain, worried, confused, frustrated) emotions frequently experienced and asked if they felt any of these emotions during their ED stay. Open ended questions were also asked about their overall visit. Descriptive statistics were calculated as differences in the proportion of patients feeling each emotion across timeframes. The open-ended question was coded by two reviewers as positive, negative or mixed. A kappa score was calculated to determine reviewer agreement. Results: 987 interviews were completed. In general, the proportion of patients feeling negative emotions remained consistent while positive emotions increased as EDST implementation progressed. For open-ended responses, the percentage of overtly positive experiences increased significantly from 2015 to 2017 (p=0.006), while overtly negative experiences did not significantly change. Reviewers agreed in the coding of the open-ended responses in 97.6% of surveys. The kappa score for reviewer agreement was 0.96 (95%CI 0.94-0.98) indicating almost perfect agreement. Conclusion: Partial implementation of EDST positively impacted patients experience of emergency department visits.

Introduction: In 2016, the Emergency Department (ED) Return Visit Quality Program (RVQP) was developed to promote a culture of quality in Ontario EDs, by mandating large-volume EDs to audit charts of patients who had a return visit leading to hospital admission (RV). This program provides an opportunity to identify possible adverse events (AEs) and quality issues, which can then be addressed to improve patient care. Methods: The RVQP requires EDs to audit a set number of 72-hour RVs for potential AEs/quality issues, as well as all 7-day RVs for one of three key paired sentinel diagnoses (acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis). Submitted audits and their AEs/quality issues were analyzed by a team of emergency physicians with quality improvement (QI) expertise, and qualitative metrics were derived. Using the general inductive method, we conducted a qualitative analysis with Health Quality Ontario (HQO), and HQO completed an independent analysis of the submitted narrative reports. Our objective is to report on the qualitative and quantitative metrics of the program, and to explore emerging themes from the AEs/quality issues identified. Results: There were 36,304 72-hour RVs flagged, which represent 0.99% of all 3,672,708 ED visits in the province of Ontario for the 86 EDs participating in the first year of the program. Overall, 2,584 audits were conducted. For the audits involving all-cause 72-hour RVs, 571 (24%) of cases had AEs/quality issues identified. Of the 219 audits involving sentinel diagnoses, 107 (49%) audits identified AEs/quality issues. The qualitative analysis revealed 11 themes, which were classified into three groups : issues related to patient characteristics or actions (elder care, patient risk profile, left without being seen); issues related to actions or processes of the ED team (physician cognitive lapses, handover/communication, high risk medications, documentation, radiology, vital signs); and healthcare system issues (imaging/test availability, discharge planning). Over one hundred local QI projects were completed or planned as a result of the audits performed. Conclusion: The RVQP promotes a culture of quality by highlighting potential AEs and quality themes that can then be targeted to increase patient safety and quality of care in Ontario EDs. Numerous QI projects were undertaken in the first year of the program, and future efforts will monitor the completion and success of these. The program can be easily adapted in other jurisdictions.

Introduction: Patient-reported outcome measures (PROM) are questionnaires that can be used to elicit care outcome information from patients. We sought to develop and validate the first PROM for adult patients without a primary mental health or addictions presentation receiving emergency department (ED) care and who were not hospitalized. Methods: PROM development used a multi-phase process based on national and international guidance (FDA, NQF, ISPOR). Phase 1: ED outcome conceptual framework qualitative interviews with ED patients post-discharge informed four core domains (previously published). Phase 2: Item generation scoping review of the literature and existing instruments identified candidate questions relevant for each domain for inclusion in tool. Phase 3: Cognitive debriefing existing and newly written questions were tested with ED patients post-discharge for comprehension and wording preference. Phase 4: Field and validity testing revised tool pilot tested on a national online survey panel and then again at 2 weeks (test-retest). Phase 5: Final item reduction using a Delphi process involving ED clinicians, researchers, patients and system administrators. Phase 6: Validation - psychometric testing of PROM-ED 1.0. Results: Four core outcome domains were defined in Phase 1: (1) understanding; (2) symptom relief; (3) reassurance and (4) having a plan. The domains informed a review of existing relevant questionnaires and instruments and the writing of additional questions creating an initial long-form questionnaire. Eight patients participated in cognitive debriefing of the long-form questionnaire. Expert clinicians, researchers and patient partners provided input on item refinement and reduction. Four hundred forty-four patients completed a second version of the long-form questionnaire (add in retest numbers) which informed the final item reduction process by a modified Delphi method involving 21 diverse contributors. The questionnaire was validated and underwent final revisions to create the 21 questions that constitute PROM-ED 1.0. Conclusion: Using accepted PROM instrument development methodology, we developed the first outcome questionnaire for use with adult ED patients who are not hospitalized. This questionnaire can be used to systematically gather patient-reported outcome information that could support and inform improvement work in ED care.

Introduction: Resource allocation planning (RAP) for emergency medical services (EMS) systems determines optimal resources for patient needs in order to minimize morbidity and mortality. The British Columbia Emergency Health Services developed a new RAP using an evidenced informed methodology, statistical analysis of outcomes and with further clinical input from EMS physicians, paramedics and allied EMS providers. The revised RAP was implemented on a pan provincial basis in fall of 2013. It is unknown how the modifications will affect outcomes of EMS cases. Population-based analysis was used to determine the effect of a comprehensive RAP changes by comparing 24-hour mortality before and after province-wide implementation of the revised RAP. Methods: The primary outcome, 24-hour mortality, was obtained through linked provincial health administrative data. All adult cases with evaluable outcome data were included in the analysis. A pre and post methodology was used to evaluate the effect of post-RAP revision (post-RAP-revision) on 24-hour mortality compared to pre-RAP revision (pre-RAP-revision). Multivariable logistic regression was used to adjust for variations in other significant factors associated with 24-hour mortality. The interrupted time series (ITS) estimated any immediate changes in the level or trend of outcome after the start of the revised RAP implementation (fall of 2013), while simultaneously controlling for pre-existing trends. Results: The cohort is comprised of 562,546 cases (April 2012 March 2015). In the multivariate model, adjusted for age, sex, urban/metro region, season, day hour, and MPDS determinant, the probability of dying within 24 hours of EMS call was 7% lower in the post-RAP-revision cohort (OR=0.936; 95% CI: 0.886 - 0.989; P=0.018). A sub-group analysis of immediately life-threatening cases demonstrated similar effect (OR=0.890; 95% CI: 0.808 - 0.981; P=0.019) Conclusion: Our results demonstrate that a comprehensive, evidence informed reconstruction of a provincial EMS RAP is feasible. Despite considerable change in crew level response and resource allocation, there was significant decrease in 24 hour mortality in a large pan-provincial population based patient cohort.

Introduction: Maintaining and enhancing competence in the breadth of Emergency Medicine (EM) is an ongoing challenge for all clinicians. In particular, resuscitative care in EM involves high-stakes clinical encounters that demand strong procedural skills, effective leadership, and up-to-date knowledge. However, Canadian emergency physicians are not required to complete any specific ongoing training for these encounters beyond general CPD requirements of professional colleges. Simulation-based medical education (SBME) is an effective modality for enhancing technical (e.g. procedural) and non-technical (i.e. Crisis Resource Management) skills in crisis situations, and has been embedded in undergraduate and postgraduate medical curricula worldwide. We present a novel comprehensive curriculum of simulation-based CPD designed specifically for academic emergency physicians (AEPs) at our centre. Methods: The curriculum development involved a departmental needs assessment survey, focus groups with AEPs, data from safety metrics and critical incidents, and consultations with senior departmental leadership. Institutional support was provided in the form of a $25,000 grant to fund a physician Program Lead, monthly session instructors, and simulation centre operating costs. Based on the results of the needs assessment, a two-year curriculum was mapped out and tailored to the available resources. Results: CPD simulation commenced in January 2017 and occurs monthly for three hours, immediately following departmental Grand Rounds to provide convenient scheduling. Our needs assessment identified two key types of educational needs: (1) Crisis Resource Management skills and (2) frequent practice of high-stakes critical care procedures (e.g. central lines). The first six months of implementation was dedicated to low-fidelity skills labs to facilitate the transition to SBME. After this, the program transitioned to a hybrid model involving two high-fidelity simulated resuscitations and one skills lab per session. Conclusion: We have introduced a comprehensive curriculum of ongoing simulation-based CPD in our department based on the educational needs of our AEPs. Key to our successful implementation has been support from educational and administrative leadership within our department. Ongoing challenges include securing adequate protected time from clinical duties for program facilitators and participants. Future work will include establishing permanent funding, CPD accreditation, and a formal program evaluation.

Introduction: A proportion of Emergency Department (ED) visits may be treated in out-of-hospital settings. The objective of this curriculum was to expand paramedic competencies to safely risk stratify patients and divert low risk, low acuity patients from EDs with and without physician oversight. Methods: We followed Kerns 6-step Curriculum Development Framework . (a) We identified a problem, and (b) completed a needs assessment by retrospectively reviewing the clinical pathways of 3000 patients were cared for and transported by paramedics and received care at an EDs. We used this data to identify competencies (e.g., diagnostics, interventions, reasoning needs) and targeted patient types that would result in the most significant advancements to paramedic services. These were translated to (c) goals and objectives. Results: Our (d) educational strategies involved a 14-week intensive patient-type and case-based curriculum. (e) Implementation involved 3 days/wk of clinical rotations supplemented with 2 days/wk of a mixed curriculum (i.e., fixed instruction using blended didactic small and large group sessions; flexible/individualized curriculum based on identified needs; formative assessments; self and peer-directed learning; simulations). (f) Assessment involved knowledge and application tests, clinical placement and simulation assessments; case development, assignments, and OSCE. Evaluation outcomes included student performance scores across 7-dimensions, clinical placement and student feedback. Thirteen Advanced Care Paramedics from York Region Paramedic Services completed the program. Challenges included provincial stakeholder consensus, and formally addressing clinical suspicion in a protocol based field within a limited time frame. Conclusion: A curriculum for expanded paramedic practice to risk stratify and divert targeted low risk patients from EDs resulted in new paramedic competencies and scope of practice. It received high evaluations from clinical staff and students. Successful candidates will undergo a 1-year study for validation and safety.

Introduction: Medical journals are an essential venue for knowledge translation. Skilled reviewers and editors are required to ensure quality standards in research publications and yet postgraduate programs rarely include this training in their curricula. Imparting appropriate skills and developing capacity in journalship has thus proved challenging. The Canadian Journal of Emergency Medicine (CJEM) is the national journal for Emergency Medicine (EM) in Canada. The CJEM editorial board recently decided to provide longitudinal mentorship for junior academic faculty members and trainees through an editorial internship. The internship had three goals for participants: (1) introduce and develop the responsibilities and skills of a good editor; (2) enhance a career in academic EM; and, (3) galvanize future participation as a reviewer or editor in scientific publications. Methods: The senior editorial board of CJEM and the inaugural intern developed a one-year Editorial Internship that was launched in June 2017. The curricular framework was designed by current and prior CJEM senior editors from four Canadian universities, and was informed by similar programs in the United States. The curriculum was refined iteratively based on feedback and discussion between the senior editors and intern. The internship was designed for a single individual in the Canadian EM community, including residents, pediatric fellows and practicing emergency physicians. Results: To develop the responsibilities and skills of being a good editor, the intern performed six mentored reviews of manuscripts either under current review at CJEM or previous submissions identified as difficult peer review decisions. In addition, the intern learned about CJEM values and norms by participating in monthly videoconference meetings and quarterly editorial board meetings. To enhance an academic career, the intern was assigned two writing projects under the guidance of senior editors for publication in CJEM, and completed an online critical appraisal course. Conclusion: The inaugural editorial intern gained experience as an editor and produced scholarly work. We feel the internship met its first two goals, and CJEM has committed to continue the internship annually. The ultimate determination of whether the internship achieved its third goal will only be known after longitudinal tracking of participants career involvement in academic publishing and editing.

Introduction: Approximately 2-3 percent of emergency department (ED) visits are due to eye-related complaints, adding to the ED workload. Many of these could be seen instead by an optometrist who specializes in the examination, diagnosis and treatment of eye-related disorders. We sought to determine the proportion of ED patients with isolated eye-related complaints that could be managed by an optometrist. Methods: We performed an administrative database study and descriptive analysis of all patients presenting to Calgary EDs with eye-related complaints during a one-year period. We determined optometry eligibility by reviewing discharge diagnoses and assessing whether that condition was within the Alberta Association of Optometrys (AAO) defined scope of practice. Patients were considered ineligible if their condition was related to bites, stings, thermal burns, assault, MVA or operative complications; if they required hospitalization or referral to a non-eye specialist (e.g. neurology); if they had associated headache, dizziness, syncope, hypertension, neurologic abnormality (e.g. diplopia); if they had facial cellulitis, orbital infections, adverse drug effects, or if they underwent observation in the ED because of concerns about a cardiac or neurological condition. Results: In 2015, 7686 patients were seen in Calgarys 5 EDs with eye related complaints. Of these, 76.2% were optometry-eligible and 75% of optometry-eligible patients arrived during day or evening hours (0800-2100). The most common presenting complaints were visual disturbance (24.8%), redness (22.1%), and pain or photophobia (16.4%). Optometry-eligible patients waited an average of 110 min and had an ED LOS of 149 min. Conclusion: Approximately 3 in every 4 patients seen in the ED for eye related complaints could alternatively be seen by an optometrist. Further research is required to establish the feasibility of diversion to an optometrist from the ED for eye-related complaints.

Introduction: Frailty is a geriatric syndrome conferring a high risk of declining functional capacities. Some serum biomarkers were associated with frailty, but no study has investigated this possible association among community-dwelling seniors with minor injuries in the emergency department (ED). The aim was to determine if ED serum biomarker assay combined with frailty status improve the prediction of 3-months functional or mobility impairments in this population, beyond frailty status alone. Methods: This prospective sub-study of the CETI cohort includes 190 participants (age 65 years, ED consultation within 2 weeks of a minor injury, independent in daily activities 4 weeks prior to injury, and discharged home from EDs). Biomarkers were obtained from blood samples at baseline (ED visit). Normal vs. at risk physiological states were defined according to clinical threshold values. Also, the patients were screened for frailty at baseline) while their functional (OARS scale) and mobility characteristics were assessed at the ED visit and 3 months later. Patients were classified as robust or pre-frail/frail according of the CHSA-CFS and SOF scales. Simple generalized linear models with a binomial distribution and a log link function were used to explore the differences in functional and mobility outcomes at three months across sub-groups (RR). Results: When compared to robust ones, ED pre-frail/frail patients were less functional in their instrumental activities of day living (p=0.004), slower walkers (p=0.02), more frequent users of walking aids (p=0.03), more fearful of falling (p=0.006), went outside their home less often weekly (p=0.004) and had higher abnormal creatinine levels (p=0.02). We observed an overall 3-month functional decline in around 10% of patients combined with worsened mobility characteristics. We found that vitamin D [RR: 0.51 (0.07-3.9)], glucose (RR: 0.27 [(0.03-2.16)]) and creatinine (RR: [1.10 [(0.40-2.97]) modulate the prediction of 3-months mobility impairments. However, ED frailty status with CHSA-CFS and SOF scales clearly remained the stronger predictor of mobility impairments [vitamin DRR: 2.93 (1.12-7.65); glucoseRR: 2.36 (0.85-6.55); creatinine: RR2.06 (1.21-3.53)]. Conclusion: Since they do not improve the prediction of 3-months functional or mobility impairments associated with frailty status, ED biomarker assays are not useful in adequately screening for frailty among independent seniors with minor injuries.