Introduction: Electronic health record (EHR) implementation can be associated with a slowdown in performance and delayed return to pre go-live productivity. The objective of this study is to describe the impact of a go-live strategy including diversion, public advertising of the go-live, and extra physician staffing to mitigate productivity loss. Methods: Lions Gate Hospital (LGH), an urban community hospital and rural referral centre with 250 beds and 65,000 annual ED visits went live with Cerner HER (Cerner Corporation, Kansas, MO) on April 28, 2018. The implementation included complete electronic ordering and electronic physician documentation. We compared patients seen per hour, time to physician (TTMD), ED length of stay (EDLOS), patients per hour left without being seen (LWBS), and admission rate (AR) for the 6 weeks prior to implementation (Pre), 2 weeks during (Imp), and 6 weeks after (Post) for LGH and a control hospital (Richmond Hospital – comparable in size/acuity) for the same periods. Medians were compared using the Mann-Whitney test for patients/hour, EDLOS and TTMD, and chi-square for AR and LWBS. Results: Patients/hour seen went from 2.1/hour in the pre phase, but dropped to 1.7/hr in the 2 week period following implementation (P < 0.05). During weeks 2-8 post implementation, 2,3 patients per hour were seen (P = 0.38 compared to Pre phase). At the control hospital, patients per hour were comparable across all time periods (Ps > 0.3). Median time to physician was 54, 56, and 54 minutes at LGH for the Pre, Imp, and Post time periods (Ps > 0.3). Median EDLOS was 184, 196, and 184 minutes in the pre, Imp, and post phases (P Imp versus pre = 0.11; Pre versus post = 0.54). LWBS rate was 1.3%, 2.9, and 2.4% (Ps for Imp and Post versus pre <0.05) at LGH, but the pattern was similar for the control hospital (2.9%, 4.1% and 4.0%’ Ps <0.05). There was no significant change in ambulance arrivals or admission rate at either hospital (Ps > 0.2). Conclusion: A deliberate implementation strategy that focuses on ED physician upstaffing and visit diversion can smooth the impact of the implementation of an EHR so that patient care is not impacted significantly. Return to normal productivity occurred by 8 weeks post go-live. We demonstrate a strategy that may support easier implementation at other sites.

Introduction: Transportation of patients better served at an alternative destinations (diversion) is part of a proposed solution to emergency department (ED) overcrowding. We evaluated the pilot implementation of the “Mental Health and Addiction Triage and Transport Protocol”. This is the first Canadian diversion protocol that allows paramedics to transport intoxicated or mental health patients to an alternative facility, bypassing the ED. Our aim was to implement a safe diversion protocol to allow patients to access more appropriate service without transportation to the emergency department. Methods: A retrospective analysis was conducted on patients presenting to EMS with intoxication or psychiatric issues. Study outcomes were protocol compliance, determined through missed protocol opportunities, noncompliance, and protocol failure (presentation to ED within 48 hours of appropriate diversion); and protocol safety, determined through patient morbidity (hospital admission within 48 hours of diversion) and mortality. Data was abstracted from EMS reports, hospital records, and discharge forms from alternative facilities. Data was analyzed qualitatively and quantitatively. Results: From June 1st, 2015 to May 31st, 2016 Greater Sudbury Paramedic Services responded to 1376 calls for mental health or intoxicated patients. 241 (17.5%) met diversion criteria, 158 (12.9%) patients were diverted and 83 (4.6%) met diversion criteria but were transported to the ED. Of the diverted patients 9 (5.6%) represented to the ED <48rs later and were admitted. Of the 158 diversions, 113 (72%) were transported to Withdrawal Management Services (WMS) and 45 (28%) were taken to Crisis Intervention (CI). There was protocol noncompliance in 77 cases, 69 (89.6%) were due to incomplete recording of vital signs; 6 (10.3%) were direct protocol violations of being transferred with vital sings outside the acceptable range. Conclusion: The Mental Health and Addiction Triage and Transport Protocol has the potential to safely divert 1 in 6 mental health or addiction patients to an alternative facility.

Introduction: Undifferentiated hypotension remains one of the most life-threatening presentations to emergency departments (ED) around the world. An accurate and rapid initial assessment is essential, as shock carries a high mortality with multiple unique etiologies and management plans. Point of care ultrasound (PoCUS) has emerged as a promising tool to improve these diagnostic and management challenges, yet its reliability in this setting remains unclear. Methods: We performed a systematic review of Medline, EMBASE, CINAHL, Cochrane, and clinicaltrials.gov databases from inception to June 8, 2018. Databases were reviewed by two independent researchers and all languages were included. The methodological quality of included studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Our primary outcome was diagnostic accuracy of PoCUS in hypotension, with secondary outcomes including patient outcomes and changes to management. Results: Our literature search revealed 5345 articles after duplicates were removed, leaving 235 articles for full article review. Following full article review, 9 studies remained and were included in the systematic review. There were 2 randomized control trials, 6 prospective cohort trials, and 1 retrospective cohort trial. For our primary outcome of diagnostic accuracy, eight studies were included; we extracted Kappa values ranging from 0.70 to 0.971, pooled sensitivity ranging from 69% to 88%, and pooled specificity ranging from 88% to 96%. Four studies reported on management change including results reporting shorter time to disposition, change in diagnostic test ordering (18% to 31%), change in consultation (13.6%), change in admission location (12%) and change in management plan (25% to 40%). Only one study reported on patient outcomes, which revealed no survival or length of stay benefit. Conclusion: When assessing for the diagnostic accuracy of PoCUS in the setting of undifferentiated hypotension presenting to the emergency department, we found fair consistency between PoCUS and final diagnosis with high Kappa values, fair to good pooled sensitivities, and good to excellent specificities. There was no strong evidence indicating improved outcomes. However, the large amount of heterogeneity amongst studies has limited our ability to make a strong conclusion except that future research should focus on a uniform study design and patient focused outcomes.

Introduction: Patients with major bleeding (e.g. gastrointestinal bleeding, and intracranial hemorrhage [ICH]) are commonly encountered in the Emergency Department (ED). A growing number of patients are on either oral or parenteral anticoagulation (AC), but the impact of AC on outcomes of patients with major bleeding is unknown. With regards to oral anticoagulation (OAC), we particularly sought to analyze differences between patients on Warfarin or Direct Oral Anticoagulants (DOACs). Methods: We analyzed a prospectively collected registry (2011-2016) of patients who presented to the ED with major bleeding at two academic hospitals. “Major bleeding” was defined by the International Society on Thrombosis and Haemostasis criteria. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Secondary outcomes included discharge to long-term care among survivors, total hospital length of stay (LOS) among survivors, and total hospital costs. Results: 1,477 patients with major bleeding were included. AC use was found among 215 total patients (14.6%). Among OAC patients (n = 181), 141 (77.9%) had used Warfarin, and 40 (22.1%) had used a DOAC. 484 patients (32.8%) died in-hospital. AC use was associated with higher in-hospital mortality (adjusted odds ratio [OR]: 1.50 [1.17-1.93]). Among survivors to discharge, AC use was associated with higher discharge to long-term care (adjusted OR: 1.73 [1.18-2.57]), prolonged median LOS (19 days vs. 16 days, P = 0.03), and higher mean costs ($69,273 vs. $58,156, P = 0.02). With regards to OAC, a higher proportion of ICH was seen among patients on Warfarin (39.0% vs. 32.5%), as compared to DOACs. No difference in mortality was seen between DOACs and Warfarin (adjusted OR: 0.84 [0.40-1.72]). Patients with major bleeding on Warfarin had longer median LOS (11 days vs. 6 days, P = 0.03) and higher total costs ($51,524 vs. $35,176, P < 0.01) than patients on DOACs. Conclusion: AC use was associated with higher mortality among ED patients with major bleeding. Among survivors, AC use was associated with increased LOS, costs, and discharge to long-term care. Among OAC patients, no difference in mortality was found. Warfarin was associated with prolonged LOS and costs, likely secondary to higher incidence of ICH, as compared to DOACs.

Introduction: Elevated intracranial pressure (ICP) is a devastating complication of brain injury, such as traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, and other conditions. Delay to diagnosis and treatment are associated with increased morbidity and mortality. For Emergency Department (ED) physicians, invasive ICP measurement is typically not available. We sought to summarize and compare the accuracy of physical examination, imaging, and ultrasonography of the optic nerve sheath diameter (ONSD) for diagnosis of elevated ICP. Methods: We searched Medline, EMBASE and 4 other databases from inception through August 2018. We included only English studies (randomized controlled trials, cohort and case-control studies). Gold standard was ICP≥20 mmHg on invasive ICP monitoring. Two reviewers independently screened studies and extracted data. We assessed risk of bias using Quality Assessment of Diagnostic Accuracy Studies 2 criteria. Hierarchical Summary Receiver Operating Characteristic model generated summary diagnostic accuracy estimates. Results: We included 37 studies (n = 4,768, kappa = 0.96). Of exam signs, pooled sensitivity and specificity for increased ICP were: mydriasis (28.2% [95% CI: 16.0-44.8], 85.9.0% [95% CI: 74.9-92.5]), motor posturing (54.3% [95% CI: 36.6-71.0], 63.6% [95% CI: 46.5-77.8]) and Glasgow Coma Scale (GCS) ≤8 (75.8% [95% CI: 62.4-85.5], 39.9% [95% CI: 26.9-54.5]). Computed tomography findings: compression of basal cisterns had 85.9% [95% CI: 58.0-96.4] sensitivity and 61.0% [95% CI: 29.1-85.6] specificity; any midline shift had 80.9% [95% CI: 64.3-90.9] sensitivity and 42.7% [95% CI: 24.0-63.7] specificity; midline shift≥1cm had 20.7% [95% CI: 13.0-31.3] sensitivity and 89.2% {95% CI: 77.5-95.2] specificity. Finally, pooled area under the ROC curve describing accuracy for ONSD sonography for ICP was 0.94 (95% CI: 0.91-0.96). Conclusion: The absence of any one physical exam feature (e.g. mydriasis, posturing, or decreased GCS) is not sufficient to rule-out elevated ICP. Significant midline shift is highly suggestive of elevated ICP, but absence of shift does not rule it out. ONSD sonography may be useful in diagnosing elevated ICP. High suspicion of elevated ICP may necessitate treatment and transfer to a centre capable of invasive ICP monitoring.

Introduction: An increasing number of patients with end-stage diseases present to emergency departments (EDs) for physical, spiritual, psychological and social care. The objective of this study was to identify patients with end-stage diseases with palliative care (PC) needs and document their frequency of ED visits. Methods: This prospective cohort study was conducted in two Canadian EDs. Using a modified palliative care screening tool, volunteer ED physicians were asked to identify adult patients with end-stage, chronic conditions including cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), heart failure (HF), cirrhosis, dementia and/or progressive central nervous system (PCNS) disease. Demographic data were collected from these tools and data regarding patients’ visits in both the 6 months prior to and 30 days following their index visits were collected from the ED Information System. Bivariate analyses were completed using Student's t and chi-square test. Results: A total of 663 patients with end-stage illness were identified; 338 (51%) were female and the median age was 76 (IQR: 63, 85). Cancer was the most common presentation (41%), followed by dementia (23%), COPD (16%), HF (9%), CKD (9%), PCNS disease (9%) and cirrhosis (7%). These patients made a total of 1277 visits in the 6 months prior to and 288 in the 30 days following the index visit. Patients presenting to the EDs with cancer (p = 0.001), cirrhosis (p = 0.005) and CKD (p = 0.03) were more likely to visit an ED in the 6 months prior to their index visit. In contrast, patients presenting with dementia (p < 0.0001) and PCNS disease (p = 0.02) were significantly less likely to present to an ED in the 6 months prior to their index visit. Patients presenting with cirrhosis or CKD had the highest average number of ED visits in the 6 months prior to their index visit (cirrhosis: 4.59 visits, SD: 3.8, p < 0.0001; CKD: 4.39 visits, SD: 3.8, p = 0.0001). Of these patients, those presenting with end-stage cirrhosis were significantly more likely to make a return visit to an ED within 30 days after their index visit (p = 0.014). Conclusion: Cancer is the most common condition for patients with end-stage, chronic illnesses in these EDs. Those presenting with cirrhosis or CKD are at a significantly higher risk of repeat visits to the EDs. This study has identified potential deficits in care and can serve as a baseline for future intervention studies.

Introduction: Emergency medicine (EM) residents are expected become proficient in a number of rarely performed, high risk procedures. We developed Critical Care Skills Training Day for senior FRCP and CCFP EM residents at a single university program to fill a gap in resident confidence with these procedures. The day applies principles of deliberate practice with focused feedback using simulation-based training for several rarely performed procedures including thoracotomy, fibre-optic intubation, pericardiocentesis, resuscitative hysterotomy and central line insertion. The objectives of this work was to improve the residents’ scores of self-perceived comfort independently performing these procedures by completion of the training day. Methods: Clinician educators, residency program directors and simulation specialists designed and taught the curriculum. We used pre- and post-training day surveys blending Likert, multiple choice and free text comments to measure comfort performing each procedure, overall satisfaction and usefulness of this training. Descriptive statistics were used to analyze results. Pre-post differences were assessed using paired sample T-tests. Comments and themes from course evaluations were used to make yearly iterative changes. Results: A total of 95 residents completed the curriculum between 2016-2018. 89 completed evaluations (93%). Residents reported significant (p < 0.05) improvement in comfort independently performing fibre optic intubation, thoracotomy and central line insertion. The day was rated very highly, 9.4/10 (SD, 0.72), over 3 years. Feedback was positive with participants identifying opportunities for repeated practice, feedback from instructors and practical tips to improve performance as valuable aspects. Iterative changes were made yearly in response to resident feedback including introduction of new procedures, incorporating skills into sim-based cases, and different training models for skill training. Conclusion: Critical Care Skills Training Day for EM residents was created using the principle of deliberate practice to fill a perceived gap in resident training. Residents who completed the annual curriculum showed a marked increase in comfort independently performing several of the procedures. Ongoing challenges include the length of the day, economies of scale, and training models available for the rare procedures. Future directions include the integration of longitudinal objective performance evaluations to align with the competency by design curriculum.

Introduction: The optimal initial management approach for ureteral colic is unclear. Guidelines recommend spontaneous passage for most patients, but early stone intervention may rapidly terminate acute episodes. We compared 60-day treatment failure rates in matched patients undergoing early intervention versus spontaneous passage. Methods: We used administrative data and structured chart review to study all emergency department (ED) patients at nine Canadian hospitals who had an index ureteral colic visit and a computed tomography (CT) confirmed 2.0-9.9 mm stone during 2014. Using Cox Proportional Hazards models, we assessed 60-day treatment failure, defined as hospitalization or rescue intervention, in patients undergoing early intervention compared to propensity-score matched controls undergoing trial of spontaneous passage. Results: From 3,081 eligible patients, mean age 51 years and 70% male, we matched 577 patients in each group (total 1154). Control and intervention cohorts were balanced on all parameters and propensity scores, which reflect the conditional probability a patient would undergo early intervention, were similarly distributed. In the time to event analysis, 21.8% in both groups experienced the composite primary outcome of treatment failure (difference = 0%; 95% CI, -4.8 to 4.8%). Early intervention patients required more ED revisits (36.1% v. 25.5%; difference 10.6%; 95% CI 5.3 to 15.9%) and more 60-day hospitalizations (20.1% v. 12.8%). The strongest predictors of adverse outcome were stone size, proximal or middle stone location, and ED length of stay. Conclusion: If applied broadly to patients with 2.0-9.9mm ureteral stones, an early interventional approach was associated with similar rates of treatment failure, but more hospitalizations and emergency revisits. Research clarifying subgroups most likely to benefit will facilitate better targeting of early intervention, potentially reducing patient morbidity and improving system utilization.

Introduction: We implemented a pharmacist-led antimicrobial stewardship (AMS) service for patients discharged from the pediatric emergency department (PED). This service, supported by a collaborative practice agreement, allows pharmacists to follow up with patients and independently stop, start, or adjust antimicrobial agents based on culture results. The primary objective of our study was to evaluate the impact of this service on the rate of return visits to the PED within 96 hours. The secondary objective was to evaluate the appropriateness of the prescribed antimicrobial agent at follow up. Methods: This study was completed as a retrospective chart review 6 months pre-implementation (January 1st, 2016 to June 31st, 2016) and 6 months post-implementation (February 1st, 2017 to July 31st, 2017) of a pharmacist-led AMS service. A research assistant extracted data from electronic medical records using a standardized data collection form. All patients discharged from the PED with a suspected infection whose cultures fell within the parameters of the collaborative practice agreement were included in this study. Data were reported descriptively and compared using a two-sided chi-square test. Results: This study included 1070 patient encounters pre-implementation and 1040 patient encounters post-implementation of the AMS service. The most commonly reviewed culture was urine (38% pre-implementation and 41% post-implementation). The rate of return visits to the PED within 96 hours was 12.0% (129/1070) pre-implementation vs 10.0% (100/1049) post-implementation phase (p = 0.07). A significantly higher percentage of inappropriate antimicrobial therapy was identified at the time of follow up in the pre-implementation phase (7.0%, 68/975) compared to the post-implementation phase (5.0%, 46/952), p = 0.047. Conclusion: Although this pharmacist-led AMS service did not affect the rate of return visits within 96 hours, it may have led to more judicious use of antimicrobial agents.

Introduction: Effective communication to develop a shared understanding of patient expectations is critical to a positive encounter in the Emergency Department (ED). However, there is limited research examining Patient/Caregiver (P/C ) expectations in the ED and what factors lead to P/C presentation. This study aims to address this gap by answering the following questions: 1) What are common P/C reported factors affecting ED presentation? 2) What are common P/C expectations of an ED visit? 3) How do P/C expectations vary based on ED site or factors affecting presentation in the ED? Methods: The Preparing Emergency Patients and Providers (PrEPP) tool was designed to collect P/C expectations, worries, perceived causes of symptoms, and factors affecting presentation from a convenience sample of patient visits to the emergency department (ED). The PrEPP tool was provided to all P/Cs with CTAS 2-5 when they registered at one of 4 EDs in the Halifax area from January to June 2016. Completed tools were collected in a REDCap database where qualitative data was coded into categories (i.e. presenting illness, injury). Descriptive and chi-squared statistical analyses were performed. Results: In total, 11,418 PrEPP tools were collected; representing 12% of the total ED visits to the 4 ED sites during the study period. The main factors affecting ED presentation were: self-referral 68%, family/friends 20%, telehealth 8%, unable to see their GP 7%, GP referral 6%, or walk-in-clinic 5%. P/Cs main causes of worry were: presenting illness 19%, injury 15%, or pain 14%. The main expectations for the ED visit were to get a: physician's opinion 73%, x-ray 40%, or blood test 20%. Most P/Cs indicated they did not expect medication during (63%), or after (66%), their ED visit. There were significant differences in P/C expectations between adult and pediatric EDs (χ2 = 720.949, df = 14, P = 0.000) and those P/Cs unable or able to access primary care prior to ED presentation (χ2 = 38.980, df = 1, P = 0.000). The rate of expecting a physician's opinion at the pediatric ED was higher than the adult ED (77.6% vs 70.9%), while lower for expecting CT/MRIs (4.6% vs 11.4%). P/Cs who were unable to access primary care prior to ED presentation expected services which were available at primary care at a higher rate than those who accessed primary care (58.5% vs 36.7%). Conclusion: Our findings identify some of the factors that influence P/C's decision to present to the ED and their expectations of the ED visit.

Introduction: Near-infrared spectroscopy (NIRS) can be used to monitor the oxygen saturation of hemoglobin in any given superficial tissue. However, the measurements provided by different oximeters can vary a lot. Little is known about the specific patient characteristics that could affect the inter-device agreement of tissular oximeters. This study aimed to evaluate the association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement of two tissue oximeters, the INVOS 5100c and the Equanox 7600. Methods: In this prospective cohort study, tissue saturations and skinfold thickness were measured at four different sites on both sides of the body in healthy adult (≥18 years old) volunteers. The association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement (absolute difference between the oximetry values provided by the two oximeters) was first assessed with a Pearson's correlation and a scatter plot. Subsequently, a linear mixed model was used to evaluate the impact of the subcutaneous fat and other covariables (age, sex) on the inter-device agreement while adjusting for the repeated measurements across different sites for the same volunteers. Results: From January to March 2015, 53 healthy volunteers were included in this study with ages ranging between 20 and 81 years old, on which a total of 848 measures were taken. Higher skinfold measures were associated with an increase in the difference between measures provided by both oximeters (Slope = -0.59, Pearson correlation coefficient = -0.51, p < 0.001). This observed association persisted in a linear mixed model (-0.48 [95% confidence interval {CI}-0.61 to -0.36], p < 0.001). The sex of the volunteers also influenced the inter-oximeter agreement (Women:-5.77 [95%CI -8.43 to -3.11], p < 0.001), as well as the forearm sites (Left forearm: −7.16 [95%CI -9.85 to –4.47], p < 0.001; right forearm: −7.01 [95%CI -9.61 to −4.40], p < 0.001). Conclusion: The quantity of subcutaneous fat, as well as the sex of the volunteers and the measurement sites, impacted the inter-device agreement of two commonly used oximeters. Given these findings, monitoring using tissue oximetry should be interpreted with great care when there is a significant quantity of subcutaneous fat.

Introduction: Guidelines recommend serial conventional cardiac troponin (cTn) measurements 6-9 hours apart for non-ST-elevation myocardial infarction (NSTEMI) diagnosis. We sought to develop a pathway based on absolute/relative changes between two serial conventional cardiac troponin I (cTnI) values 3-hours apart for 15-day MACE identification. Methods: This was a prospective cohort study conducted in the two large ED's at the Ottawa Hospital. Adults with NSTEMI symptoms were enrolled over 32 months. Patients with STEMI, hospitalized for unstable angina, or with only one cTnI were excluded. We collected baseline characteristics, Siemens Vista cTnI at 0 and 3-hours after ED presentation, disposition, and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (AMI, revascularization, or death due to cardiac ischemia/unknown cause). We analysed cTnI values by 99th percentile cut-off multiples (45, 100 and 250ng/L). Results: 1,683 patients (mean age 64.7 years; 55.3% female; median ED LOS 7 hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI ≤45ng/L; and 58 (3.4%) of the 213 patients with one value≥100ng/L but both <250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one value >45ng/L but both <100ng/L based on 3 or 6-hour cTnI, one patient with Δ<10ng/L and 6 of 19 patients with Δ≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95%CI 96.7-100%) and 94.6% specificity (95%CI 93.4-95.7%). Conclusion: The OTP, using two conventional cTnI measurements performed 3-hours apart, should lead to better identification of NSTEMI particularly those with values >99th percentile cut-off, standardize management and reduce the ED LOS.

Introduction: Acute upper gastrointestinal bleeding (UGIB) is a common presentation to emergency departments (ED). Of these patients, 35-45% receive a blood transfusion. Guidelines for blood transfusion in UGIB have been well established, and recommend a hemoglobin (Hb) level below 70 g/L as the transfusion target in a stable patient. There is no consensus on a transfusion threshold for unstable UGIB. There is limited data regarding physician practices in the ED. The aim of our study is to determine the appropriateness, by expert consensus, of blood transfusions in UGIB in a tertiary care hospital ED. Methods: We retrospectively reviewed patients presenting with UGIB to the University of Alberta Hospital ED in 2016. These patients were then screened for blood transfusions. Data were obtained from the patient records. Chart derived data were verified with records obtained from the blood bank. For each patient, the history, vitals, Glasgow Blatchford Score (GBS), relevant labs, and record of blood transfusions were collected and organized into a case summary. Each patient summary was presented individually to a panel of three expert clinicians (2 Gastroenterology, 1 Emergency Medicine), who then decided on the appropriateness of each blood transfusion by consensus. Results: Blood transfusions (data available 395/400) were given to 51% (202/395) of patients presenting with UGIB. Of these, 86% (174/202) were judged to be appropriate. Of the 395 patients, 34% (135/395) had a Hb of <70 g/L. Of these, 93% (126/135) were transfused, and all of these were considered appropriate. 18% (70/395) had a Hb between 71-80. 74% (52/70) of these patients were given blood, and 79% (41/52) were considered appropriate. 13% (50/395) of the patients had a Hb between 81-90, with 28% (14/50) receiving a transfusion. Of these, 36% (5/14) were deemed to be appropriate. 35% (140/395) of patients had a Hb of >90. 7% (10/140) of these received blood. 20% (2/10) were considered appropriate. Conclusion: The panel of expert clinicians judged 86% of the blood transfusions to be appropriate. All transfusions under the recommended guideline of 70 g/L were considered appropriate. In addition, the majority of transfusions above a Hb of 70 g/L were considered appropriate, but 37% were not. Further studies evaluating the feasibility of current guideline recommendations in an ED setting are required. Educational interventions should be created to reduce inappropriate blood transfusions above a Hb 70 g/L.

Introduction: Point-of-care ultrasonography (PoCUS) is being incorporated into Canadian undergraduate medical school curricula. The purpose of this study was to evaluate novel PoCUS education sessions to determine what aspects of the sessions benefitted from hands-on training and which PoCUS skills were retained over time. Methods: Second year medical students voluntarily received three different PoCUS training sessions, each lasting three hours. Prior to the sessions, participants prepared independently with pre-circulated online learning materials. After a 15-minute lecture, experienced PoCUS providers led small group (1 instructor: 5 students), live scanning sessions. Evaluations were conducted before and after each session using expert validated multiple choice questions testing general and procedural knowledge, image recognition and interpretation. Volunteer students were evaluated via direct observation of live scanning using an objective structured assessment of technical skills (OSAT) based on the O-score and then re-evaluated at 2 months post-training to assess PoCUS skills retention. Results: 40 second year medical students participated in extended Focused Assessment with Sonography for Trauma (eFAST), cardiac, and gallbladder PoCUS sessions. The live-training sessions significantly improved student PoCUS knowledge beyond what they learned independently for eFAST (p < 0.001), cardiac (p < 0.001), and gallbladder (p = 0.02). The largest improvement was noted in procedural knowledge test scores improving from 44.0% to 84.0% (n = 38). 16 students were evaluated after each session with a mean O-score of 2.37. 8 students returned two months later to be re-evaluated demonstrating a change in O-scores for eFAST (2.00 to 2.38, p = 0.15), cardiac (2.28 to 2.00, p = 0.32), and gallbladder (2.91 to 1.88, p < 0.001). Conclusion: Procedural PoCUS knowledge benefited the most with hands-on training. eFAST and cardiac PoCUS competency was maintained over time while gallbladder PoCUS competency degraded suggesting that targeted PoCUS skills training may be possible. Further study is required to determine the best use of PoCUS resources in undergraduate medical education.

Innovation Concept: Consultation skills (the collaborator role) are key for safe and effective Emergency Medicine practice. The tool described uses educational techniques familiar to Emergency Physicians and residents (rapid cycle deliberate practice and focused debriefing) to incorporate teaching of this skill into on-shift clinical teaching of Emergency Medicine residents. Methods: We searched the literature for consultation teaching methods. We developed a tool to teach consultation as part of on-shift clinical teaching using pedagogical concepts familiar to Emergency Medicine residents, rapid cycle deliberate practice and focused debriefing. The developed tool has three phases; 1) Introduction to a framework for good consultation skills, 2) Managing push-back and understanding competing frames of reference and 3) Direct observation and feedback on the actual consultation. The tool is designed to be used during a clinical shift. Over a series of consecutive cycles the resident refines a consultation and is eventually directly observed during the actual interaction with a consultant. Curriculum, Tool or Material: For each of the three phases the tool provides a framework for the preceptor to use to guide the presentation and discussion. During phases 1 and 2 the resident will present the consultation a number of times and the preceptor will provide focused debriefing allowing the presentation to be refined and optimized. During phase 3 the preceptor provides direct observation of the actual consultation followed by focused debriefing. Phase 1: Focuses on understanding the learners current skill level and presents a framework for a high quality consultation. Phase 2: Introduces the concept of competing frames of reference and push-back and patient centred strategies for managing this situation. Phase 3: The actual consultation interaction between resident and consultant is observed and debriefed. Conclusion: Consultation skills are important in the day to day practice of Emergency Medicine but rarely the subject of specific teaching. The tool presented can be used during clinical shifts to teach consultation skills using pedagogy familiar to both Emergency Physicians adEM residents.

Innovation Concept: Emergency medicine (EM) programs have restructured their training using a Competence by Design model. This model emphasizes entrustable professional activities (EPAs) that residents must fulfill before advancing in their training. The first EPA (EPA 1) for the transition to discipline (TTD) stage involves managing the unstable patient. Data from the University of Toronto (U of T) program suggests residents lack enough exposure to these patient presentations during TTD – creating a disconnect between anticipated clinical exposure and the expectation for residents to achieve competence in EPA 1. Methods: To overcome this gap, U of T EM faculty specifically targeted EPA 1 while designing the TTD curriculum. Kern's six-step approach to curriculum development in medical education was used. This six-step approach involves: problem identification, needs assessment, goals and objectives, education strategies, implementation and evaluation. To maximize feasibility of the new curriculum, existing sessions were mapped against EPAs and required training activities to identify synchrony where possible. Residents were scheduled on EM rotations with weekly academic days that included this novel curriculum. Curriculum, Tool or Material: Didactic lectures, procedural workshops and simulation were closely integrated in TTD to address EPA 1. Lectures introduced approaches to cardinal presentations. An interactive workshop introduced ACLS and PALS algorithms and defibrillator use. Three simulation sessions focused on ACLS, shock, airway, trauma and the altered patient. A final simulation session allowed spaced-repetition and integration of these topics. After the completion of TTD, residents participated in a six-scenario simulation OSCE directly assessing EPA 1. Conclusion: The curriculum was evaluated using a multifaceted approach including surveys, self-assessments, faculty feedback and OSCE performance. Overall, the curriculum achieved its goal in addressing EPA 1. It was well-received by faculty and residents. Residents rated the sessions highly, and self-reported improved confidence in assessing unstable patients and adhering to ACLS algorithms. The simulation OSCE demonstrated expected competency by residents in EPA 1. One limitation identified was the lack of a pediatric simulation session which has now been incorporated into the curriculum. Moving forward, this innovative curriculum will undergo continuous cycles of evaluation and improvement with a goal of applying a similar design to other stages of CBD.

Innovation Concept: Medical students often face challenges when entering clerkship. The abundance of teaching tools and online resources make it difficult for learners to navigate and apply knowledge in a clinical setting. Although valuable study aids exist across Emergency Medicine (EM) clerkship curriculums, a convenient resource tailored to junior learners for on-shift use is lacking. We created an academic resource with the intent of assessing student engagement with the handbook. Methods: Ottawa's Clerkship Guide to Emergency Medicine was developed using information from a commonly used EM textbook and relevant literature. After a comprehensive peer-review by staff EM physicians, the resource was published online and made available to learners in March 2018. To assess utility of this resource, a national survey was administered followed by a Likert-type analysis. Website metrics and the survey results were used to guide a sustainable model for annual student-driven resource updates. Curriculum, Tool or Material: The handbook contains high-yield EM topics organized into one-page summaries. The main sections include resuscitation, symptoms-based approach, and medical emergencies. Students can access the handbook online, via mobile app, or use a printable version. Over 7300 unique downloads have occurred since launch. Our national survey revealed that of the total respondents (N = 171, 93.6% 3rd-year clerks, 31.6% uOttawa students), 97.1% (n = 166) had used the handbook on shift. A majority were able to find an answer to their clinical question either fully (53%, n = 88) or partially (46.4%, n = 77) and many would recommend this resource as-is (62.7%, n = 104) or with some modifications (34.3%, n = 57). Compared to the student's preferred clinical resource, mean Likert-type scores showed a significant (p < 0.01) positive difference in favor of the handbook regarding themes of organization (3.83 vs. 4.38), length (3.43 vs. 4.76) and ease in accessibility (3.46 vs. 4.79). Conclusion: The value of this handbook for junior learners entering their acute care rotation is evident. We demonstrated that student uptake of this handbook was robust. Compared to commonly used resources, students felt this handbook was more organized, concise in length, and easy to integrate into their clinical workflow. Implementation of this handbook across Canadian EM curriculums may bridge the EM knowledge gap in junior learners and off-service residents.

Innovation Concept: Resuscitative thoracotomy (RT) is a life-saving procedure in select trauma patients. However, RT is infrequently performed, limiting trainee exposure. In a survey of American training programs, graduating residents had performed an average of 3 RTs. There is no published data regarding the number of RTs observed and performed by Canadian trainees. We theorized that RT procedural exposure and comfort level would be low in emergency medicine (EM) trainees at our institution due to lack of exposure. Thus, we aimed to create a first person procedural video using local resources to teach RT. Methods: We first created a needs assessment survey conducted within Western University Division of Emergency Medicine over two months in 2018. Senior residents observed an average of 1.5 RT procedures and participated in an average of 0.6. Furthermore, 88% of senior residents cited a lack of confidence in their ability to perform this procedure and 87% indicated an instructional video would be a valuable educational tool. We created a video described in detail below. Prior to video distribution a survey was distributed asking respondents to list the critical steps in performing an RT. Participants were then asked to view the video and complete the survey again. Responses were scored by two independent reviewers. Curriculum, Tool or Material: An immersive cadaveric simulation video was developed in collaboration with a trauma surgeon at our institution. The video reviewed our thoracotomy tray, RT indications/contraindications, and demonstrated a narrated first-person RT on a floppy embalmed cadaver. Potential difficulties encountered during the procedure are highlighted throughout the video with troubleshooting tips suggested. Conclusion: We had 46 survey respondents from our division (25 residents and 21 consultants). After viewing the video, procedural step scores were significantly higher for junior FRCPC (p = 0.001), senior FRCPC (p = 0.013), and CCFP-EM (p < 0.001) residents as well as consultants (p = 0.016). There was also an increase in the number of respondents who reported confidence in their ability to perform RT post-video (n = 4 pre-video; n = 11 post-video). This video is an inexpensive, effective way to teach the critical procedural steps of RT and can be easily adapted for use at other institutions. Next steps for further education in this topic include development of a hands-on cadaveric simulation curriculum for residents.

Innovation Concet: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application that has the potential to guide the management of critically ill patients in the emergency department. The objective of this study was to determine the effectiveness of a brief training workshop for teaching a resuscitative TEE protocol to emergency medicine residents using a high-fidelity simulator. Methods: Emergency medicine residents with no prior TEE experience that were rotating through a university-affiliated emergency department were invited to participate in the study. Participants completed a questionnaire and baseline skill assessment using a high-fidelity simulator. The training session included a 20 minute lecture followed by 10 simulated repetitions of a 5-view TEE sequence with instructor feedback. Learning was evaluated by a skill assessment immediately after training and a transfer test 1-2 weeks after the training session. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. The primary outcome of this study was the percentage of successful views before and after training as determined by two blinded reviewers using an anchored scoring tool. Secondary outcomes included time to scan completion and diagnostic accuracy on the transfer test. Assessment scores were compared using a two-tailed t-test. Curriculum, Tool or Material: 22 of 25 (88%) of invited residents agreed to participate in the study. Percentage of successful views increased from 44.5% (SD 27.9) at baseline to 98.6% (SD 3.5) after training (p < 0.001), and was 86.8% (SD 12.1) on transfer testing (p < 0.001). Time to complete the scan was 330 seconds at baseline, 125 seconds after training (p < 0.001), and 184 seconds (p < 0.001) in the transfer test. Participants made the correct diagnosis in 75% (SD 25.6) of the cases in the simulated patient encounter. The descending aorta view had the highest success rate (93.2%) and the midesophageal long axis view had the lowest success rate (75.0%). Conclusion: A brief simulation-based workshop was effective for teaching emergency medicine residents a five-view resuscitative TEE protocol. Future studies are needed to determine optimal methods for long-term skill retention.

Innovation Concept: Transition to independent practice is challenging and early career physicians are more prone to burnout and error. Despite recommendations for formal mentorship to support physicians, only 43.6% of US academic Emergency Medicine departments have such programs. We describe an innovative mentorship program designed to support these early career physicians and enhance quality of care, career longevity, and wellness. We operationalized mentorship in which experienced, highly regarded, empathic mentors guide mentees in their personal and professional development. Methods: In this program two Emergency Physician mentors were teamed with each newly hired Emergency Physician. Mentees could request their own mentors, and teams were matched on the basis of shared personal and academic interests. Mentors received academic funding and training on good mentorship practice, roles and responsibilities, and feedback. Teams had to meet formally at least twice a year, with additional contact as needed. While mentees set the meeting agenda, teams were also encouraged to address four main areas. These areas were identified from a targeted needs assessment and literature review. They include: 1) clinical process and care, 2) departmental structure and culture, 3) teaching and scholarship, and 4) physician wellness. After meetings, mentees summarized and submitted the topics discussed and reflected on action plans. An oversight committee supported the program. Curriculum, Tool or Material: All nine (9) newly hired physicians joined the program in Fall 2018. As of December 2018, six (6) teams have had formal meetings. They discussed the following areas: clinical processes and care (50%), departmental structure and culture (100%), teaching and scholarship (67%), and physician wellness (100%). Other areas discussed include: academic career, financial planning, and networking. Teams spent 20-60% of the time formulating steps to achieve mentee career goals. They spent 40-60% of the time discussing skills and resources needed. End of year program evaluation will include outcomes such as satisfaction, value, effectiveness, projects, promotions, and awards. The results will shape future program design. Conclusion: We implemented a mentorship program for newly hired Emergency Physicians. As mentorship is integral to successful transition to independent practice, this program model could be highly beneficial to other academic Emergency Medicine departments.