Background: Homelessness is a growing Canada-wide concern. Those with no fixed address have increased rates of emergency department (ED) utilization and increased healthcare spending compared to the general population, with higher rates of acute and chronic illnesses, as well as all-cause mortality. EDs are uniquely situated to act as an access point to the network of available community services, however referral rates from the ED is uncertain. To date, there has been no data collected on London, Ontario's homeless population, their health burden, and their utilization patterns of the ED. Aim Statement: The primary objective of this study is to describe ED visits for adult patients with no fixed address in London, Ontario to assess for potential areas to improve care. Measures & Design: This is a retrospective chart review, of patients with no fixed address visiting London, Ontario Emergency Departments in 2018. ED visits were identified and pulled using either a diagnosis of “homeless”, a lack of postal code, or a postal code for a known shelter. Cases included based on postal code were manually reviewed to determine whether the patient had a resident address with the same postal code. Evaluation/Results: From this search, 4,294 visits were identified for 1237 unique patients. The median visits per person was 1 (IQR 1-2), with 388 patients having 3 or more visits, and the max being 138 visits. The median age was 38 (IQR 28-52), with 73% male. Ground ambulance was used for 46% of visits. 28% of visits were CTAS 1&2 and 5% were CTAS 5. Police facilitated visits in 401 cases. Top 3 discharge diagnosis categories were mental health (19%), infection (18%), drug misuse (17%). Discussion/Impact: Several errors were identified with our search strategy suggesting the current system of capturing homelessness in the EPR is not accurate, leading to an underestimation of the problem and limiting our ability to describe this population. The Ministry of Health mandates homelessness be applied as a tertiary discharge diagnosis during coding of the patient visit if possible. However, use of this code is inconsistent leading to large-scale omission of visits and an underrepresentation of pediatric cases. Systemic steps should be taken to improve identification of these patients moving forward.

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

Introduction: Extreme heat events due to climate change are becoming increasingly frequent and severe, and may have an impact on human health. Administrative database studies using International Classification of Diseases 10th revision codes (ICD-10) are powerful tools to measure the burden of acute heat illness (AHI) in Canada. We aimed to assess the validity of the coding algorithm for emergency department (ED) encounters for AHI in our region. Methods: Two independent reviewers retrospectively abstracted data from 507 medical records of patients presenting at two EDs in Ontario between May-September 2015-2018. The Gold Standard definition of an AHI is chart-documented heat exposure with a heat related complaint, such as syncope while working outdoors on a hot day. To determine ICD coding algorithm positive predictive value (PPV), records that were previously coded as ICD-10 heat illnesses were compared to the Gold Standard for AHI. To determine sensitivity (Sn), specificity (Sp) and negative predictive values (NPV), the Gold Standard was compared to randomly selected records. A total of 326,702 ED visits were included in study period with 208 having an ICD-10 code related to heat illness. Sample size calculation demonstrated a need to manually review 62 previously coded heat illnesses and 931 random cases, of which 50 and 474 have been reviewed, respectively. In both abstractions, 20% of cases underwent a blinded duplicate review. Results: In our review of 474 random records, 2 cases were identified as AHI but without an appropriate ICD-10 code, 445 were not AHIs, and no cases had been identified as having an AHI ICD-10 inappropriately applied. In our review of 50 previously coded heat illnesses, 34 were found to be appropriately coded and 16 inappropriately coded, as AHI ICD-10. Average patient age and gender of heat illness vs non-heat illness ED presentations were 32 and 48 years of age and 49% and 64% male, respectively. The leading complaint in AHI was heat stroke/exhaustion (39%), followed by headaches (15%), dizziness (9%), shortness of breath (9%) and syncope/presyncope (6%). 76% of all heat illness presentations presented following a period of physical exertion. Conclusion: Final calculation of Sn, Sp, PPV, NPV for the algorithm will occur upon completion of the review. Preliminary results suggest that ICD-10 coding for AHI may be applied correctly in the ED. This study will help to determine if administrative data can accurately be used to measure the burden of heat illness in Canada.

Introduction: Patients who present to the Emergency Department (ED) with a drug overdose often require long periods of monitoring. After their initial assessment and stabilization, they spend a significant amount of time in a high cost acute care bed in the ED for monitoring until they are medically cleared for psychiatric care or to be discharged. The shift length at this ED is a maximum of 8 hours; meaning any patients staying over 8 hours must be handed over between physicians, increasing the chance of medical errors. The objective of this study is to examine the total ED length of stay (LOS) of this patient group after physician initial assessment (PIA) to determine if there is there justification for the creation of a toxicology observation or short-stay unit for these patients. Methods: A single-centre, blinded retrospective chart review was conducted examining all adult patients presenting to the ED at an urban academic tertiary care centre with a drug overdose in 2018. Variables examined include: Disposition (home, admitted to acute care setting, admitted to non-acute care setting), time from PIA to disposition and total length of stay from PIA to discharge home or admission to hospital. The primary outcome is total length of stay in the ED after PIA.M Results: A total of 1006 patients presenting with an overdose were included. A total of 388 patients were admitted with 44% (172) having an ED LOS greater than 8 hours and 36% (138) staying 8 hours after PIA. The median [IQR] LOS in the ED for all patients was 343 minutes [191-565] while the median [IQR] time to PIA was 37 minutes [15-97]. The majority of these patients (54%) were discharged with no consulting services involved, 23% received a consult to psychiatry, 22% were consulted to internal medicine and 5% of patients were consulted to Critical Care Medicine. Conclusion: This demonstrates patients presenting to the ED with an overdose are seen in the ED by a physician quickly, however many stay in the department over 5 hours from their initial assessment in a monitored setting. While a majority of these patients are able to go home, 44% of admitted patients wait greater than 8 hours in the ED on monitors. The creation of a toxicology observation unit would be helpful for this population to increase patient safety and ease ED bed congestion.

Introduction: Atrial fibrillation (AF) and atrial flutter (AFL) are two common arrhythmias that present to the emergency department (ED) and are a major risk factor for stroke. The 2014 Canadian Cardiovascular Society (CCS) guidelines recommend starting oral anticoagulation (OAC) upon ED discharge for patients with CHADS65 scores of ≥1 to reduce stroke risk. The goal of this study was to identify whether the ED patient population presenting with new onset AF/AFL with CHADS65 ≥ 1 are appropriately initiated on OAC by ED physicians. Methods: This was a retrospective chart review (Jan-Dec 2017) of ED visits at two academic hospitals in Ontario. The year 2017 was chosen to allow for adequate time from the publishing of the CCS guidelines for uptake into clinical practice. Inclusion criteria: patients with a new diagnosis of AF/AFL who are discharged by ED physicians. Exclusion criteria: patients with a history of AF/AFL, already on OAC, admitted to hospital, presenting with arrhythmia other than AF/AFL, and charts without adequate information to calculate CHADS65 score. Charts were reviewed in detail to assess CHADS65 score, ED physician decision to prescribe OAC, referral rates to outpatient clinics and timing of follow up. Results: A total of 1272 charts were reviewed. 1124 were excluded. 148 charts were identified as patients with new onset AF/AFL presenting to the ED who were discharged by ED physicians. 24/148 (16%) were appropriately prescribed OAC. 124/148 (84%) were not prescribed OAC. Of these 40/124 (32%) were CHADS65 0 while the other 84/124 (67%) were CHADS65 ≥ 1 who should have been considered for OAC. Further review determined that 78/84 (92%) were referred to outpatient clinics for the decision regarding OAC with the mean (SD) number of days to follow up being 11(±15). Importantly 1/84 (1.2%) returned prior to their scheduled appointment with a stroke. Only 6/84 (7%) had no follow up arranged. Conclusion: Overall, we found that the rate of OAC prescription by ED physicians for patients being discharged with a new diagnosis of AF/AFL with a CHADS65 score ≥1 was 16%. This is despite the CCS 2014 recommendation of starting OAC for all patients with a CHADS65 score ≥1. It appears that ED physicians are continuing to defer the decision to prescribe OAC to outpatient clinics. Further projects can explore barriers to application of the CCS guidelines and create knowledge translation tools.

Introduction: The treatment of cutaneous abscesses in the Emergency Department (ED) is common. While most sources describe only incision and drainage (I&D) followed by healing through secondary intention, recent literature suggests that primary repair following I&D results in similar rates of healing as well as treatment failures when compared to standard care in the ED. The primary goal of this research project was to describe the variability in practice with respect to self-reported management of abscesses among Canadian ED physicians and explore potential reluctance in adopting primary repair as a management strategy. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 9-question survey probed the willingness of physicians to perform primary closure of abscess in the ED as well as factors that dissuade them from performing this type of closure. The primary outcome was the quantification of practice variability among ED physicians with respect to abscess closure in the ED. The data was presented with simple descriptive statistics. Results: 217 surveys were completed out of 1145 eligible physicians. Physicians working at academic centres comprised 53% of responses, with 47% coming from community centres. Over half of responses were from physicians in practice at least ten years (65.9%). The overwhelming majority of physicians indicated that they manage abscesses following I&D by secondary closure (96.3%). The two main concerns dissuading respondents from performing primary closure of abscesses included risk of treatment failure (47.8%) and the procedure not being considered standard of care (36.7%). Despite these concerns, 67.3% of physicians indicated a willingness to perform primary closure if further evidence supported its use. These physicians were most likely to consider primary closure at the head and neck, breast, trunk, and extremities, however, only 1.5% considered primary closure appropriate for perianal or pilonidal abscesses. Conclusion: This study demonstrates that almost all Canadian ED physicians, regardless of experience or practice centre, manage cutaneous abscesses with I&D followed by healing via secondary intention. With increasing evidence supporting the use of primary closure, many physicians may be willing to adopt primary closure as part of the management of cutaneous abscesses in the ED.

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.

Introduction: Endotracheal intubation (ETI) is a lifesaving procedure commonly performed by emergency department (ED) physicians that may lead to patient discomfort or adverse events (e.g., unintended extubation) if sedation is inadequate. No ED-based sedation guidelines currently exist, so individual practice varies widely. This study's objective was to describe the self-reported post-ETI sedation practice of Canadian adult ED physicians. Methods: An anonymous, cross-sectional, web-based survey featuring 7 common ED scenarios requiring ETI was distributed to adult ED physician members of the Canadian Association of Emergency Physicians (CAEP). Scenarios included post-cardiac arrest, hypercapnic and hypoxic respiratory failure, status epilepticus, polytrauma, traumatic brain injury, and toxicology. Participants indicated first and second choice of sedative medication following ETI, as well as bolus vs. infusion administration in each scenario. Data was presented by descriptive statistics. Results: 207 (response rate 16.8%) ED physicians responded to the survey. Emergency medicine training of respondents included CCFP-EM (47.0%), FRCPC (35.8%), and CCFP (13.9%). 51.0% of respondents work primarily in academic/teaching hospitals and 40.4% work in community teaching hospitals. On average, responding physicians report providing care for 4.9 ± 6.8 (mean ± SD) intubated adult patients per month for varying durations (39.2% for 1–2 hours, 27.8% for 2–4 hours, and 22.7% for ≤1 hour). Combining all clinical scenarios, propofol was the most frequently used medication for post-ETI sedation (38.0% of all responses) and was the most frequently used agent except for the post-cardiac arrest, polytrauma, and hypercapnic respiratory failure scenarios. Ketamine was used second most frequently (28.2%), with midazolam being third most common (14.5%). Post-ETI sedation was provided by > 98% of physicians in all situations except the post-cardiac arrest (26.1% indicating no sedation) and toxicology (15.5% indicating no sedation) scenarios. Sedation was provided by infusion in 74.6% of cases and bolus in 25.4%. Conclusion: Significant practice variability with respect to post-ETI sedation exists amongst Canadian emergency physicians. Future quality improvement studies should examine sedation provided in real clinical scenarios with a goal of establishing best sedation practices to improve patient safety and quality of care.

Introduction: Patients with diabetes who are in emerging adulthood, defined as the life stage between 18-29 years, have unique challenges in managing their illness and are at risk of acute complications and loss to follow-up. The studys objective was to describe emergency department (ED) utilization for hyperglycemia in emerging adults with diabetes and to characterize 30-day outcomes including return visits and admission for hyperglycemia. Methods: This was a health records review of emerging adults presenting over a one-year period to four tertiary care EDs with a diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Research personnel collected data on patient characteristics, treatment, disposition, and determined if patients returned to the ED for hyperglycemia within 30 days. Descriptive statistics were used to summarize the data where appropriate. Results: There were 185 ED encounters for hyperglycemia, representing 116 unique emerging adult patients. Mean (SD) age was 23 (3.5) years and 50.9% were female. 80 (69.0%) had known type 1 diabetes, 11 (9.5%) had type 2, and 25 (21.5%) were newly diagnosed in the ED. Of 185 visits, 98 (53.0%) resulted in hospital admission. 56 (30.3%) returned to the ED for hyperglycemia within 30 days of their initial encounter, and 21 (11.4%) resulted in admission on this subsequent visit. Conclusion: We characterized ED utilization and 30-day outcomes of emerging adults with diabetes for hyperglycemia. Future research should focus on earlier identification of those at higher risk for recurrent ED visits or admission and the efficacy of interventions to prevent these adverse outcomes.

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. In 2015, the American Heart Association release updated guidelines dictating best practices in post-return of spontaneous circulation (ROSC) care, advocating for more liberal utilization of emergent coronary angiography. We sought to determine if the post-ROSC care at our centre during our study period adhered to the previously published (2010) guidelines. Methods: We performed a retrospective analysis (Sept. 2011 - June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Key variables included rates of post-ROSC emergent angiography, survival to hospital discharge and survival to hospital discharge with favourable neurologic outcome (modified Rankin score 2). Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. Of those who achieved sustained ROSC, median age was 65 years (IQR=21.75), 66.8% were male. ECG interpretation data was available on 214 patients, of whom 56 had definite STEMI, and 135 had definite absence of STEMI. 37/56 (66.1%) definite STEMI patients received coronary angiography within 24 hours of presentation, as per AHA guidelines. 58/262 (22.1%) post-ROSC patients overall received coronary angiography within 24 hours of presentation to the ED. Of those 58 patients who received emergent angiography, 38 (65.5%) underwent percutaneous coronary intervention (PCI). No patients received fibrinolysis. Of post-ROSC patients who received emergent coronary angiography, 40/58 (69.0%) survived to hospital discharge and 37/58 (63.8%) survived with good neurologic outcome. In comparison, 55/204 (27.0%) who did not receive emergent angiography survived to hospital discharge and 18.8% survived with good neurologic outcome. Conclusion: Only 22.1% of patients with OHCA, and only 66.1% with ECG-proven STEMI underwent emergent coronary angiography post-ROSC. Further investigation into causes for delay or the withholding of emergent angiography is necessary.

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. We sought to determine if outcomes from out of hospital cardiac arrest (OHCA) at our centre were consistent with recently published North American outcomes data from the Resuscitation Outcomes Consortium (ROC). Methods: We performed a retrospective analysis (Sept 2011 June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, in-hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. 92 (35.1%) were receiving ongoing CPR at the time of their presentation to the ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. A total of 95 patients survived to hospital discharge (36.3% of patients who achieved sustained ROSC, 17.1% of those who were transported to the ED, and 10.4% of the all OHCA). Of those who survived to hospital discharge who had neurologic outcome data, 90.5% had a modified Rankin score of 2. Initial presenting rhythm with EMS was ventricular fibrillation or pulseless ventricular tachycardia in 233 patients. Of these, 212 (91.0%) were transported to the ED, 134 (57.5%) achieved sustained ROSC, and 71 (30.5%) survived to hospital discharge. 54/60 (90.0%) of those with a documented neurologic exam had a favourable neurologic outcome. Initial presenting rhythm with EMS was PEA or asystole in 636 patients. Of these, 320 (50.3%) were transported to the ED, 115 (18.1%) achieved sustained ROSC, and 17 (2.7%) survived to hospital discharge. 9/10 (90%) of those with a documented neurologic exam had a favourable neurologic outcome. 358 of the arrests were witnessed. Of these, 274 (76.5%) were transported to the ED, 150 (41.9%) achieved sustained ROSC, and 51 (15.9%) survived to hospital discharge. 47/53 (88.7%) of those with a documented neurologic exam had a favourable neurologic outcome. Conclusion: Outcomes from out of hospital cardiac arrest in London, Ontario are comparable to other sites across North America.

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: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), carry significant morbidity for individuals even after discharge. The objective of this study was to describe the patient-important outcomes and burden of disease for emergency department (ED) patients with hyperglycemia after discharge from hospital. Methods: This was a prospective cohort study of patients 18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS over a 15-month period (Jul 2016-Oct 2017). During the ED visit, consent was obtained for a telephone follow-up call to determine patient-important outcomes. Trained research personnel collected data from medical records and completed a 14 day telephone follow-up using a standardized questionnaire to determine medication changes, missed days of school or work, and repeat admissions or visits to a healthcare provider. Descriptive statistics were used where appropriate to summarize the data. Results: Thus far, 172 patients have been enrolled in our study. Mean (SD) age is 53.9 (19.3) years and 97 (56.4%) are male. 65 (37.8%) patients were admitted from their initial ED visit. Of the 125 patients (72.7%) providing post-discharge outcomes, 75 (60.0%) required an adjustment to their diabetes medications or insulin. 21 (16.8%) patients missed days of school or work for a median (IQR) duration of 3.5 (1.3, 7.0) days. 85 (68.0%) saw another healthcare provider within a 14 day period, 45 (36.0%) saw their family physician, and 34 (27.2%) saw an internist or endocrinologist. 9 (7.2%) were seen again in the ED, 5 of these patients required admission to hospital. There was one death that occurred within the follow-up period. Conclusion: This prospective study builds on our previous retrospective work and demonstrates that visits for hyperglycemia carry a significant burden of disease beyond what may be seen in a single ED encounter. Further research will attempt to identify the factors that may be predictive of adverse outcomes in hyperglycemic patients presenting to the ED.

Introduction: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.

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

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

Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.

Introduction: Emergency physicians (EP) often work at undesirable hours. In response to deleterious effects on quality of life for EPs, traditional 2300-0700 night shifts have been replaced at some centres with staggered 6-hour casino shifts (22:00-04:00 and 04:00-10:00). Though purported to allow for better sleep and recovery patterns, no evidence exists to support the benefits on sleep or quality of life that is used to justify a casino shift model. Using a before and after survey model, this study examines the impact of overhauling night work from a traditional 8-hour shift to casino shifts on the quality of life and job satisfaction of EPs working in an academic emergency department (ED). Methods: In 2010, an initial online, 37-item survey, was sent to all EPs working in the ED, just prior to the transition to casino shifts. 6 years following the transition, a slightly modified 37-item survey was again distributed to all current EPs working at that same centre. Participants rated their level of agreement on a 7-point Likert scale regarding questions related to night work. Results from the two surveys were compared. Results: 43 2010- and 47 2016-surveys were completed. In 2016, recovery to baseline function after a single early shift (22:00-04:00) was most common after 1 day at 52.4%, and after multiple early shifts was ≥2 days at 66.7%. Recovery after a single late shift (04:00-10:00) was most common at 1 day at 54.8%, and after multiple late shifts was ≥2 days at 59.5%. This was in contrast to 2010, when 55.8% recovered from a single traditional night shift after 1 day, and 95.3% required ≥2 days to recover from multiple traditional night shifts. In relation to casino shifts, 40.5% of respondents stated that night shifts are the greatest drawback of their job, compared to 79.1% previously. A minority of respondents felt that teaching (36.5%), diagnostic test interpretation (23.2%), and quality of handover (33.5%) were inferior on early and late night shifts compared to other shifts (74.4%, 58.1%, and 60.5% for traditional night shifts respectively).95.0% of respondents preferred casino over traditional night shifts. Conclusion: There were self-reported improvements in all domains following the implementation of casino shifts.

Introduction: London Health Sciences Centre (LHSC) includes two academic, urban hospitals in London, Canada. The hospital-standardized mortality ratio (HSMR) is consistently higher than provincial and national averages. Unpublished data reveals that sepsis contributes the largest number of statistically unexpected deaths to LHSC’s HSMR calculation. Factors contributing to in-hospital sepsis mortality are hypothesized to include demography, emergency department (ED) flow or sepsis treatment. Methods: Retrospective chart review of patients aged >=18 years, presenting to an LHSC ED between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis (ICD-10 diagnostic codes A4xx and R65). Data were abstracted from electronic health records. Regional, provincial and national data was retrieved from CIHI and Statistics Canada. Results: Median age and sex in London and across Canada are similar (48.2 years vs 48.9 years; 48% male vs 49% male). Baseline prevalences of diabetes, hypertension, COPD and mood disorders were similar in the Local Health Integration Network and Ontario (6% vs 7%, 19% vs 19%, 3% vs 4%, and 10% vs 8%). Median “Physician Initial Assessment,” (PIA) times for sepsis patients at LHSC were faster than median Canadian PIA times for CTAS I and II patients (CTAS I: 7 min vs 11 min, CTAS II: 34 min vs 54 min), and slower for CTAS III-V patients (CTAS III: 98 min vs 79 min, CTAS IV: 99 min vs 66 min, CTAS V: 132 min vs 53 min). Median ED length of stay for admitted, high acuity (CTAS I-III) patients was 6 h at LHSC versus 10 h across Canada.Median [IQR] time to intravenous fluid resuscitation was 60.5 min [29.8-101.2] for septic shock patients and 77.0 min [36.0-127.0] for expired patients. Median [IQR] time to antibiotics was 130 min [73.0-229.0] for sepsis patients, 106 min [60.0-189.0] for severe sepsis patients, and 82 min [42.2-142] for septic shock patients. Conclusion: Excess sepsis-related mortality at LHSC is not convincingly related to patient demographics or ED flow. Gains may be made by improving time to antibiotics and IV fluids.