Introduction: Outside of key conditions such as cardiac arrest and trauma, little is known about the epidemiology of mortality of all transported EMS patients. The objective of this study is to describe characteristics of EMS patients who after transport die in a health care facility. Methods: EMS transport events over one year (April, 2015-16) from a BLS/ALS system serving an urban/rural population of approximately 2 million were linked with in-hospital datasets to determine proportion of all-cause in-hospital mortality by Medical Priority Dispatch System (MPDS) determinant (911 call triage system), age in years (>=18 yrs. - adult, <=17 yrs. - pediatric), sex, day of week, season, time (in six hour periods), and emergency department Canadian Triage and Acuity Scale (CTAS). The MPDS card, patient chief complaint, and ED diagnosis category (International Classification of Disease v.10 - Canadian) with the highest proportion of mortality are also reported. Analyses included two-sided t-test or chi-square with alpha <0.05. Results: A total of 239,534 EMS events resulted in 159,507 patient transports; 141,114 were included for analysis after duplicate removal (89.1% linkage), with 127,867 reporting final healthcare system outcome. There were 4,269 who died (3.3%; 95%CI 3.2%, 3.4%). The proportion of mortality by MPDS determinant was, from most to least critical 911 call, Echo (7.3%), Delta (37.2%), Charlie (31.3%), Bravo (5.8%), Alpha (18.3%), and Omega (0.3%). For adults the mean age of survivors was less than non-survivors (57.7 vs. 75.8; p<0.001), but pediatric survivors were older than non-survivors (8.7 vs. 2.8; p<0.001). There were more males that died than females (53.0% vs. 47.0%; p<0.001). There was no statistically significant difference in the day of week (p=0.592), but there was by season with the highest mortality in winter (27.1%; p=0.045). The highest mortality occurred with patients presenting to EMS between 0600-1200 hours (34.6%), and the lowest between 0000-0600 hours (11.8%; p<0.001). Mortality by CTAS was category 1 (27.1%), 2 (36.7%), 3 (29.9%), 4 (4.3%), and 5 (0.5%). The highest mortality was seen in MPDS card 26-Sick Person (specific diagnosis) (19.1%), chief complaint shortness of breath (19.3%), and ED diagnoses pertaining to the circulatory system (31.1%). Conclusion: Significant all-cause in-hospital mortality differences were found between event, patient, and clinical characteristics. These data provide foundational and hypothesis generating knowledge regarding mortality in transported EMS patients that can be used to guide research and training. Future research should further explore the characteristics of those that access health care through the EMS system.

Introduction: To determine trends in identified self-perceived knowledge deficits of paramedics, training barriers and desired methods of self-directed education. Methods: A written survey was delivered to all paramedics in an Ontario base-hospital. Respondents were asked to identify deficits from a 37-point, anatomic systems-based list. Preferred educational modalities to address knowledge deficits and factors taken into consideration when choosing self-directed education were captured. Top 5 perceived deficit topics, number of perceived deficits, top 5 factors associated with training modality chosen and factors taken into consideration for choosing training modalities, were compared against paramedic age, training (Advanced Care Paramedic; ACP, or Primary Care Paramedic; PCP) and primary location of practice (urban, rural, mixed setting). Results: Of 1262 paramedics, 746 (59.11%) completed the survey. PCPs had a higher report of deficit in both neonatal resuscitation and arrhythmia than ACPs (48.3% vs 58.8%, p=0.015; 40.3% vs 58.5%, p<0.001). Paramedics who listed rural as their primary practice location were more likely to report a deficit in pediatric respiratory disorder than those with a mixed urban/rural and primary urban practice (65.9% vs 46.3%, p=0.000; 65.9% vs 45.9%, p=0.001;) as well as a higher median number of listed deficits (9.00 vs 6.00 vs 6.00, p<0.001). ACPs were more likely to consider scheduling, location/ease of attending and cost as barriers than PCPs (85.4% vs 63.8%, p=0.000; 69.5% vs 51.4%, p=0.002; 69.5% vs 39.5%, p=0.000) while reporting an increased desire for webinar material than PCPs (56.1% vs 40.4%, p=0.007). There were no significant differences found by age. Conclusion: Targeted educational needs-based assessments can help ensure appropriate topics are delivered in a fashion that overcomes identified barriers to self-directed learning. From our analysis, increased awareness of ease of attending sessions and preferred modalities, such as webinars may be beneficial; especially for ACPs who require more annual continuing educational hours. Paramedics in rural locations may require increased continuing education, especially for rarely encountered, high risk situations, such as pediatric critical care. These findings can help direct future education in our system and others.

Introduction: The number of refugees accepted to Canada grew from 24,600 in 2014 to 46,700 in 2016. Many of these refugees have young families and the number of child refugees has increased accordingly. Although child refugee health care has been in the forefront of media and medical attention recently, there is limited data on injury patterns in this population. Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) collects data on injuries in children presenting to the emergency department (ED). Our objective is to examine the clinical presentations and outcomes of refugee children with injuries presenting to a tertiary care paediatric ED. Methods: Our paediatric hospital has approximately 70,000 ED visits per year of which 13,000 are due to injuries and/or poisonings. The CHIRPP database was accessed to identify children with injuries presenting to our ED from April 2014 to March 2017 with Interim Federal Health Program (IFHP) registration status. All patient charts were reviewed to extract demographic and clinical care information. Results: There were 74 children with 81 ED visits during the study period of whom 19% were transferred from other facilities. Most of them (72%) were males with a mean age of 8.7 years (standard deviation 4.29). There were significant medical histories in 32% of children. The presentation to our ED (greater than 24 hours post-injury) was seen in 25% of visits. Twenty five percent of injured children were seen in our ED. The distribution of Canadian Triage Acuity Score (CTAS) scores 1, 2, 3, 4, and 5 were 0%, 16%, 37%, 46% and 1% respectively. However, subspecialty consultations were required in 69%, 60% and 27% of CTAS 2, 3 and 4 children respectively. Overall, 46% of all patients required subspecialty consults. The top three categories of injuries include fractures (23%), soft tissue injuries (20%) and lacerations (17%). More than half (56%) required diagnostic imaging. Most (89%) were treated in ED and discharged (average length-of-stay 3 hours 55 minutes) and 11% required admissions. 47% of children lacked primary care physicians. Conclusion: Almost half of refugee children with IFHP status require DI testing, sub-specialty consultations and primary care referrals when presenting to our ED with injuries. Follow up arrangements are needed as many do not have access to primary care providers. This demonstrates a need for securing primary care providers early for this vulnerable population.

Introduction: Hypothermia in severe trauma patients can increase mortality by 25%. Active re-warming decreases mortality and is recommended in trauma management guidelines. Despite this, many emergency medical services (EMS) vehicles do not carry equipment for active re-warming. This study sought to determine the local rate of hypothermia in major trauma patients on trauma centre arrival (TCA), and to establish which patients are at highest risk by identifying factors present in the pre-hospital setting associated with hypothermia in a humid continental climate. Methods: This single-centre retrospective chart review included adults (age 18) in the local trauma registry (trauma team activation or injury severity score >12) from January 2009-June 2016. Patients were excluded if: temperature on TCA unknown or 38°C, not transported by EMS, or if there was >24 hrs from injury to TCA. The primary outcome was the rate of hypothermia (<35°C) in major trauma patients transported by EMS on arrival at the local trauma centre. Secondary outcomes included hospital length of stay and survival to discharge. Logistic regression was used to identify predictors of hypothermia on TCA; it included the following factors: age, sex, weight, number of comorbidities, injury severity, injury mechanism, EMS modality, direct transport from scene or referred from peripheral hospital, time on scene, transport time, local temperature, and pre-hospital heart rate, systolic blood pressure (SBP), intubation, and volume of crystalloid. Results: A total of 3070 adult traumas were included, 159 of which were hypothermic on TCA a rate of 5%. Multivariate analysis identified seven risk factors for hypothermia: intubation pre-hospital (OR 8.10, p<0.001), blunt trauma (OR 3.37, p=0.044 vs. penetrating, and OR 7.35, p=0.023 vs. other), direct transport (OR 1.94, p=0.005), number of comorbidities (OR 1.14, p=0.036), injury severity (OR 1.03, p<0.001), 1°C local temperature drop (OR 1.03, p<0.001), and 1mmHg SBP drop (OR 1.01, p<0.001). Ninety-four percent of normothermic patients and 69.2% of hypothermic patients survived to discharge. Average length of stay was 7.98 and 15.23 days respectively. Conclusion: Avoidance of hypothermia is imperative to the management of major trauma patients. Those at highest risk in a humid continental climate are severely injured blunt trauma patients with multiple co-morbidities, a low pre-hospital SBP and EMS intubation. Future studies should focus on the benefits of pre-hospital rewarming in these high-risk patients.

Introduction: Many survivors of sexual and domestic assault return to violent environments following post-assault care. The objective of this study was to estimate the annual prevalence of revictimization and examine factors associated with return emergency department (ED) visits following their initial encounter for sexual or domestic assault. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital is the only program in Ottawa offering emergency and forensic care for survivors of sexual assault and domestic violence. Information on demographics, assailant characteristics and clinical presentation were extracted from the SAPACP case registry (January 1 2015- January 31 2016). We conducted descriptive analyses to describe the study sample, and bivariable and multivariable logistic regression modelling to assess factors most strongly associated with revictimization using odds ratios (OR), adjusted OR (AOR) and 95% confidence intervals (CI). Results: Among 377 unique patients seen at the SAPACP, there were 409 encounters for sexual and domestic violence. There were 24 revictimization cases (6.4%) with the number of repeat visits ranging from 2-6. There were 343 (91.0%) female patients and 182 (48.3) under the age of 25. There were 243 (64.5%) sexual assaults, 125 (33.2%) physical assaults, and 42 (11.1%) verbal assaults. Compared to patients who presented once, revictimized patients were more likely to have experienced violence from a current or former intimate partner (AOR:3.02, 95% CI:1.24-7.34), have a substance use disorder (AOR:5.57, 95% CI:2.11-14.68), and were more likely to be taking anti-depressants (AOR:3.34, 95% CI:1.39-8.01). Conclusion: This study has identified a high prevalence of revictimization, with some clients being revictimized as many as 6 subsequent times. Key factors to help identify patients at risk of revictimization are assaults by intimate partners, having substance use problems, and being on antidepressants. Reducing revictimization and preventing further violence is a critical component of care to ensure survivors are safe following their ED encounter.

Introduction: In the past few years, there has been an increase in awareness of the challenge of managing work related stress in EMS. Extant research has liked different types of chronic and critical incident stress to stress reactions like posttraumatic stress. However, there is no tool to capture the transactional stresses which are associated with the day to day provision of service (e.g., dealing with offload delays or mandatory overtime) and interacting with allied professions (e.g., emergency department staff) or allied agencies (e.g., law enforcement). The purpose of this study was to develop and validate a measure which captured transactional stresses in paramedics Methods: An online survey was conducted with ten Canadian Paramedic Services with a 40.5% response rate (n= 717). Factor analysis was used to identify variation in responses related to the latent factor of transactional stress. The scale was validated using both exploratory and confirmatory factor analyses. Results: The sample of transactional stress questions was split to allow for multiple analyses (EFA n=360/ CFA n=357). In the exploratory factor analysis, principal axis factoring with an oblique rotation revealed a two-factor, twelve item solution, (KMO=.832, x2=1440.19, df=66, p<.001). Confirmatory factor analysis also endorsed a two factor, 12 item solution, (x2 =130.39, df=51, p<.001, CFI=.95, TLI= .93, RMSEA= .07, SRMR= .06). Results supported two groups of six-item factors that captured transactional stress in the provision of service. The factors, clearly aligned with transactional stress issues internal to the ambulance and transactional stress relationships external to the ambulance. Both subscales demonstrated good internal reliability (= .843/ =.768) and were correlated (p.01) with a convergent validity measure. Conclusion: This study successfully validated a two-factor scale which captures stress associated with the day to day provision of EMS and the interaction with allied professions. The development of this measure of transactional stresses further expands the potential that paramedics, Paramedic Services, employers, and prehospital physicians may understand the dynamics that influence provider health and safety. As a result, there may be greater opportunities to intervene holistically to improve paramedic health and well-being.

Introduction: Prevalence and incidence of delirium in older patients admitted to acute and long-term care facilities ranges between 9.6% and 89% but little is known in the context of emergency department (ED) incident delirium. Literature regarding the incidence of delirium in the ED and its potential impacts on hospital length of stay (LOS), functional status and unplanned ED readmissions is scant, its consequences have yet to be clearly identified in order to orient modern acute medical care. Methods: This study is part of the multicenter prospective cohort INDEED study. Three Canadian EDs completed the two years prospective study (March-July 2015 and Feb-May 2016). Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Patients were assessed 2x/day during their entire ED stay and up to 24 hours on hospital ward by research assistants (RA). The primary outcome of this study was incident delirium in the ED or within 24 h of ward admission. Functional and cognitive status were assessed using validated Older Americans’ Resources and Services and the Telephone Interview for Cognitive Status- modified tools. The Confusion Assessment Method (CAM) was used to detect incident delirium. ED and hospital administrative data were collected. Inter-observer agreement was realized among RA. Results: Incident delirium was not different between sites, nor between phases, nor between times from one site to another. All phases confounded, there is between 7 to 11% of ED related incident delirious episodes. Differences were seen in ED LOS between sites in non-delirious patients, but also between some sites for delirious participants (p<0.05). Only one site had a difference in ED LOS between their delirious and non-delirious patients, respectively of 52.1 and 40.1 hours (p<0.05). There is also a difference between sites in the time between arrival to the ED and the incidence of delirium (p=0.003). Kappa statistics were computed to measure inter-rater reliability of the CAM. Based on an alpha of 5%, 138 patients would allow 80% power for an estimated overall incidence proportion of 15 % with 5% precision.. Other predictive delirium variables, such as cognitive status, environmental factors, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between sites and phases. Conclusion: The fact that incidence of delirium was the same for all sites, despite the differences of ED LOS and different time periods suggest that many other modifiable and non-modifiable factors along LOS influenced the incidence of ED induced delirium. Emergency physician should concentrate on improving senior-friendly environment for the ED.

Introduction: Every year 40,000 out-of-hospital cardiac arrests (OHCA) occur in Canada. Only 1 in 10 survive. Early bystander cardiopulmonary resuscitation (CPR) and defibrillation can triple odds of survival. PulsePoint is a mobile device application designed to crowdsource bystander CPR and public access defibrillation for victims of OHCA. Kingston, Ontario was the first Canadian city to launch PulsePoint. The objective of this project was to determine feasibility of PulsePoint implementation in a Canadian setting and to describe system performance. Methods: This was a descriptive observational study. We included all 9-1-1 incidents involving PulsePoint system activation in Kingston, Ontario and all confirmed, public location OHCAs assessed by local emergency medical services (EMS) between March 23, 2015 to January 23, 2017. By using time and location data from PulsePoint system alert notifications, we attempted to link each PulsePoint activation to de-identified ambulance call records. Results: Between March 23, 2015 to January 23, 2017, there were 258 PulsePoint system activations in Kingston and a total of 32 cases of confirmed OHCAs. Only 58 (22%) of PulsePoint activations could be linked to EMS records with high confidence. Of these linked cases, 10 were confirmed OHCAs, reflecting 17% (10/58) of all linked PulsePoint activations and 31% (10/32) of all confirmed OHCAs. Of the remaining 48 cases that triggered PulsePoint activation numerous final paramedic problem codes were assigned of which 14% (8/58) were deemed alcohol intoxication, 10% (6/58) were active seizures, 7% (4/58) were behavioural/psychiatric events, among others. 10 incidents (17%) that triggered PulsePoint activation did not have an assigned final paramedic problem code. Conclusion: Implementation of PulsePoint is feasible in Canadian communities. Improved capabilities for linking with local EMS data will improve data capture, program monitoring capacity, and opportunity for research. The impact of PulsePoint on clinical outcomes remains uncertain and should be determined in future research.

Introduction: It is documented that physicians and nurses fail to detect delirium in more than half of cases from various clinical settings, which could have serious consequences for seniors and for our health care system. The present study aimed to describe the rate of documented incident delirium in 5 Canadian Emergency departments (ED) by health professionals (HP). Methods: This study is part of the multicenter prospective cohort INDEED study. Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Delirium status was assessed twice daily using the Confusion Assessment Method (CAM) by trained research assistants (RA). HP reviewed patient charts to assess detection of delirium. HP had no specific routine detection of delirious ED patients. Inter-observer agreement was realized among RA. Comparison of detection between RA and HP was realized with univariate analyses. Results: Among the 652 included patients, 66 developed a delirium as evaluated with the CAM by the RA. Among those 66 patients, only 10 deliriums (15.2%) were documented in the patients medical file by the HP. 54 (81.8%) patients with a CAM positive for delirium by the RA were not recorded by the HP, 2 had incomplete charts. The delirium index was significantly higher in the HP reported group compared to the HP not reported, respectively 7.1 and 4.5 (p<0.05). Other predictive delirium variables, such as cognitive status, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between groups. Conclusion: It seems that health professionals missed 81.8% of the potential delirious ED patients in comparison to routine structured screening of delirium. HP could identify patients with a greater severity of symptoms. Our study points out the need to better identify elders at risk to develop delirium and the need for fast and reliable tools to improve the screening of this disorder.

Introduction: Delays in transfer to an in-patient bed of admitted patients boarded in the ED has been identified as one of the chief drivers of ED overcrowding. Our study aims to replicate findings from a previous study in identifying patient characteristics associated with increased boarding time, and the impact of increased boarding time on in-patient length of stay (IPLOS). Methods: We conducted a retrospective single-centre observational study during the period between January 1, 2015 December 31, 2015 at a very high volume community hospital (~ 75,000 ED visits/year). All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean time to in-patient bed (TTB), as well as patient-specific and institutional factors that were associated with prolonged boarding times ( 12 hours) were identified. Mean IP LOS was calculated for those with prolonged boarding times and compared to those without prolonged boarding times. Results: There were 8,096 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher boarding times than those admitted to other services, with a mean boarding time of 17.4 hrs, as compared to 4.2 hrs, 5.7 hrs, and 4.0 hrs for those admitted to Surgery, Critical Care and Pediatrics respectively. Within Medicine patients, there was a statistically significant greater odds of prolonged boarding time for patients who were older, had a greater comorbidity burden, and required more specialized in-patient care (i.e. an isolation bed or telemetry bed). Medicine patients with prolonged boarding times also experienced 0.7 days longer IP LOS, even after correcting for age and comorbidity (mean adjusted IP LOS 10.6 days versus 11.3 days). Conclusion: Within our study period, older, sicker patients and those patients requiring more resource-intensive in-patient care have the longest ED boarding times. These prolonged ‘boarding’ times are associated with significantly increased IP LOS.

Introduction: Accurate triage is important because under-triage may delay critical care for emergent patients and over-triage may inhibit efficient management of emergency department (ED) resources. In Korea, the Korean Triage and Acuity Scale (KTAS) was developed based on the CTAS in 2015. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient’s severity when degree of pain was used as a modifier. Methods: This was a retrospective observational cohort study, conducted in an ED of urban tertiary university hospital with more than 90,000 visits per year. We studied adult patients who visited the ED from January 2016 to June 2016. Patients were devided into pain group and non-pain group according to whether the degree of pain was used as a modifier in the KTAS evaluation. We used acute area registration, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and hospital mortality as markers to determine urgent patients. To evaluate discriminative ability of KTAS, the odds ratios of each KTAS values compared to KTAS 3 for the urgent patients were calculated. And to compare the predictive power of KTAS for urgent patients between the two groups, the area under the receiver operating characteristic (ROC) curves were compared by DeLongs method. Results: There were 9,175 (37.8%) patients in the pain group and 15,078 (62.2%) patients in the non-pain group. When KTAS was assessed as 2, only 20.3% of the patients in the pain group were registered to the acute area, while 71.2% of the patients in the non-pain group were registered to the acute area (p<0.001). And the proportion of emergency procedure, admission, ICU admission, and mortality was also higher in patients with pain group. Similarly, in the patients of KTAS 3, the proportion of urgent patients was higher in the non-pain group except emergency operation. The odds ratio for the occurrence of urgent patients decreased as the KTAS value increased in both groups, however, the difference between the odds ratios of each KTAS was more evident in the non-pain group. In pain group, compared to patients with KTAS 3, the odds ratio (95% CI) for acute area registration were 2.32 (1.92-2.80), 0.61 (0.51-0.73), and 0.35 (0.23-0.53) for patients with KTAS 2, 4, 5, respectively; in non-pain group, odds ratio were 5.59 (5.09-6.13), 0.28 (0.25-0.32), and 0.13 (0.10-0.16). The non-pain group showed better predictive power of KTAS for acute area registration than pain group; AUC (95% CI), 0.864 (0.861-0.867) vs. 0.810 (0.802-0.818), p<0.0001). The predictability of KTAS was also higher in non-pain group for emergency procedure, emergency operation, admission, and ICU admission. Conclusion: We have confirmed that the use of pain severity as a modifier in KTAS is a factor affecting accuracy. The acuity level is overestimated when pain severity is used as modifier in KTAS evaluation.

Introduction: Community Paramedics (CPs) require access to timely blood analysis in the field to guide treatment and transport decisions. Point of care testing (POCT), as opposed to traditional laboratory analysis, may offer a solution, but limited research exists on CP POCT. The objective of this study is to compare the validity of two POCT devices (Abbott i-STAT® and Alere epoc®) and their use by CPs in the community. Methods: In a CP programme responding to 6,000 annual patient care events, a split sample validation of POCT against traditional laboratory analysis for seven analytes (sodium, potassium, chloride, creatinine, hemoglobin, hematocrit, and glucose) was conducted on a consecutive sample of patients. The difference of proportion of discrepant results between POCT and laboratory was compared using a two sample proportion test. Usability was analysed by survey of CP experience, an expert heuristic evaluation of devices, a review of device-logged errors, coded observations of POCT use during quality control testing, and a linear mixed effects model of Systems Usability Scale (SUS) adjusted for CP clinical and POCT experience. Results: Of 1,649 CP calls for service screened for enrollment, 174 had a blood draw, with 108 patient care encounters (62.1%) enrolled from 73 participants. Participants had a mean age of 58.7 years (SD16.3); 49% were female. In 4 of 646 (0.6%) individual comparisons, POCT reported a critical value that the laboratory did not; with no statistically significant difference in the number of discrepant critical values reported with epoc® compared to i-STAT®. There were no instances of the laboratory reporting a critical value when POCT did not. In 88 of 1,046 (8.4%) individual comparisons, the a priori defined acceptable difference between POCT and the laboratory was exceeded; occurring more often in epoc® (10.7%;95%CI:8.1%,13.3%) compared to i-STAT® (6.1%;95%CI:4.1%,8.2%)(p=0.007). Eighteen of 19 CP surveys were returned, with 11/18 (61.1%) preferring i-STAT® over epoc®. The i-STAT® had a higher mean SUS score (higher usability) compared to the epoc® (84.0/100 vs. 59.6/100; p=0.011). Fewer field blood analysis device-logged errors occurred in i-STAT® (7.8%;95%CI:2.9%,12.7%) compared to epoc® (15.5%;95%CI:9.3%,21.7%) although not statistically significant (p=0.063). Conclusion: CP programs can expect valid results from POCT. Usability assessment suggests a preference for i-STAT.

Introduction: Our emergency department (ED) sees a low volume of high acuity pediatric cases. A needs assessment revealed that 68% of our Emergency Physicians (EP) manage pediatric patients in less than 25% of their shifts. The same percentage of EPs as well as ED nurses indicated they were uncomfortable managing a critically unwell neonate. Thus, an interprofessional curriculum focused on pediatric emergencies for ED staff was developed. In-situ simulation education was chosen as the most appropriate method to consolidate each didactic block of curriculum, and uncover important system gaps. Methods: Needs assessment conducted, and emerging themes informed IPE curriculum objectives. A committee of experts in simulation, pediatric emergencies and nursing education designed a full-day, RCPSC accredited, interprofessional in-situ simulation program. Results: Progressive segmental strategy maximized learning outcomes. The initial phase (2 hrs) comprised an” early recognition of sepsis” seminar and 4 rotating skills stations (equipment familiarity, sedating the child, IV starts, and mixing IV medication). This deliberate, adaptive, customized practice was enhanced by expert facilitation at each station, directly engaging participants and providing real-time feedback. The second phase allowed interprofessional teams of MDs, RNs and Physician Assistants to apply knowledge gained from the didactic and skills stations to in-situ simulated emergencies. Each group participated in two pediatric emergency scenarios. Scenarios ran 20 minutes, followed by a 40 minute debrief. Each scenario had a trained debriefer and content expert. The day concluded with a final debrief, attended by all participants. Formalized checklists assessed participants knowledge translation during simulation exercises. Participants assessed facilitators and evaluated the simulation day and curriculum via anonymous feedback forms. Debriefing sessions were scribed and knowledge gaps and system errors were recorded. Results were distributed to ED leaders and responsibilities assigned to key stakeholders to ensure accountability and improvement in system errors. Results All participants reported the experience to be relevant and helpful in their learning. All participants requested more frequent simulation days. System gaps identified included: use of metric vs imperial measurements, non-compatible laryngoscope equipment, inadequate identification of team personnel. As a result, the above-mentioned equipment has been replaced, and we are developing resuscitation room ID stickers for all team roles. Conclusion: Simulation as a culmination to a didactic curriculum provides a safe environment to translate acquired knowledge, increasing ED staff comfort and familiarity with rare pediatric cases. Additionally, is an excellent tool to reveal system gaps and allow us to fill these gaps to improve departmental functioning and safety.

Introduction: Mass Gathering Medicine (MGM) is a growing field within emergency medicine (EM) and providing care at electronic dance music events (EDMEs) is an increasingly popular activity with MGM groups. Often, health care students are allowed to participate. However, there is a lack of documented curricula to train junior learners in providing medical care at these events. To address this, we developed and initiated an interprofessional, simulation-based workshop for University of Alberta health care students interested in working at EDMEs. Methods: We used Kerns six-step approach to develop the workshops. Our MGM Interest Group identified a need for educational sessions in toxicology case management at EDMEs. A subsequent literature review revealed a paucity of pre-existing curricula on this topic for MGM learners. We created goals and objectives for the workshops, reflecting the knowledge, skills and attitudinal competencies required to provide appropriate medical care at these events. The workshops were implemented and evaluated in November 2016 and 2017. Results: A total of 44 medical and nursing students attended the workshops. An EM resident and staff physician, both with prior experience working at EDMEs, led each session. Each workshop began with a short didactic lecture followed by two hours of case-based training using two standardized patients and a high fidelity simulator. Topics were chosen based on previously published articles describing medical cases seen at EDMEs. The simulation replicated the actual space, noise and equipment available at the medical tents at these events. Two interprofessional learner groups took turns managing a different set of 3 patients: Set 1-opioid overdose (OD), alcohol/vomiting, sympathomimetic OD; Set 2-opioid OD not responsive to naloxone, anticholinergic/seizure, OD with hyperthermia. Initial assessment, medical management and team communication skills were emphasized. Debriefing was provided to learners immediately after each set of cases. After each workshop, the learners completed evaluation forms utilizing both Likert scale and open-ended responses. Overall, students were extremely complimentary about the workshop structure, content and communication skills teaching. They were especially appreciative of the opportunity to participate in their first interprofessional team experience. Conclusion: To address local needs, a well-received simulation-based workshop was created to train students in toxicology case management at EDMEs. Future work will include using this workshop in a just-in-time fashion before upcoming EDMEs and documenting students actual use of skills taught (Kirkpatrick level 3). The workshop will also be further modified to implement more detailed interprofessional objectives and can provide a venue for EM residents to practice teaching interprofessional education competencies as part of their CanMEDS Scholar role.

Introduction: As the value of interactive teaching becomes increasingly recognized, the Flipped Classroom model is receiving more attention in the medical education community. In this model, learners master core declarative knowledge through self-learning prior to class and then expand upon this learning with integrative class exercises. The objective of this study was to assess the effectiveness of the new Flipped Classroom in a Canadian Emergency Medicine postgraduate program. Methods: The residents and staff were educated on the new model. An online questionnaire was sent to all EM residents and staff who had participated in the program 9 months after implementation. The survey tool assessed the participants opinions on utility, time-management, effectiveness in learning material, sustainability, collaboration with other members and overall impressions. Resident scores on national preparatory examinations including the Canadian In-Training Examination (CITE) and the American Board of Emergency medicine (ABEM) were compared before and after implementation of the new model. Results: Teaching staff were trained in the Flipped Classroom model and the majority of teaching sessions for the 2016 academic year were carried out using this paradigm. In addition, third year postgraduates received intensive training in the theory and implementation of interactive teaching techniques. A curriculum renewal committee generated objectives for each teaching session and suggested materials for learner pre-reading. Conclusion: Overall, both residents and staff physicians indicated that the flipped classroom model is a better format for EM academic day learning. Residents and staff collaborated more and felt more engaged during academic day. Residents spent more time preparing for the sessions with the new model, while staff spent less time preparing. Paired comparisons of same residency years for test exam scores using Wilcoxon signed-rank test showed an improvement in both CITE and ABEM exam test scores. In conclusion, the new flipped classroom model produced improvements in educational experience, satisfaction, and test examination scores.

Introduction: Advanced care planning (ACP) and Goals of Care (GOC) discussions are becoming increasingly common in our emergency departments (ED). The national ACP task group has found that the majority of Canadians have not had prior ACP/GOC discussions, nor have they obtained proper documentation of their wishes. The task of having these difficult but important conversations falls frequently to the ED. Despite this, our emergency medicine (EM) residents receive little formal training in ACP discussions. To address this need, we developed and implemented a workshop in ACP/GOC conversations for the University of Alberta EM academic curriculum. Methods: A literature search was performed to identify best practices for ACP discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked to identify previous difficult ACP discussions and highlight aspects of these cases that were challenging in the ED environment. These experiences, best practices and published APC curricula informed the development of a 3-hour case-based workshop that was implemented in the 2016/17 academic year for EM staff and residents. Results: Cases utilized in the workshop emphasized common ACP/GOC situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC whose family did not accept the GOC designation. Case 2: A 72 year old with multiple comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with decreased LOC whose family asks for an ACP discussion in the ED. Participants were divided into groups (5-6 members). Each small group analyzed and discussed each case before the participants reconvened and discussed their opinions in one large group. ACP experts from palliative care, emergency medical services and EM facilitated the discussions highlighting the best practices from the literature for each case reviewed. Pre and post Likert surveys were distributed to workshop participants to assess changes in confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically significant improvement in learner confidence within the following areas (N=21; P<0.05): identifying patients appropriate for GOC discussions, initiating GOC discussions, and identifying barriers to GOC, in the ED. The majority (89%) of participants agreed the workshops should become part of our academic curriculum. Conclusion: An ACP/GOC workshop was successfully implemented and further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead, we will look at using other teaching modalities such as simulation to further enhance the delivery of the curriculum. We will also attempt to capture defined physician behaviors (e.g. documenting GOC in the ED chart, sending letters to family physicians documenting GOC discussions) to gauge uptake of the workshop principles into clinical practice.

Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Mircroskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Endotracheal intubation is a complex task with a clinically significant complication and failure rate. Methods: Two doctors and three nurses developed stepwise team microskills checklist from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 36 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. The microskills checklist was used in four phases: 1. Group discussion of each microskill step 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback. Changes are recorded. 3. Total task run though without interruption. Changes are recorded. 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Results. Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 13/30, RNs 7/16. The commonest changes in practice were patient positioning (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 4.8/5). Conclusion: Microskills checklist facilitate endotracheal intubation with a bougie skill development in interprofessional teams in this provisional analysis.

Introduction: Medical images (e.g. radiographs) are the most commonly ordered tests in emergency medicine. As such, emergency medicine physicians are faced with the task of learning the skill of interpreting these images to an expert performance level by the time they provide opinions that guide patient management decisions. However, discordant interpretations of these images between emergency physicians and expert counterparts (e.g. radiologists) is a common cause of medical error. In pediatrics, this problem is even greater due to the changing physiology with age. Methods: ImageSim (https://imagesim.com/) is an evidence-based on-line learning platform derived and validated over an 11 year period (https://imagesim.com/research-and-efficacy/). This learning system incorporates the concepts of cognitive simulation, gamification, deliberate practice, and performance-based competency in the presentation and interpretation of medical images. Specifically, ImageSim presents images as they are experienced in clinical practice and incorporates a normal to abnormal ratio is representative of that seen in emergency medicine. Further, it forces the participant to commit to the case being normal or abnormal and if abnormal, the participant has to visually locate the specific area of pathology on the image. The participant submits a response and gets text and visual feedback with every case. After each case, the participant gets to play again until they reach a desired competency threshold (80% is bronze resident; 90% silver staff emergency medicine physician; 97% gold radiologist). Importantly, the learning experience also emphasizes deliberate practice such that the learning system provides hundreds of case examples and therefore each participants performance has the opportunity to improve along their individual learning curve. Results: Course selection was made based on known medical image interpretation knowledge gaps for practicing emergency physicians. Currently, ImageSim live courses include pediatric musculoskeletal radiographs (2,100 cases, 7 modules) and pediatric chest radiographs (434 cases). In 2018, we will also release a pediatric point-of-care ultrasound course (400 cases, 4 modules) and the pre-pubertal female genital examination (150 cases). For a demo, go to https://imagesim.com/demo/. Using ImageSim, the deliberate practice of about 120 cases (1 hour time commitment) increases accuracy on average by 15%. Currently integrated into 10 emergency medicine training programs and there are about 300 continuing medical education world-wide participants. Conclusion: While acquiring mastery for these images may take years to acquire via clinical practice alone, this learning system can potentially help achieve this in just a few hours.

Introduction: Global Emergency Medicine (Global EM) is growing rapidly as an academic niche in Canada. An increasing number of Canadian emergency physicians work internationally as part of their practice, and trainees consistently seek out international projects and electives. For the most part however, residents have had to create their own training opportunities as formal Global EM fellowship training has been lacking in Canada. To address this identified need, Queens University established a Global EM fellowship, the first of its kind in the country. Methods: The fellowship is designed to provide the skills necessary for an academic career in Global Emergency Medicine. Curriculum and objectives are modeled on similar well-established fellowships in the United States. Areas of expertise include emergency medicine systems development, humanitarian medicine, disaster response, public health, tropical medicine, research, administration and education. Fellows have the opportunity to tailor their training according to their specific interests within these domains. Importantly, the fellowship provides direct mentorship from academic global EM and public health physicians, and networking opportunities within the global health sphere. Results: The two-year fellowship curriculum is divided between: 1) coursework to complete a Master of Public Health (MPH) Degree 2) fieldwork 3) relevant international emergency medicine training courses and 4) clinical work in the emergency departments at the Kingston Health Sciences Center. The Queens Global EM fellowship admitted its first fellow in August 2017. To date, the inaugural fellow has completed the MissionCraft Leadership in Disaster Relief course as well as a Humanitarian U Disaster and Response course, in addition to submitting a research grant as a co-principal investigator, starting coursework for an MPH degree and giving several invited lectures on humanitarian medicine. The fellow also travelled to Lebanon to support research in collaboration with aid organizations responding to the Syrian crisis. Upcoming fieldwork involves teaching at a newly established emergency medicine residency program in Haiti as well as a humanitarian crisis deployment. Conclusion: In response to a lack of formal international emergency medicine training opportunities in Canada, Queens University has established a Global Emergency Medicine fellowship. The fellowship aims to provide protected time, access to field opportunities and dedicated mentorship to develop the skills necessary to succeed as an academic Global EM physician. We believe it provides a unique opportunity to significantly expand fellows experiences in global health fieldwork, education and research while continuing to practice in a Canadian tertiary emergency department.

Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years of age with fractures: to 1) improve the proportion who receive analgesic medication from 35% to 50%; 2) improve the proportion who have a documented pain score from 23% to 50%, and 3) reduce median time to analgesia from 59 minutes to 30 minutes, within 1 year. Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children <17 years with a diagnosis of fracture who have a documented pain score, proportion who receive an analgesic medication, and minutes to analgesia. The measure for procedural pain was the proportion of children <12 years who receive topical anesthetic prior to a needle procedure for a laboratory test. Length of stay for pediatric patients and all patients were balancing measures. Run charts were used to detect special cause. Difference in proportions were compared using 2. Final analysis will include interrupted time series. Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (p<0.001). For children with fractures, the proportion with pain scores increased from 23% to 35% (p<0.001), proportion receiving analgesic medication increased from 35% to 42% (p<0.001), and median minutes to analgesia decreased from 59 to 43. Insufficient time points at this stage preclude identification of special cause. Conclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.