Introduction: Atrial fibrillation and flutter (AFF) represent the most common arrhythmia presentations to emergency departments (EDs). Some research suggests that women with AFF experience different symptoms, receive different treatment and have worse outcomes than men. This study explored sex differences in risk factors, medication, and outcomes before and after ED visits for acute AFF. Methods: Adult patients presenting to the one of three hospitals affiliated with the University of Alberta with acute AFF were enrolled. Following informed consent, each patient completed a survey administered by a trained researcher, administrative ED information (e.g., ED times) was collected from the ED information system, a chart review on treatments was conducted and patients were contacted for follow-up at 7 days via telephone. Descriptive (median and interquartile range {IQR} and proportions) and simple (Wilcoxon-Mann-Whitney, chi-square, z-proportion) statistics are presented for continuous and dichotomous outcomes. Results: Overall, 217 patients were enrolled; the median age was 64 years (IQR: 55, 73) and 39% were female. Males presenting to the ED with AFF were 10 years younger than females (p<0.001); however, females weighed significantly less (median weight 69 vs. 95 kg; p<0.001), consumed less alcohol (12 vs 60 drinks/year; p<0.001) and were less likely to be ex-smokers (p=0.022) than men with AFF. Women arrived by Emergency Medical Services (EMS) (p=0.037), experienced palpitations (p=0.042), and reported a history of hypertension (p=0.022) more frequently than men. Females were more often prescribed oral anticoagulants before (p= 0.041) and after (p=0.011) the ED visit, and females with a history of AFF were less likely to present without anticoagulant/antiplatelet therapy (p=0.015). Overall, both sexes had similar attempts at cardioversion (59.4% vs. 61.3%) and hospitalizations (12.5% vs. 8.6%), respectively. If initial chemical cardioversion failed, females were more likely to receive subsequent electrical cardioversion (60.0% vs. 26.7%, p=0.036) than men. Conclusion: Overall, both women and men present frequently to the ED with AFF. Compared to men with AFF, women present with symptoms 10 years later, have different risk factors, experience more severe symptoms and use EMS more commonly; however, outcomes were similar. Unexplained sex-based variations in-ED and post-ED management are evident and these differences warrant further scrutiny.

Introduction: Emergency medicine (EM) is known to be a high-stress specialty. Work related stress and burnout have been reported to negatively impact physician-patient interactions, collaboration and ultimately overall physician mental and physical health. We sought to assess the rates of burnout among emergency physicians working at a single large Canadian tertiary care center and to identify higher risk groups. We hypothesized burnout rates to be uniformly high. Methods: We conducted a local cross-sectional study to assess burnout among adult and pediatric emergency physicians, fellows and residents at London Health Sciences Centre (LHSC). A total of 118 participants were invited to complete an anonymous online survey encompassing demographics, the validated MBI tool (Maslach Burnout Inventory) with additional questions aimed at identifying determinants of emergency physician burnout at LHSC. Each respondents three MBI scale scores for Emotional Exhaustion, Depersonalization and Personal Accomplishment were recorded with a possible range of 0-6. Descriptive statistics were calculated and relationships between risk factors (age, gender, years of practice, marital status, and credentials) and burnout scores were examined using t-tests, one-way ANOVAs, and/or regression analyses where appropriate. Results: To date the survey had a 50% (59/118) response rate. Of the 59 respondents 24 (40%) were female, the mean (SD) age was 40.6 years (10.5) and years of practice ranged from 1 to 35, with a mean of 13. Survey results indicated a high degree of burnout among LHSC EM physicians with a mean (SD) Emotional Exhaustion Score of 2.9 (1.3) and Depersonalization score of 2.4 (1.3), indicating that physicians felt burnt out from work between once a day to once a week. Inversely, the protective variable of Personal Accomplishment, with a score of 4.7 (0.9), indicated daily to weekly feelings of accomplishment. Female physicians (independent samples t-test, p=0.003) and those having fewer years of practice (linear regression, R2=0.188, p=0.04) were identified to have higher burnout. We did not identify any factors associated with Personal Accomplishment. Conclusion: Consistent with previous literature, LHSC emergency physicians were shown to be at risk for moderate to severe burnout. High risk groups identified included gender (female) and fewer years of practice. We did not identify any factors to be protective. Despite this, LHSC emergency physicians showed a high degree of personal accomplishment. While all physicians experience burnout, targeted interventions to newer female staff could have the highest benefit.

Introduction: Hospital access block, often called Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving Health Care system. The multiple, dynamic, and inter-dependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems analysis and approach. One technique described in similar contexts is Front Line Ownership (FLO) based on the theoretical framework of positive deviance. The aim of this study is to discover where pragmatic bottom-up insights and adaptive work-arounds can be elicited, described, iterated, and potentially implemented at a broader scale to catalyze systems change, in service of improving patient flow. Methods: This is a qualitative study which identified, convened, and surveyed stakeholders representing three components of the system. Purposive sampling was used to gather a full range of perspectives from three groups: 1) patients and or families, 2) front-line providers, and 3) management/leaders. Interviews were recorded and transcribed by a third party, then each transcription was coded independently by two investigators (at least one of which was the PI). Informed consent was obtained from all participants and each was offered the opportunity to review the transcription to ensure accuracy. A framework analysis was used to synthesize, reflect upon, and interpret the data from multiple perspectives using a structured, iterative approach. Results: In part 1 of this study, three broad over-lapping themes emerged from the analysis as being areas of opportunity for reducing hospital access block. They are: 1. Boundary Conditions (the historical, organizational cultural, psychological, economic, and other contexts influencing system performance), 2. Systems Integration (how well the parts interface with each other relate to the whole), and 3. Operations management (the more technical aspects of patient flow). When these three broad themes are cross-analyzed with a more conventional input-throughput-output approach, previously under-emphasized avenues for improvement may become apparent. Conclusion: A front-line ownership analysis of ED overcrowding is feasible. There are adaptive behaviors by some front-line individuals at each “level” of perspective that have been identified and could be modified and implemented locally to improve patient flow in the ED (and the rest of the health system).

Introduction: Tourniquets are a mainstay of hemorrhage management. However, there is insufficient evidence to guide device sselection. This review analyses the literature on tourniquets, for the following outcomes: lower-extremity arterial hemostasis, application speed, and pain. Methods: Studies were limited to English. Non-human studies, case series, and intra-operative applications were excluded. A systematic review of MEDLINE, PubMed, Google Scholar, and the Cochrane Database from 1992 to Dec 2017 was performed. Article citations were also assessed. Results: Twenty-one studies met criteria, testing 28 tourniquet devices. The most popular devices for arterial hemostasis were the Combat Application Tourniquet (C-A-T) (662 applications), Special Operations Forces Tactical Tourniquet (SOFTT) (307 applications), blood pressure cuff (80 applications), rubber tubing (58 applications) and the Emergency Medical Tourniquet (EMT) (52 applications). The blood pressure cuff achieved the highest (weighted averages) rate of 99% (95% CI 93 to 100) based on four studies of 80 applications. Followed by the EMT which achieved 83% (95% CI 72 to 93), based on three studies of 52 applications (p<0.01). The fastest device to apply, taking 17 seconds (95% CI 11 to 23), was surgical tubing, based on two studies totalling 30 applications. The next fastest was the blood pressure cuff, requiring 20 seconds (95% CI 18 to 22), based on two studies totaling 58 applications (though there was no statistical difference in application time, p=0.08). Tolerance could not be analyzed, due to heterogeneity of outcome measures. Conclusion: This is the first meta-analysis of tourniquet outcomes. The literature lacks a standard approach to device application. The quality of evidence is of very low due to the small sample sizes, lack of blinding, selective outcome reporting and result inconsistency. Common medical equipment appear to outperform commercial tourniquets for arterial hemostasis and speed of application; however, they are some of the least studied devices.

Introduction: Prehospital blood transfusion has been adopted by many civilian helicopter emergency medical service (HEMS) agencies and early outcomes are positive. Shock Trauma Air Rescue Service (STARS) operates six bases in Western Canada and in 2013 implemented a prehospital transfusion program. We describe the processes and standard work ensuring safe storage, administration, and stewardship of this precious resource. Our aim was to produce a sustainable and safe blood storage system that could be carried on each mission flown. Methods: Close collaboration with transfusion services and adherence to Canadian Transfusion Standards was key at each step of development. An inexpensive, reusable, temperature controlled thermal packaging device was obtained along with an electronic temperature logger. Conditioning of the device and temperature maintenance (1 6C) was tested to ensure safe storage conditions. Online training programs were developed for air medical crew (AMC) as well as transport physicians (TPs) regarding administration indications, safety, and stewardship processes. Blood traceability and usage was monitored on an ongoing basis for quality assurance. Results: Two units of O negative packed red blood cells (pRBCs) are now carried on each flight. The blood box is conditioned and prepared by transfusion services for routine exchange every 72 hours. If pRBCs are administered the blood bank is immediately notified for preparation of another cooler. Unused blood is returned to blood bank circulation. Conclusion: The introduction of the STARS blood on board program supports the provision of emergent transfusion to selected patients in the pre-hospital environment. Our standard work and stewardship processes minimize wastage of blood products while keeping it readily available for critically ill and injured patients. Subsequent work will aim to describe characteristics and patient centred outcomes.

Introduction: Seeking patient outcome feedback (POF), defined as obtaining information on a patients clinical course beyond ones care, is crucial to the learning process. However, the lack of POF is a major pitfall of emergency medicine. Emergency department (ED) bouncebacks, which are characterized as patients with unplanned returns to the ED after being discharged, are an important type of POF to study because they represent a potential misdiagnosis or mismanagement and can highlight areas for physician self-improvement. Currently, most hospitals do not relay details about ED bouncebacks back to the treating physician, unless a grave error occurred. This studys purpose is to provide weekly reports to all physicians in the ED on patients who have unplanned returns within 7 days of discharge from the ED, and evaluate the impact this has on the physicians practice on seeking POF. Methods: A new weekly report was distributed to physicians working at an academic hospital outlining the patients who have returned within 7 days of discharge from the ED, their new presenting complaint and final disposition. An online survey was also administered to all ED staff evaluating the amount of POF they sought pre and post report, and their attitude towards the new reports. Results: 22 responses were received, for a response rate of 85%. The majority of respondents follow the reports (73%) and actively seek POF by looking up patients charts and results(70%). Additionally, 58% state that they seek POF more often since receiving these reports, for both the bouncebacks and their other patients. Furthermore, 37% claimed that the reports helped improve the appropriateness of their referrals and 32% stated it helped increase their confidence in their clinical practice. The majority of physicians (87%) found the reports to be helpful and would like to continue receiving it. Conclusion: Weekly bounceback reports are a high-yield tool for increasing POF sought in the ED and have benefits for both the physician and the department as a whole. They can be used to not only identify patients who may have had an error in their management, but also help to improve physicians’ clinical skills by encouraging and enabling follow-up of patients they managed. Thus, bounceback reports are a valuable tool to provide to physicians and should be considered by ED Departments.

Introduction: Aeromedical helicopters and fixed wing aircraft are used across Canada to transfer patients to definitive care. Given height limitation in aeromedical transport, CPR performance can be affected. An adapted manual compression technique has been proposed by H. Koch (pron. Cook) that uses the elbow to compress the sternum rather than the conventional hand. This preliminary study evaluated the quality of Koch compressions versus conventional bimanual compressions. Methods: Paramedics (5), registered nurses (3) and a physician (1) were recruited. Each participant performed a 2 minute cycle of each technique, were randomized to determine which technique was performed first, and rested 5 minutes between compression cycles. A Resusci Anne SkillReporter manikin atop a stretcher in a BK117 helicopter was used. The compressors performed without feedback or prompting. Outcomes include compression rate, depth, recoil, and fatigue. Results: The mean conventional compression rate was (bpm) 118 +/− 13 versus 111 +/− 10 in the Koch scenario (p=0.02) (target 100 to 120). Mean conventional compression depth (mm) was 44 +/− 9 versus 49 +/− 7 in the Koch scenario (p=0.01) (target 50 to 60). The mean percentage of compressions with complete release in the conventional scenario was 86 +/− 20 versus 84 +/− 22 in the Koch scenario (p=0.9) (target 100%). Using a Modified Borg Scale of 1 to 10, mean provider fatigue after conventional CPR was 7 (+/− 1.6) versus 3 (+/− 1.2) using Koch technique (p<0.001). On average, Koch technique improved the percentage of compressions at target rate by 26%, the percentage at correct depth by 9%, overall compression quality score by 13% and were more less fatiguing. Conclusion: Using an elbow in a height-restricted environment improved compression depth and reduced provider fatigue. From our limited data, Koch compressions appear to improve compression quality. Further study and external validation are required.

Introduction: Emergency Department Overcrowding (EDOC) is a multifactorial issue that leads to Access Block for patients needing emergency care. Identified as a national problem, patients presenting to a Canadian Emergency Department (ED) at a time of overcrowding have higher rates of admission to hospital and increased seven-day mortality. Using the well accepted input-throughput-output model to study EDOC, current research has focused on throughput as a measure of patient flow, reported as ED length of stay (LOS). In fact, ED LOS and ED beds occupied by inpatients are two “extremely important indicators of EDOC identified by a 2005 survey of Canadian ED directors. One proposed solution to improve ED throughput is to utilize a physician at triage (PAT) to rapidly assess newly arriving patients. In 2017, a pilot PAT program was trialed at Kelowna General Hospital (KGH), a tertiary care hospital, as part of a PDSA cycle. The aim was to mitigate EDOC by improving ED throughput by the end of 2018, to meet the national targets for ED LOS suggested in the 2013 CAEP position statement. Methods: During the fiscal periods 1-6 (April 1 to September 7, 2017) a PAT shift occurred daily from 1000-2200, over four long weekends. ED LOS, time to inpatient bed, time to physician initial assessment (PIA), number of British Columbia Ambulance Service (BCAS) offload delays, and number of patients who left without being seen (LWBS) were extracted from an administrative database. Results were retrospectively analyzed and compared to data from 1000-2200 of non-PAT trial days during the trial periods. Results: Median ED LOS decreased from 3.8 to 3.4 hours for high-acuity patients (CTAS 1-3), from 2.1 to 1.8 hours for low-acuity patients (CTAS 4-5), and from 9.3 to 8.0 hours for all admitted patients. During PAT trial weekends, there was a decrease in the average time to PIA by 65% (from 73 to 26 minutes for CTAS 2-5), average number of daily BCAS offload delays by 39% (from 2.3 to 1.4 delays per day), and number of patients who LWBS from 2.4% to 1.7%. Conclusion: The implementation of PAT was associated with improvements in all five measures of ED throughput, providing a potential solution for EDOC at KGH. ED LOS was reduced compared to non-PAT control days, successfully meeting the suggested national targets. PAT could improve efficiency, resulting in the ability to see more patients in the ED, and increase the quality and safety of ED practice. Next, we hope to prospectively evaluate PAT, continuing to analyze these process measures, perform a cost-benefit analysis, and formally assess ED staff and patient perceptions of the program.

Introduction: Pulmonary Embolism (PE) management in Emergency Department (ED) confers a substantial cost burden representing opportunities for improvements in decision-making. The Pulmonary Embolism Severity Index (PESI) is a validated tool to prognosticate patients with PE supporting admit versus (vs.) discharge decisions from the ED. Despite existing evidence, PESI is under-used in patients with PE. We sought to evaluate PESI scores and patient disposition from 4 EDs within Calgary to determine discordance between them and the effect of the discordance on readmission and mortality. Methods: Retrospective review of adult patients 18 years, diagnosed with PE between January-June 2016 at 4 EDs in Calgary Health Region. Patients were divided into high-risk PESI (score>85) and low-risk PESI (score 0-85). Chi-Square (2) test was used for comparison between the groups. Primary outcome measure was rate of discordance between PESI risk and disposition decision and identify factors driving the discordance. Secondary outcome measures included comparing 30-day readmission rate, 30-day and 90-day mortality between the discordant PESI groups. Results: 365 patients were diagnosed with PE in the study period with 60% being admitted and 40% discharged. The median PESI score in admitted patients was 85 (26-172) vs. 68 (20-163) in discharged patients. 51% of admitted patients had a low-risk PESI score and 24% of the discharged patients were high-risk PESI. 30-day readmission rate was 22.9% vs 5.3% (p=0.002) in discharged patients with high-risk PESI vs. discharged patients with low-risk PESI. Hypoxemia was the most common (62%) justification for admission in low-risk PESI groups. Among discharged patients we noted an 8.6% 90-day mortality in the high-risk vs. 0% in the low-risk PESI groups. Conclusion: Discharging a PE patient from the ED with a high PESI score carries a significant risk of ED revisit and readmission. Hypoxia was the reason for admission in majority of low risk PE patients.

Introduction: Laceration is common in children presenting to the emergency department (ED). They are often uncooperative related to pain and distressed during repair. Currently, there are wide variations regarding sedation and analgesia practices when sutures are required. There is a growing interest in the intranasal (IN) route for procedural sedation and pain control because of its effectiveness potential and ease of administration. Few studies have evaluated IN ketamine for procedural sedation in children with reported doses ranging from 3 to 9 mg/kg. The objective is to evaluate the optimal IN ketamine dose for effective and safe procedural sedation for laceration repair in children aged 1 to 12 years. Methods: A dose escalation clinical trial with an initial dose of 3 mg/kg of IN ketamine up to a maximum dose of 9 mg/kg in children 1 to 12 years old, using a 3+3 trial design. For each tested dose, 3 patients are enrolled. Escalation to the next dose is permitted if sedation is unsuccessful in at least one patient without serious adverse event (SAE). Regression to prior dose is warranted in the occurrence of two or more SEAs. This process is repeated until effective sedation for 6 patients at two consecutive doses is achieved with a maximum of 1 SAE or if regression occurs. The primary outcome is the optimal dose for successful procedural sedation as per the PERC/PECARN consensus criteria. Secondary outcome, namely, pain and anxiety levels, parent, patient and provider satisfaction, recovery time, length of stay in the ED, side effects and adverse event are recorded. Results: Nine patients have been recruited from March to December 2017 with median age of 2.9 years-old and with laceration length of 2 to 5 cm and with facial involvement in 55% of cases, respectively. Sedation was successful in 1/3, 1/3 and 3/3 of patients at doses of 3, 4, 5 mg/kg respectively, without any SAE. Median time from ketamine administration to return to baseline status and discharge were 35 and 98 min, respectively. We expect to complete patient recruitment in March 2018. Conclusion: The results from our trial is a groundwork for future dose-finding study. Pending study completion, a multicentric dose validation trial, is set up to further validate the optimal dose from dosINK1 trial. IN ketamine has the potential to improve the field of procedural sedation for children by introducing an effective IN agent with respiratory stability but without the need for an IV line insertion not otherwise needed.

Introduction: Hepatitis C virus (HCV) infection represents a significant public health problem in Canada and it is estimated that nearly half of individuals with chronic hepatitis C infection are unaware of their disease status. Previous studies of urban emergency department (ED) based screening programs have shown a prevalence ranging from 7.3 to 26% in high risk patients presenting to the ED . The advent of new treatment regimens with high rates of virologic cure strengthens the case for identifying the optimal setting for screening and testing individuals who may benefit from treatment. The proposed pilot project of ED-based screening for hepatitis C virus will aim to determine the prevalence of undiagnosed HCV infection and to link patients with chronic HCV infection to appropriate specialized follow-up care. Methods: We will be conducting a prospective cohort study of patients presenting to an urban emergency department between March and May 2018. Patients will be screened using high risk criteria for HCV infection as per national guidelines. Eligible patients will be offered and consented for a rapid point of care antibody test. Individuals with a positive antibody screen will have confirmatory testing and be linked to hepatology follow-up. The primary outcome will be the prevalence of hepatitis C virus among tested patients. Secondary outcomes will include the proportion of high risk patients without a primary care MD or access to alternate care settings where screening may occur, as well as the proportion of HCV-positive patients who are successfully linked to care. Results: We expect to screen approximately 2000 participants during the study period leading to an estimated 400 rapid antibody tests. Based on published results from other centres, we estimate that a significant proportion of screened patients will test positive for chronic HCV infection ( > 10%). Descriptive analyses will be performed for all variables using proportions with 95% confidence intervals. Conclusion: To our knowledge, no emergency department in Canada has undertaken protocoled HCV screening using rapid antibody testing in the ED. Results will inform the future development of integrated ED-based screening programs in novel settings more likely to be accessed by the at-risk population. Linking patients with chronic HCV infection to appropriate care will decrease the number of individuals developing HCV-related cirrhosis and hepatocellular carcinoma, thereby improving patient outcomes and reducing the future impact on our health care system.

Introduction: Lower gastrointestinal bleeding (LGIB) can result in serious adverse events, including recurrent bleeding, need for intervention and death. Endoscopy is important in the management of LGIB, however gastroenterologists have limited resources to safe endoscopy. Risk stratification of LGIB patients can aid physicians in disposition decisions. Objective: to develop a clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day serious adverse events. Methods: We conducted a health records review and included 372 adult ED patients who presented with an acute LGIB. The outcome was a 30-day composite outcome consisting of all-cause death, recurrent LGIB, need for intervention to control the bleed and ICU admission. A second researcher confirmed data-collection of 10% of the data and we calculated a -value for inter-rater reliability. We analyzed the data using stepwise backwards selection and SELECTION=SCORE option and calculated the diagnostic accuracy of the final model. Results: Age 75 years, hemoglobin 100 g/L, INR 2.0, a bloody stool in the ED and a past medical history of colorectal polyps were significant predictors in the multivariable regression analysis. The AUC was 0.83 (95% CI 0.77-0.89), sensitivity 0.96 (0.90-1.00), specificity 0.53 (0.48-0.59), and negative likelihood ratio 0.08 (0.02-0.30) for a cut-off score of 1. Conclusion: This model showed good ability to identify LGIB patients at low risk for adverse events as evidenced by the high AUC, sensitivity and negative likelihood ratio. Future, large prospective studies should be done to confirm the data, after which it should be validated and implemented.

Introduction: Safe and efficient handovers between emergency medical services (EMS) practitioners and emergency nurses are vital as poor transitions may lead to loss of information and place patients at risk for adverse events. We conducted a mixed methods systematic review to a) examine factors that disrupt or improve handovers from EMS practitioners to emergency department nurses, and b) investigate the effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. Methods: We searched electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); grey literature (grey literature databases, organization websites, querying experts in emergency medicine); and reference lists of the included studies. Citation tracking was conducted for the included studies. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the Joanna Briggs Institute Critic Appraisal Checklist for Qualitative Research. Narrative and thematic synthesis were conducted to integrate and explore relationships within the data. Results: Twenty-two studies were included in this review from the 6150 records initially retrieved. Our analysis suggests that qualitative, quantitative, and mixed methods research approaches have been utilized to explore handovers. Studies (n=11) have predominantly explored existing patterns of handovers focusing on barriers and facilitators. Interventions (e.g. multimedia transmission of pre-hospital information, tailored e-learning program) were investigated in five studies. Results suggest that lack of formal handover training, workflow interruptions, workload, and strained working relationships between EMS and nursing are perceived threats to optimal handovers. Conclusion: The findings from this review can inform the development of handover interventions and contribute to a more rigorous approach to researching handovers between EMS practitioners and emergency nurses. Furthermore, there is a need for studies in which specific interventions to optimize handovers are examined.

Introduction: Emergency physicians must achieve and maintain competence in numerous procedural skills, many of which are high stakes, time dependent, and used infrequently in clinical practice. Mental practice (MP) is the systematic use of mental imagery to see and feel an action in ones imagination without engaging in actual physical movement, and has been shown to enhance skill acquisition and performance in music and athletics. In this scoping review, we describe the utility and effectiveness of MP as a tool for procedural skill acquisition in medicine. Methods: An electronic search of MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, Open Grey, Conference Proceedings Index, ProQuest Dissertations and Theses and Google Scholar was conducted. Included studies evaluated MP for learning medically related technical skills using any method of mental training (script memorization, hypo-therapy, psychotherapy). Two independent reviewers screened articles for inclusion, and data was extracted using a standardized tool. Results: Our search returned 2028 results, of which 61 were eligible for inclusion. Forty-three studies evaluated MP interventions for technical skill development. Of these, 69.6% focused on minimally invasive surgical skills. The most common outcome measure was quantitative evaluation of skill via observer-scored checklist (69.6%). Other outcomes included stress, time to task completion, and haptic and movement data from surgical simulators. 82.6% of studies demonstrated a positive effect of MP on skill acquisition or performance. The quality of the trials was modest, and only 34.7% of published work provided clear detail on specific MP strategies. Conclusion: MP is an effective tool for procedural skills training. Areas outside of minimally invasive surgery are under-represented, and more data is needed on MP for rare or emergent procedures that typify emergency care. The minority of studies reviewed reported methods for developing and validating MP interventions in sufficient detail, a practice that should be adopted in future trials.

Introduction: During a hockey game, athletes who are suspected of having sustained a concussion are removed from the game and evaluated. The modified balance error scoring system (MBESS) assessment, an essential part of the concussion evaluation, is performed in the dressing room, barefoot on a hard surface after equipment removal. While, players that pass the concussion assessment may re-dress and return to play, the equipment removal and re-dressing delays their return into the game. The objective of our study was to develop and evaluate a new in-skates balance error scoring system (SBESS) to reduce the delay in returning to the game. Methods: A prospective randomized single blinded study was conducted with 80 healthy university hockey players split into two groups. An at-rest group performed the SBESS assessment at rest on two separate occasions. A post-exercise group performed the test once at rest and once after exercise. The SBESS consisted of performing 4 different stances for 20 seconds each without equipment removal. The assessments were video recorded, and 3 independent reviewers scored the videos. For both the at-rest and post-exercise groups, the primary outcome measured was the number of balance errors. The secondary outcome was the number of falls. Statistics: For the primary outcome, both inter-rater and intra-rater reliability were calculated. The concordance between the SBESS and the currently used baseline pre-season balance score (MBESS) was also assessed. Results: The number of cumulative balance errors for all four stances varied between 4 and 7 for both groups without any significant exercise effect. No athletes fell. For inter-rater reliability, the intra-class correlation (ICC) was above 0.86, ranging from 0.86-0.92 for most stances except for the easiest stance, for which it was 0.66. For intra-rater reliability, the ICC ranged from 0.88 to 1 for all stances and raters. There was a lack of concordance between the SBESS and MBESS. Conclusion: The SBESS is a reliable balance test that can be safely performed in healthy athletes wearing their full equipment. The next step will be to evaluate the use of this test on concussed hockey athletes

Introduction: Traditionally, out of hospital cardiac arrests (CA) have poor outcomes. Incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly to supplement ACLS to provide better outcomes for patients. Current literature suggests potentially improved outcomes, including neurological function. We assessed the feasibility of introduction of ECPR to a regional hospital using a 4-phase study. We report phase-1, an estimation of the number of potential candidates for ECPR in our setting. Methods: Following development and agreement on local criteria for selection of patients for ECPR using a modified Delphi Technique, inclusion and exclusion criteria were applied retrospectively, to a database comprising 4 years of emergency department (ED) cardiac arrests (n=395). This provided estimates of the number of patients who would have qualified for EMS transport for ECPR and initiation of ECPR in the ED. Results: Application of criteria would result in 20.0% (95% CI 16.2-24.3%) of CA being transported to the ED for ECPR (mean 18.5 patients per year). In the ED 4.6% (95% CI 2.83-7.26%) would be eligible to receive ECPR (4.3 patients per year). Incorporating downtime criteria, 3.0% (95% CI 1.6-5.3%) qualify. After considering local in-house cardiac catheterization hours 9.4% (95% CI 6.8-12.9%) and 5.4% (95% CI 3.5-8.2%), without and with EMS rhythm assumptions respectively, would be eligible for transport. For placement on pump, 3.0% (95% CI 1.6-5.3%) and 2.4% (95% CI 1.2-4.6%), without and with use of total downtime respectively, were eligible. Conclusion: If historical patterns of CA were to continue, we believe that an ECPR program may be feasible in our regional hospital setting, with a small number of selected cardiac arrest patients meeting eligibility for transportation and initiation of ECPR. These numbers suggest that an ECPR program would not be resource intensive, yet would be sufficiently busy to maintain adequate team competency.

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.

Introduction: Patients with new onset and chronic atrial fibrillation and/or flutter (AFF) present to emergency departments (ED) with symptoms requiring acute management decisions. Most research has focused on patients with acute (<48 hours and/or <7 days with adequate anticoagulation) presentations of AFF and for whom rhythm control is considered safe. This study explored the demographic characteristics, risk factors, anticoagulant/anti-platelet prescription, and outcomes for patients with symptomatic AFF. Methods: A convenience sample of adult patients presenting to the one of three hospitals affiliated with the University of Alberta with symptoms of acute AFF were enrolled, within a fee-for-service billing environment. Following informed consent, a trained researcher administered a survey to each patient, recorded administrative details (e.g., triage, times, laboratory tests) from the ED information system, a chart review on treatments was conducted and patients were contacted for follow-up at 7 days via telephone. Descriptive (median and interquartile range {IQR} and proportions) and simple (t-tests, chi-square) statistics are presented for continuous and dichotomous outcomes, respectively. Results: Overall, 217 patients were enrolled; the median age was 64 (IQR: 55, 73) and 132 (61%) were male. Overall, 42 (19.4%) patients arrived by ambulance; 8 (4%) spontaneously converted or were diagnosed with another arrhythmia between arrival and obtaining an ECG. A prior history of AFF was common 152 (71%), as were the following cardiovascular and other risk factors: 176 (81.1%) consumed alcohol, 104 (48%) were current or former smokers, 86 (39.6%) had hypertension, 22 (10%) had CAD, and 10 (5%) had COPD. These patients most commonly reported palpitations 183 (84%) as their dominant symptom. Anti-platelets and anticoagulants were common prior to the ED 145 (67%), and 36 (17%) of patients were discharged from the ED without one of these medications. Overall, 80 (37%) patients had chronic AFF or an unknown timeline; no efforts were made to restore NSR in these patients. A dominant pattern for electrical cardioversion was observed; of 129 cases where cardioversion was attempted, 84 (65%) had electrical first and 45 (35%) had chemical first cardioversion attempts. Overall, 22 (49%) of 45 patients receiving chemical first were successfully converted to NSR. Patients with AFF history who were cardioverted were less likely hospitalized than those not-cardioverted (3% vs. 16%, p=0.006); 21 (10%) were admitted to hospital. Conclusion: In this center, patients with AFF often present to the ED with high acuity, with severe symptoms and receive aggressive care. The use of anticoagulants suggests an appreciation of thrombo-embolic risks, both in the community and ED settings. Like many EDs, this center appears to have a signature for AFF management, related to evidence gaps, physician preferences, and perhaps funding models.

Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is widely recognized as a major contributor to overcrowding, particularly in very high-volume hospitals. The issue of bed boarding is directly tied to hospital-wide capacity, flow and operations. Early morning discharge from inpatient units has been identified as a low-cost intervention to decrease bed boarding, as it allows earlier transfer of admitted patients from the ED. Several hospitals have instituted discharge before noon, or discharge before 10AM policies, practices and targets. Our objectives were 1) to assess the current status of flow within 3 high-volume community hospitals with respect to time of day of discharges from the in-patient units and time of day of transfers from the ED to in-patient units, and 2) to assess the association between time of transfer from the ED and total ED Length of Stay (EDLOS) of admitted patients. Methods: We conducted a retrospective multi-centre observational study during the period of January 1, 2015 to December 31, 2015 at three high-volume community hospitals within Ontario, Canada. All patients admitted to the Medicine service were identified. Time of discharge from the in-patient units and time of transfer from the ED were collected for all patients. EDLOS was calculated for all patients as a function of time of transfer from the ED. Results: Preliminary findings show that, for the three community hospitals, only 11.7% - 19.6% of admitted patients were discharged from the in-patient units during the period between 6AM and 12PM, with a peak discharge time of 2PM in all three hospitals. A concurrent lag was observed in the time of transfer of patients from the ED, with peak transfer times occurring the late afternoon between 3PM and 9PM, and coinciding with a peak in patient volume in the ED. Patients transferred out of the ED earlier in the day (between 12AM 11:59AM) had between 1.4 hours to 8.0 hours lower mean EDLOS when compared to those patients transferred later in the day (between 12PM 11:59PM). Conclusion: Hospital-wide flow and operational issues have a significant impact on ED bed boarding, and potential efficiencies seem at the current time to be underutilized. Interventions aimed at optimizing flow must be implemented alongside those aimed at increasing capacity in order to improve bed boarding. ** These findings are best communicated in graphic form to better represent the dynamics of the flow in and out of the ED over a 24-hour period, and will be presented in graphic format if selected for the conference.

Introduction: The increased availability and increased utilization of Computed Tomography (CT) imaging as a diagnostic tool has in the past several years led to concerns regarding the unknown and potentially harmful effects of ionizing radiation exposure to patients, as well as the increased cost to the health care system. Multiple education campaigns (e.g. Choosing Wisely) and institution-wide interventions have been implemented in order to limit the use of potentially unnecessary CT imaging. Two specific modalities CT head and CT angiography to rule out pulmonary embolism (CT PE) have been identified as potential targets of these interventions due to their likely overutilization in the clinical ED setting. The objective of this study was to determine the interphysician variability in the ordering rates of CT head and CT PE, and to determine if any correlation existed between CT head and CT PE ordering rates among physicians. Methods: Data was collected on all diagnostic imaging ordered by ED physicians at two very high volume community hospitals during the 4-year period between 2013 and 2016. Analysis was limited to those physicians who worked at least 3 of the 4 years at either site and saw at least 1000 patients per year. The ordering rates for each physician were calculated by dividing the number of the imaging modality ordered over the total number of patients seen. Correlation coefficients (r values) were calculated to determine if a linear correlation existed between increased CT head and increased CT PE ordering rates. Results: The DI ordering data for a total of 44 ED physicians were analyzed. Results show average 4-year ordering rates for CT heads among ED physicians ranging from 4.0% to 13.9%, and CT PE ordering rates ranging from 0.1% - 1.7%. The correlation coefficient between CT head and CT PE ordering rates was positive for all 4 years, with a statistically significant (p<0.05) correlation coefficient of 0.53. Conclusion: There is a wide degree of variability in DI ordering patterns among physicians working within the same clinical environment. Further exploration of this interphysician variability will be helpful in designing strategies to mitigate overutilization of diagnostic imaging.