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

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

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

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

Introduction: Acute upper gastrointestinal bleeding is a potentially life-threatening medical emergency that frequently requires red blood cell (RBC) transfusions. However, the optimal hemoglobin thresholds for transfusion is controversial. The objective of this study was to establish the most efficacious transfusion threshold. Methods: A systematic review of the published literature was completed. MEDLINE, Health technology assessment database, Cochrane central register, Cochrane database of systematic reviews, and EMBASE were searched from inception to May 2015 using search terms including “blood transfusions”, “hemoglobin”, and “red blood cell”. Studies were included if they: reported original data, were peer-reviewed, studied adult populations, were randomized controlled clinical trials and primarily focused on clinical efficacy or effectiveness of liberal and restrictive pre-transfusion hemoglobin level thresholds. Quality was assessed using the Cochrane Risk of Bias tool. Data were extracted and meta-analysis was conducted using a random effects model to determine the risk ratio for: all-cause mortality, further bleeding and any adverse events. All steps were completed independently by two reviewers. Results: The literature search identified 4037 unique abstracts. Of these, 156 abstracts proceeded to full text review. 154 articles were excluded during full-text review resulting in 2 articles for final analysis. The total number of participants included was 701. The hemoglobin threshold to transfuse RBC varied between 70-80g/L versus 90-100g/L in restrictive and liberal policies, respectively. Both studies were at low risk of bias. Meta-analysis resulted in a pooled decreased risk of all-cause mortality (RR 0.65, 95% CI 0.44-0.96), re-bleeding (RR 0.63, 95% CI 0.46-0.85) and adverse events (RR 0.83, 95% CI 0.73-0.95) in the restrictive blood transfusion group versus the liberal blood transfusion group. Conclusion: While the evidence is limited, the risk of death is lower and there is no significant harm for a restrictive strategy. In this context, there is a decreased risk of transfusion associated adverse events among those receiving a restrictive strategy and should be considered for its impact on patient safety and health system resources.

Introduction: In 2011, Canada had a foreign-born population of about 6,775,800 people. They represented 20.6% of the total population, the highest proportion among the G8 countries. Immigrants encounter significant barriers to accessing primary healthcare. This is thought to be due to lower education level, employment status and the healthy immigrant effect. Our objective was to assess in an immigrant population without a primary care physician, would similar socioeconomic barriers also prevent access to the emergency department. Methods: Data regarding individuals’ ≥12 years of age from the Canadian Community Health Survey, 2007 to 2008 were analyzed (N=134,073, response rate 93%). Our study population comprised 15,554 individuals identified without a primary care physician who used emergency department care. Socioeconomic variables included employment, health status, and education. Covariates included chronic health conditions, mobility, gender, age, and mental health. Prevalence estimates and confidence intervals for each variable were calculated. Weighted logistic regression models were constructed to evaluate the importance of individual risk factors and their interactions after adjustment for relevant covariates. Model parameters were estimated by the method of maximum likelihood. The Wald statistic was employed to test the significance of individual variables or interaction terms in relation to ED choice. Results: Our study population included 1,767 immigrants and 13,787 Canadian born respondents from across Canada without a primary care physician (57.3% male). Immigrants were less likely to use the emergency department then Canadian born respondents (Odds Ratio 0.4759 (95%CI 0.396-0.572). Adjusting for health, education or employment had no effect on this reduced access (Odds Ratio 0.468 (95%CI 0.378-0.579). Conclusion: In a Canadian population without a primary care physician, immigrants access the emergency department less then Canadian born respondents. However this effect is independent of previously reported social and economic barriers. Immigration status is an important but complex component of racial and ethnic disparity in access to care. Specific policy and system development targeting this at risk population are required to allow for equal access to healthcare.

Introduction: It is estimated that 6% to 13% of patients presenting to the emergency department (ED) with vaginal bleeding or abdominal pain will have ectopic pregnancy. Risk factors such as previous pelvic infections, assisted reproductive technologies and previous tubal surgery as well as prevalence of ectopic pregnancy vary geographically. To date, the surveillance of ectopic pregnancy in Canada has been limited to hospitalized patient data, excluding patients receiving methotrexate therapy, day surgery or expectant management, possibly underestimating the true prevalence. The objective of this study was to determine Ontario’s ectopic pregnancy rate and geographic variability using both inpatient and outpatient data sources. Methods: Data from the Canadian Institute for Health Information Discharge Abstract Database, Same Day Surgery Database, National Ambulatory Care Reporting System, and Ontario Health Insurance Plan (OHIP) Claims Database was retrieved for all females with valid OHIP coverage aged 15 to 45 years from July 2002 to August 2014. Using ICD-10 and OHIP codes for ectopic pregnancy, abortions and deliveries, the rates and distribution of ectopic pregnancy (per 1000 reported pregnancies) by age group and public health unit (PHU) were documented. These data were also compared to the rate of ectopic pregnancy documented using only hospitalized patient data. Results: Using inpatient and outpatient data sources, the rate of ectopic pregnancy in Ontario increased from 20.5 to 27.5 per 1000 reported pregnancies from 2002 to 2014, respectively. The rate of ectopic pregnancy using only hospitalized patient data decreased from 12.6 to 9.5 per 1000 reported pregnancies from 2002 to 2014, respectively. The median (IQR) rate of ectopic pregnancy over the 12-year study period varied across public health units in Ontario, ranging from 14.9 (12.5, 17.5) to 37.7 (29.1, 55.8) per 1000 reported pregnancies. Conclusion: The rate of ectopic pregnancy is increasing in Ontario and has been previously underreported using only hospitalized patient data. Further research is needed to identify the factors resulting in this increase as well as the outcomes of ectopic pregnancies in Ontario.

Introduction: Much of the literature investigating the challenges associated with completing high quality work-based assessments (WBAs) have raised specific concerns over the appropriate documentation of assessments of underperforming trainees or trainees in difficulty. The purpose of this study was to examine the relationship between resident performance and the quality of assessments documented by supervisors on Daily Encounter Cards (DECs). The effect of trainee proximity (i.e. on-service versus off-service status) on this relationship was also examined. Methods: A series of DECs from the Department of Emergency Medicine at the University of Ottawa was scored by two raters using the Completed Clinical Evaluation Report Rating (CCERR). The CCERR is a 9-item instrument that has previously demonstrated reliable ratings and the ability to discriminate the quality of completed DECs. A proxy measure of resident performance was calculated by averaging the scores across performance items on the DEC to produce a “mean DEC rating”. Linear regression analysis was conducted with “mean DEC rating” as the independent measure and CCERR score as the dependent measure. Separate linear regression analyses were repeated for DECs completed for on-service versus off-service residents. Results: Linear regression analysis demonstrated a small but significant inverse relationship between mean DEC rating and CCERR score (p<0.001, r=-0.184), suggesting that when residents performed poorly, their supervisors tended to document higher quality assessments, and conversely, when residents performed well, their supervisors provided lower quality assessments. Further analysis demonstrated that this relationship was present for the on-service group (p<0.001, r=-0.24). However, no relationship was observed in the off-service group (p=0.62, r=-0.05). Conclusion: Resident performance and trainee proximity are important factors impacting the quality of documented clinical performance assessments. Greater attention needs to be given to determining ways of improving the quality of assessments reported for residents who are appropriately progressing in their clinical competence as well as for off-service trainees.

Introduction: A rapid and accurate weight of a child can be of critical importance during pediatric emergencies. The Broselow Tape (BT) is the gold standard for estimating a child’s weight based on their length. It separates children into incremental weight categories. Studies have shown that the BT is not accurate. We created a new pediatric spine board (PedEBoard) that weighs the child. The objective of this study was to compare the agreement between the actual weight vs. the PedEBoard weight and BT estimated weight of children presenting to a pediatric emergency department (ED). Methods: Ethics approval was obtained from McMaster University. A power calculation was done for sample size to detect 10% error. Consecutive children were recruited who presented to McMaster University’s Children’s ED on two days in March 2015. Children were excluded if their length was outside the BT range, non-English speaking or critically ill. Children had their weight taken by the triage nurse either on an infant scale or on a traditional standing scale. The nurse also took the child’s length using a standard measuring tape or height on the standing medical scale. Infants were placed on the PedEBoard by investigators while older children were asked to lie down on the board. Investigators were blinded to the actual weight. BT weight was determined by the palmPEDi Lite app. Bland-Altman analysis was performed, comparing the percent difference between the actual weight vs. PedEBoard weight and actual weight vs. BT weight. The correlation between the PedEBoard and BT was assessed using the Spearman coefficient of rank. Data was entered into MedCalc for Windows 98, Version 15.2.2 Results: A total of 157 children were included in the study. The mean actual weight was 19.4kg (95% CI 17.4 to 21.3) vs. the PedEBoard weight 19.4kg (95% CI 17.4 to 21.3) vs. the BT weight 16.9kg (95% CI 15.6 to 18.2). Bland-Altman percent difference was 0.1% (95% CI -2.0 to 1.8%) between the actual weight and the PedEBoard weight and 9.6% (95% CI -22.0% to 41.2%) between the actual weight and the BT weight. The Spearman coefficient of rank correlation was 1.000 p<0.0001 (95% CI 0.999 to 1.000) for the PedEBoard and 0.969 p<0.001 (95% CI 0.957 to 0.977) for the BT. The BT provided the wrong weight category 80% of the time vs. 8% for the PedEBoard. Conclusion: The PedEBoard closely agreed with the actual weight of the child while the Broselow Tape estimate often did not.

Introduction: This study provides an estimate of the number of EMS calls related to police use of force events that involve struggling, intoxicated and/or emotionally distressed patients. We hypothesized there would be under-reporting of EMS risk by paramedic agencies due to lack of standardized reporting of police events by EMS services and lack of a common linked case number between prehospital agencies in Canada. Methods: Data were collected during a multi-site, prospective, consecutive cohort study of police use of force in 4 Canadian cities using standardized data forms. Use of force was defined a priori and the application of handcuffs was not considered a force modality. Inclusion criteria: all subjects ≥ 18 years of age involved in a use of force police-public encounter. We defined risk to EMS as the presence of police- and/or paramedic- assessments of violent or struggling subjects on the scene. Three separate data forms (police-report of use of force, EMS encounter, and Emergency Department (ED) visit) were linked in the study by unique ID. When police-reported EMS was activated, investigators hand searched the EMS service reports at the relevant agencies for matching call sheets. Results: From Jan 2010 to Dec 2012, we studied 3310 consecutive public-police interactions involving use of force above simple joint lock application. Subjects were male (86%) with a mean age of 33 yrs; 85% were assessed by police as emotionally disturbed, intoxicated with drugs and/or alcohol or a combination of those. 45% were violent at the scene. Police-reported EMS attendance in 24% (809/3310) of use of force events, of which only 43% (349/809) of EMS run sheets were available. In events with violent subjects, EMS transported 51% to ED compared to 35% by police transport (chi=79.7, p=0.00). Conclusion: We identified periods of professional and physical risk to paramedics attending police use of force events and found that risk significantly underrepresented in EMS data. Paramedical training would benefit from policy and procedures for response to police calls and the violent patient, the majority of whom are struggling. A common linked case number in prehospital care would enable more specific quantification of the risk for EMS providers involved in police events.

Introduction: Syncope accounts for 1% of all annual emergency department (ED) visits in Canada with only 10.3% suffering serious adverse event (SAE) within 30-days. However, 66% are transported to ED by Emergency Medical Services (EMS). Our objectives were to assess 30 day SAE among syncope patients transported by Emergency medical services (EMS), assess the need to develop an EMS clinical decision aid, and estimate anticipated health care savings by diverting patients from the ED to alternative care pathways. Methods: We conducted a prospective cohort study at four tertiary care EDs from Feb 2012 to Feb 2013. We included patients ≥16 years of age with syncope and who arrived to the ED via EMS. We collected patient demographics, medical history, 30 day SAE, EMS time points (call received, EMS arrival on scene, EMS departure from scene, time of transfer of care in the ED), critical EMS interventions, and ED length of stay. We assessed for the occurrence of any SAE (death, arrhythmia, other cardiac and non-cardiac conditions) within 30 days of ED disposition. We used descriptive analysis, unpaired two-tailed t-test and chi-square test. Ethics approval was obtained at all study sites. Results: Of 1,475 ED patients with syncope during the study period, 992 (67.3%) arrived by EMS. Mean times (SD) for EMS arrival to the scene, patient assessment at the scene and transfer of patient from scene to the ED were 10.1 (6.4), 18.9 (8.3), and 14.6 (11.5) minutes respectively. Only two patients had critical interventions enroute (pacing and defibrillation). Overall 138 (13.9%) patients suffered a SAE; 32 (3.2%) detected by EMS, 58 (5.8%) detected during ED evaluation, 48 (4.8%) after ED disposition. The average ED length of stay was 5.9(4.2) hours. Based on average of cost from two sites, we estimated that total cost of transporting syncope patients from the scene to the ED to be $4 million in Canada. The total cost of ED care for syncope patients transported by EMS in Canada was calculated at $21.5 million. Conclusion: A substantial proportion of patients arriving to the ED via EMS suffer no SAE within 30 days. Correspondingly, our results suggest a need for an EMS clinical decision aid to divert low-risk syncope patients to alternative care pathways such as family physicians or rapid access clinics. If developed and implemented, this tool can potentially reduce EMS burden, ED crowding, and reduce healthcare costs.

Introduction: Collecting patient-reported follow-up data for prospective studies in the emergency department (ED) is challenging in this acute care, minimal continuity setting. Follow-up is frequently attempted using telephone contact and in some instances mail correspondence. The objective of this study was to determine if text messaging study participants involved in an ongoing randomized trial resulted in a lower rate of attrition as compared to conventional telephone follow-up. Methods: This was a secondary analysis of research participants enrolled in a randomized controlled trial assessing head injury discharge instructions. Adult (18-64 years) patients presenting to an academic ED (annual census 65,000) with chief complaint ‘head injury’ occurring within 24 hours of ED visit were contacted by telephone 2 and 4 weeks post ED visit to complete a symptom questionnaire. During the first 4 months of study follow-up, participants were contacted by a conventional telephone call. Attrition was higher than anticipated, thus we received subsequent ethics approval for the final 3 months of follow-up duration to contact participants by text message on the day of the first telephone attempt as a reminder of the telephone interview scheduled later that day. The proportion of patients lost to follow-up at 2 and 4 weeks post ED visit was compared between participants not receiving and receiving reminder text messages. Results: 118 patients were enrolled in the study (78 underwent conventional follow-up and 40 received text messages). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) were male. During the period of conventional follow-up, 3 participants withdrew from the study. Of the remaining 75 participants, 24 (32.0%) at 2 weeks and 32 (42.7%) at 4 weeks were unable to be contacted. Of the 40 participants receiving a reminder text message, 4 (10.0%) at 2 weeks and 10 (25.0%) at 4 weeks were unable to be contacted. Overall, text messaging study participants decreased attrition by 22% (95% CI: 5.9%, 34.7%) and 17.7% (95% CI: -0.8%, 33.3%) at 2 and 4 week follow-up, respectively. Conclusion: In this young ED cohort participating in a randomized trial, text message reminders of upcoming telephone follow-up interviews decreased the rate of attrition. Text messaging is a viable, low-cost communication strategy that can improve follow-up participation in prospective research studies.

Introduction: The emergency department (ED) hospital standardized mortality ratio (ED-HSMR) measures risk-adjusted mortality for patients admitted to hospital with conditions for which ED care may improve outcomes (emergency-sensitive conditions). This study aimed to describe in-hospital mortality across Canadian provinces using the ED-HSMR. Methods: Data were extracted from hospital discharge databases from April 2009 to March 2012. The ED-HSMR was calculated as the ratio of observed deaths among patients with emergency-sensitive conditions in a hospital during a year (2010-11 or 2011-12) to the expected deaths for the same patients during the reference year (2009-10), multiplied by 100. The expected deaths were estimated using predictive models fitted from the reference year for different hospital peer-groups (teaching, large, medium and small hospitals) adjusted for comorbidities, age, diagnosis, and hospital length of stay. Thirty-seven validated emergency-sensitive conditions were included (e.g., stroke, sepsis, shock). Aggregated provincial ED-HSMR values were derived from patient-level probabilities of death. A HSMR above or below 100 respectively means that more or fewer deaths than expected occurred in hospital within a province. Results: During the study period, 1,335,379 patients were admitted to 629 hospitals across 11 provinces and territories with an emergency-sensitive condition as the most responsible diagnosis, of which 8.9% died. More in-hospital deaths (95% confidence interval) than expected were respectively observed for the years 2010-11 and 2011-12 in Newfoundland [124.3 (116.3-132.6) & 117.6 (110.1-125.5)] and Nova Scotia [116.4 (110.7-122.5) & 108.7 (103.0-114.5)], while mortality was as expected in Prince Edward Island and Manitoba, and less than expected in other provinces and territories [Territories 67.3 (48.3-91.3) & 73.2 (55.0-95.5); New Brunswick 87.7 (82.5-93.1) & 90.4 (85.2-95.8); British Columbia 92.0 (89.6-94.4) & 87.1 (84.9-89.3); Saskatchewan 92.3 (87.1-97.4) & 90.8 (86.2-95.6); Ontario 94.0 (92.6-95.4) & 88.0 (86.6-89.3); Alberta 94.1 (91.1-97.2) & 91.0 (88.2-93.9); Québec 95.7 (93.8-97.6) & N/A]. Conclusion: Our study revealed important variation in risk-adjusted mortality for patients admitted to hospital with emergency-sensitive conditions among Canadian provinces. The results should trigger more in-depth evaluations to identify the causes for these regional variations.

Introduction: A previous Canadian emergency department (ED) model determined predictors of increased workload using a manual chart review to elucidate comorbidities. We designed an electronic algorithm to capture all comorbidities based on the Charlson Comorbidity Index (CCI) for a 5 year period preceding the ED visit from the regional inpatient database. Our objective was to identify predictors correlating with physician time require to treat patients and thus develop a multivariable model to predict physician workload. Methods: From May to September 2015, two research assistants (RAs) shadowed a random sample of physicians from the six urban EDs in a single health region. They documented time spent performing clinical and non-clinical functions for patient visits. A linkage with the previously validated regional ED database was used to obtain triage acuity, age, gender, mode of arrival, and CCI scores. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit as well as time spent on history and physical exam and to derive an equation for physician workload. RA inter-rater reliability was assessed on 107 MD-patient interactions. Results: Over the 4-month period, 873 patient encounters were documented. Data from 599 completed encounters were included in the model. The median age was 49.4 (SD 22.8) and 52.2% were female. Overall, 16.0% were admitted to hospital, 64.9% of patients were CTAS 1-3, 19.6% of patients arrived by ambulance, and 15.5% of patients had a CCI score of ≥ 1. The mean time spent on history and physical was 7.0 minutes (SD 4.73) and mean total time was 19.4 minutes (SD 11.6). Using a linear regression model with total time as the dependent and EMS arrival, CTAS, and age as the independent variables, having any CCI score is a significant predictor of total time (p = 0.03). with a difference of 2.9 minutes between CCI positive versus negative patients. Higher acuity was the most significant factor associated with time spent with a mean difference of 4.4 minutes per CTAS category. The intraclass correlation coefficient value was 0.99 (95% CI 0.97-1.00) indicating excellent reliability. Conclusion: The electronically derived CCI does have value in the development of a physician workload model and can replace the use of manual chart review to define patient comorbidities.

Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the ‘closeness’ of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.

Introduction / Innovation Concept: Insertion of an internal jugular (IJ) central venous catheter (CVC) under ultrasound guidance (USG) is a complex skill that requires considerable practice in order to achieve technical proficiency. Simulation allows novices to engage in structured and high volume repetitive practice of USG IJ CVC insertion and to work through a predictable pattern of errors prior to real patient encounters. Based on earlier work on learning curves for CVC insertion, this curriculum uses a model of simulation-based high volume deliberate practice of the fundamental skills of USG CVC insertion, and was designed with careful consideration of the conditions associated with optimal learning and improvement of performance. Methods: Eight residents (post graduate year 2) from the Departments of Emergency Medicine and Anesthesiology engaged in deliberate practice of USG CVC insertion during three two-hour sessions, at 2-week intervals. Progress of the residents was monitored with direct observation and regular hand motion analysis (HMA), which was compared to performance metrics set by a local expert. Curriculum, Tool, or Material: Students reviewed online introductory ultrasound video and articles outlining internal jugular (IJ) and femoral CVC insertion prior to the first session. Session 1 focused on ultrasound skills including knobology, transducer movement, and needle tracking. This was followed by 60 minutes of deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. During sessions 2/3, students practiced complete gowning and draping using sterile technique. This was followed again by deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. Students received coaching and feedback throughout all sessions, with HMA assessment of USG IJ CVC insertion at the beginning and end of each session. After three training sessions, consisting of 85 total attempts, 5/8 residents surpassed the expert benchmark for probe hand motion, 6/8 for needle hand motion, and 1/8 for total procedure time, with the remaining residents approaching the expert benchmark for each metric. Conclusion: We have successfully developed a simulation-based curriculum for USG IJ CVC placement. Residents demonstrated continuous improvement in each session, approaching or exceeding the expert benchmarks by the end of the third session.

Introduction / Innovation Concept: Several provinces (AB, SK and QC) have recently introduced restrictions to out of province (OOP) electives. Concurrently, enhanced competency training is a prominent part of RCPSC Emergency Medicine (EM) programs (Thoma et al., 2015). We present the implications of OOP elective restrictions on RCPSC-EM training and education. The revised 2008 RCPSC-EM requirements specify a minimum of 6 months devoted to achieving a particular expertise pertinent to the practice of EM. The most restrictive policies permit up to 3 months OOP during the 5-year residency. This limits residents’ ability to pursue enhanced competency training opportunities outside their training site. Enhanced training might be a graduate degree, fellowship or clinical year designed by the resident and program director. Enhanced training can help achieve specific career goals, meet the needs of the institution where the resident will practice, and contribute to the growth and development of EM in Canada. Methods: New OOP policies are evaluated using the Health Reform Analysis (HRA) and SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis methodologies. Stated and implied reasons for reform are evaluated and stakeholder perspectives (health system authorities, partner universities, resident physicians and the general public) provided. Curriculum, Tool, or Material: The material includes previous out of province elective policies and recent reforms. Conclusion: Policies for the 4th year EM elective time are variable across universities. This has resulted in inconsistent approval of residents’ requests for OOP enhanced training. Thus, enhanced training that might be approved at one site, may not be at another. Several test cases already exist and will be presented. This data has not been previously collated or reported to our knowledge. Varied interpretation of newly emerging policies has implications for the consistency, equity, and future of EM residency training in Canada.

Introduction / Innovation Concept: Expanding point of care ultrasound education in emergency medicine (EM) programs is a necessary part of curriculum development. Our objective was to integrate core and advanced applications for point of care ultrasound in caring for critically ill patients with undifferentiated shock. We chose to develop and implement an educational module using the systematic approach of the RUSH Exam for EM residents in our institution. Methods: After review of the literature in point-of-care ultrasound, a module was designed. An educational proposal outlining the RUSH Exam training within the -EM and CCFP-EM curricula was submitted to and accepted by the residency training committee. The objectives and goals were outlined in accordance with CanMEDS roles, and the ultrasound director provided supervision for the project. Curriculum, Tool, or Material: An 8-hour educational module was implemented between October 7 and November 18, 2014. All residents received formal training on the core applications in FAST and aortic scans prior to implementation. The following components of the RUSH Exam were included: two hours of didactic teaching with video clips on advanced cardiac, IVC, DVT, and pulmonary assessment; three hours of hands-on practice on standardized patients performed in the simulation lab to practice image acquisition and interpretation; one hour of didactic teaching on the overall approach to a patient with undifferentiated shock using the RUSH Exam; and two hours of hands-on RUSH Exam practice. A corresponding research project integrating a SonoSim Livescan training platform, a simulation-based testing device, demonstrated improvement in resident performance, subjective comfort with imaging patients in shock and making clinical decisions based on the findings. Conclusion: This 8-hour RUSH Exam educational module combined theoretical learning and hands-on practice for trainees. This module significantly broadened the scope of ultrasound training in our curriculum by providing the necessary skills in approaching patients in shock in a systematic fashion. Future direction will include ongoing education in this area and expansion as appropriate.

Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.

Introduction: Point of care ultrasound for assessment of undifferentiated hypotension and shock is part of the clinical scope of Emergency Physicians in Canada. The RUSH Exam outlines a systematic approach to these patients. A RUSH Exam educational model using didactic and hands on practice was developed and implemented for Emergency Medicine (EM) residents. This study evaluated the effectiveness of the module in a simulated setting on the following endpoints: improvement in image acquisition, interpretation, speed, and subjective comfort level, among EM residents with basic ultrasound training. Methods: Approval was received from the institutional health research ethics board for this before and after simulation study. Residents in the -EM Program or CCFP-EM Program from July 2014 to July 2015 were eligible to consent. Participants were excluded if they were unable to complete all portions. All residents were educated to the same level of introductory ultrasound training based on the curriculum in place at our institution. The 8-hour intervention included RUSH didactic and hands on small group sessions. Testing before and after the intervention was performed with the SonoSim Livescan training platform. Two evaluators scored each resident on the accuracy of image acquisition, image interpretation, and time to scan completion. A before and after survey assessed resident comfort level with performing ultrasound on an emergency patient in shock, and basing decisions on ultrasound findings. Statistical analysis was performed using McNemar’s test for image acquisition and interpretation, a paired T test for time, and the Bahpkar test for the questionnaire. Results: 16 EM residents including 11 senior residents and 5 junior residents were enrolled. Improvement was achieved in the categories of IVC image acquisition and interpretation, as well as interpretation for B-lines, lung sliding, cardiac apical and parasternal long axis, and DVT (p<0.05). Subjective comfort level of performing ultrasound in shock and basing decisions on the findings was increased (p<0.0001). Among junior residents, there was an increased speed of image acquisition. Conclusion: With the introduction of the RUSH Exam educational module, EM residents showed improved image acquisition, image interpretation, speed, and comfort level when using ultrasound in critically ill patients.