2010 CAEP/ACMU Scientific Abstracts - Poster Presentations: 147-166

CAEP Abstracts

CJEM 2010;12(3):229-278

Poster presentations

147 INTENSITY of anticoagulation with warfarin and risk of adverse events in patients presenting to the emergency department

Zed PJ, Anthony CJ, Ackroyd-Stolarz S, Flinn A, Karim S, Murphy N, Christie R; Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS

Introduction: To evaluate the intensity of anticoagulation with warfarin and the risk of bleeding and thromboembolic complications in patients presenting to the emergency department (ED). Methods: A prospective, observational study was performed using a convenience sample of patients receiving warfarin and presenting to the ED over an 18-week period. Data was collected using a standardized data collection form and included chief complaint, history of present illness, past medical history, medication history and allergy status. Information from the physical examination, laboratory results and diagnostic tests, all obtained as part of routine assessment in the ED, were used as necessary. The primary outcome was the proportion of patients within, above or below the desired therapeutic range for International Normalized Ratio (INR). Bleeding complications and thromboembolic events were recorded in an attempt to determine the relationship between the intensity of anticoagulation and adverse outcomes. Results: A total of 201 patients were included with a mean age (standard deviation) of 74.0 (13.2) years and 53.7% were female. Primary indication for warfarin was atrial fibrillation (80.1%) and venous thromboembolic disease (14.9%). A therapeutic INR was observed in 88 patients (43.8%, 95% CI 36.9%–50.6%), while 45 patients (22.4%, 95% CI 16.6%–28.2%) and 68 patients (33.8%, (95% CI 27.3%–40.4%) had subtherapeutic and supratherapeutic INR, respectively. Overall, there were 27 bleeding complications (13.4%, 95% CI 8.7%–18.1%) (17 major and 10 minor) and 4 thromboembolic events (2.0%, 95% CI 0.1%–3.9%). Among patients with a bleeding complication 13 (48.1%) had a supratherapeutic INR while 2 (50.0%) patients that experienced a thromboembolic event had a subtherapeutic INR. Conclusion: The majority of patients presenting to the ED on warfarin had INRs outside the desired therapeutic range. Optimizing warfarin therapy in this patient population may prevent adverse outcomes such as thromboembolic and bleeding events. Keywords: anticoagulation, warfarin, bleeding events

148 CCFP-EM interested medical students intend to better blend their family medicine practice with their emergency medicine practice than previous cohorts

Brown A, Hillier M, McLeod S, Smallfield A, Mendelsohn D, Sedran R; London Health Sciences Centre, University of Western Ontario, London, ON

Introduction: Previous studies have reported that the majority of recent CCFP-EM graduates practise mostly emergency medicine (EM) rather than blending their practice with family medicine (FM). Some have argued that 2 years of FM training is a waste of resources for physicians who intend to practice full time EM. The objective of this study was to determine the degree to which CCFP-EM interested medical students intend to blend their FM and EM practices. Methods: An online, 47-item survey was distributed to all medical students enrolled at The University of Western Ontario for the 2008/09 academic year. Medical students who identified themselves as interested in the CCFP-EM program were asked how much time they wished to spend in FM and EM after residency. Results: Of the 563 students, 403 (71.5%) completed the survey. Of the respondents, 178 (44.2%) expressed an interest in applying to an EM residency training program, with 85 (47.8%) interested in applying to the CCFP-EM program. Of the 85 students interested in the CCFP-EM stream, 38 (44.7%) reported that they intend to practise “mostly FM” while 29 (34.1%) indicated they intend to practise “half FM and half EM.” Fifteen (17.6%) CCPFEM interested medical students responded that they intend to practise “mostly EM” and 2 (2.4%) reported that they intend to practise all EM. Thirty-four (40.0%) respondents believed that it is acceptable for residents to complete the CCFP-EM stream with the intention of practising solely EM, while 41 (48.2%) thought this is unacceptable. Conclusion: The majority of students interested in the CCFP-EM program intend to practise “mostly FM” or “half FM and half EM.” Future studies should determine whether this current cohort of medical students does indeed better blend their 2 areas of clinical practice and, if so, what factors differentiate them from previous cohorts who practise mostly EM. Keywords: family medicine stream, blended practice, survey research

149 THE INFLUENCE of a system-wide strategy to improve emergency department treatment of acute myocardial infarction

Rowe BH, Villa-Roel C, Welsh R, Montgomery C, Sookram J, Sales A; ESSC Substudy Evaluation Group; University of Alberta, Edmonton, AB

Introduction: Acute ST-segment elevation myocardial infarction (STEMI) is a time-sensitive and critical condition presenting to emergency departments (EDs). Accepted standards of care include time to ECG, thrombolysis (TL) and percutaneous coronary intervention (PCI). This study examined the influence of the Emergency Solutions and Systems Capacity (ESSC) project on achieving benchmarks as well as compared the prehospital STEMI care under the new Vital Heart Response (VHR) service. Methods: Prospective and retrospective data collections were completed by dedicated nurses on all patients with STEMI. Five 6-month periods from January 2006 to April 2009 were examined (baseline, 6, 12, 18 and 24 month post-ESSC). Baseline demographics were compared; overcrowding metrics (time to ECG, time to ED MD assessment) and evidence-based care (time to TL and/or PCI) were assessed. Kruskal–Wallis and χ² statistics were used to compare different time periods. Results: Overall, 1176 patients were included and the groups were similar among the study periods. The median age was 59 and 76% were males; 42% presented via ambulance. Selfarrival time to ECG increased from 7 to 11 minutes during the study period. Prehospital TL remained stable at approximately 5%. Median time from triage to TL for self-referred patients remained above standards throughout the study (46 v. 50 min). Use of PCI over the study increased from 45% to 56% (p = 0.025). Time from triage to PCI improved with EMS arrival (102 v. 85 min) but remained stable for self-arrival (158 v. 148 min). Time to TL, time to PCI, and time to TL and/or PCI were shorter with ambulance compared with self-arrival. Complications were rare and death occurred in approximately 3.8% of cases. Conclusion: The VHR improved prehospital STEMI care; however, the ESSC program did not improve the in-ED delivery of care for STEMI. Additional efforts are required to address the hospital-based delays in these Canadian institutions. Keywords: system-wide interventions, acute myocardial infarction, emergency crowding

150 COMMUNITY Emergency Medicine Outreach (CEMO): regional needs assessment for clinicians practising in nonurban areas

Yeung M, Cwinn AA, Curtis Lee A, Frank JR; Department of Emergency Medicine, University of Ottawa, Ottawa, ON

Introduction: Rural physicians identify significantly higher needs for emergency medicine (EM) continuing medical education (CME) than their urban counterparts. We surveyed rural physicians in order to develop a new needs-based regional outreach education program in adult EM. Methods: We conducted a multisite (12 hospitals) written needs assessment survey of all rural emergency physicians in our health region. Emergency department (ED) chiefs were offered a different survey designed to discover physicians’ unperceived needs and characteristics of the community EDs. Participants rated a list of potential EM CME topics, generated from the text by Tintinalli, results of a preliminary needs assessment survey of Chiefs and the CanMEDS Roles applied to EM. Data analysis included frequency counts of all respondents and characteristics of the community ED groups. Results: Response rates were 7/12 (58.3%) for chiefs, and 72/165 (43.6%) for physicians working in rural hospitals in the health region. Participant hospitals had annual ED visits from 21 000– 29 000; number of emergency physicians per hospital ranged from 10 to 18. Participants had graduated from medical school a mean of 16.4 years (range 1971–2006). Certifications included the following: 41/72 (56.9%) for CCFP, 10/72(13.9%) for CCFP(EM), 3/72 (4.2%) for FRCP(EM) and 6/72 (8.3%) for anesthesia. On average, respondents spend 42% (range 10%–100%) of their professional time in emergency medicine (74.6% fulltime and 25.3% parttime). Nine clinical domains had scores greater than 100: musculoskeletal, resuscitation, neurology, cardiovascular, environmental, gastrointestinal, endocrine, shock and obstetrics/gynecology. The top 3 topics outside of the Medical Expert role included the following: administration, medicolegal and scholarship. Conclusion: This needs assessment survey identified key topics to guide the professional development of community physicians. Academic emergency medicine departments can perform an important role in the design of regional EM outreach CME programs. Keywords: community emergency medicine, continuing medical education, needs assessment

151 FREQUENT users of an inner city emergency department

Geurts J, Weldon E, Palatnick W, Strome T; University of Toronto, Toronto, ON

Introduction: Within the emergency department (ED) patient population there is a subset of patients with a high number of frequent visits. Despite being small, this subset generates an inordinately high number of visits and disproportionately consumes ED resources. This retrospective chart review seeks to characterize this recidivist population to identify strategies to reduce the causes of these frequent ED visits. Methods: The frequent user was defined as a patient with 15 or more ED visits over a 1 year period. The details of each patient visit including demographics, entrance complaint, discharge diagnosis, method of arrival, Canadian Emergency Department Triage and Acuity Scale (CTAS) score, and length of stay in the ED were extracted and analyzed. Data from the entire ED population for the same period was used for comparison. Results: The review identified 92 patients who generated 2390 ED visits (out of 25 523 patients and 44 204 visits). This population was predominantly male (66%), middle-aged (median 42 yr) with no fixed address (27.2%). Patients arrived by ambulance 59.3% of the time and with less acute CTAS scores than the general emergency population. Substance use accounted for 26.9% of entrance complaints and 34.1% of discharge diagnoses. Increased lengths of stay were associated with female gender and abnormal vital signs, whereas shorter stays were associated with no fixed address and substance use (p < 0.05). Admission rates were lower than the general population and women were twice as likely as men to be admitted (p < 0.05). Patients left without being seen in 15.8% of visits. Conclusion: Highly frequent ED users are a unique population more likely to be male, younger, marginally housed and to present secondary to substance use. Admission rates among this population are low, and most patients are discharged home to the environment perpetuating the cycle of ED visits. Interventions aimed at addressing homelessness and substance abuse would potentially decrease visits and improve the overall health of this population. Keywords: frequent users, inner city care, predictors of utilization

152 CHALLENGES encountered in an international medical project in Romania: an experience in resident driven initiatives to develop resident education abroad

Stachura M, Kim K, Nowacki A; University of Toronto, Toronto, ON

Introduction: The Romania Emergency Medicine Project is an ongoing international medical project aimed at assisting the main academic emergency department (ED) in Cluj-Napoca, Romania. In May 2008, a small team from Canada travelled to Romania. One of the many objectives of this trip was to perform a needs assessment of the residency education program. Although emergency medicine (EM) is a young specialty in Romania, there exists a large, nationally accredited 5-year postgraduate medical training program. At the time of the project, the EM residency in Cluj had more than 30 residents with 1 chief resident locally and a national program director in Bucharest. Methods: This needs assessment consisted of a review of the residency curriculum and access to educational resources through direct discussions with local residents, staff physicians and administrators. Results: The following problems with the local residency program were identified collaboratively: lack of a local program director and administrative assistant, no formal educational program, no formal staff mentors, no resident involvement in academic projects and poor access to EM resources. These issues were addressed both in Cluj by the Canadian team as well as in Toronto, when the Romanian ED chief and chief resident visited as part of a knowledge exchange program. Since the completion of the project, many positive changes have occurred including the designation of a local program director, introduction of a new academic halfday and improved access to EM resources. Conclusion: The issues with the Romanian EM residency in Cluj were multifactorial, involving complex organizational, cultural and resource-based problems. Despite the above, many positive changes occurred with more changes anticipated in the future. Keywords: international EM, Romanian EM, residency training

153 DESCRIPTIVE study about prescriptions of narcotics and postanalgesic clinical monitoring of patients at the emergency department of a university hospital

Le Sage N, Mercier É, Lavoie A, Moore L, Emond M ; Laval University, Québec City, QC

Introduction: Between 60% and 80% of patients who visit the emergency department are in pain. Narcotics are often the first choice of analgesics to avoid oligoanalgesia. However, their improper use can lead to respiratory depression and possibly death. The objective of this study was to describe the prescription of intravenous narcotics and clinical monitoring of patients receiving treatment in the emergency department (ED) of a university hospital. Methods: Retrospective analysis of the records of patients over 18 years of age who received intravenous narcotics after a diagnosis of renal colic or urolithiasis in the ED. We performed descriptive analysis on data on prescription and postanalgesia monitoring derived from patient files. Results: A total of 107 randomly sampled records were reviewed. A titration of opioids was initially prescribed in 63.8% of cases, but administered as prescribed in only 23.1% of them. The vital signs most commonly monitored preand postanalgesia were blood pressure (91.9%) and heart rate (92.3%). Paradoxically, oxygen saturation, respiratory rate and the level of sedation were respectively recorded in 79%, 50% and 3% of the cases. Finally, the reassessment of pain 0–30 minutes after analgesia was only performed in 75% of the cases. Conclusion: In this retrospective chart review, titration of intravenous analgesics seem to be rarely administered exactly as prescribed. Furthermore, the most important vital signs to check after the administration of a narcotic (respiratory rate, oxygen saturation) and the level of sedation are not routinely recorded on files. Following this study, a standardized protocol including the systematic use of the Richmond vigilanceagitation scale for the level of sedation was established. A phase II study is planned to assess the postimplantation impact. Keywords: descriptive analysis, narcotics

154 MANAGEMENT of community-acquired pneumonia in a rural emergency department

Smallfield A, Bhimani M; South Huron Hospital, Exeter, ON, London Health Sciences Centre, London, ON

Introduction: Pneumonia is a common presentation to emergency departments (EDs) across Canada. Evidence based consensus guidelines exist to assist in the management of pneumonia. No studies to date have evaluated conformity to these guidelines in rural EDs. We proposed to evaluate community-acquired pneumonia management in a rural ED and to investigate the adherence to consensus guidelines with respect to choice of antibiotic and patient admission. Methods: A retrospective chart review was conducted on patients diagnosed with pneumonia in a small rural ED. Demographic information for each case was collected. The type of antibiotic, route of antibiotic administration, disposition at discharge from ED, hospital length of stay, diagnostic investigations ordered in the ED and patient comorbidities were analyzed. Results: A total of 628 charts were reviewed. Patients who were under 18 or who were already on antibiotics for pneumonia at the time of presentation were excluded from the study. The final sample consisted of 393 patients whose median age was 68 years (54.20% men). Patients received antibiotics either orally (83.46%), intravenously (14.25%) or both (1.53%). Of those patients who were treated as outpatients, 69.96% received a first or second choice antibiotic according to consensus guidelines. Of those who were admitted, 71.30% received treatment with a first or second choice antibiotic regimen that was in accordance to the guidelines. The admission rate was 29.26%, 1.27% of patients were transferred to another facility and 69.47% of patients were treated as outpatients. Median length of hospital stay for admissions was 4 days. Conclusion: Communityacquired pneumonia management guidelines are being followed in a rural ED with respect to antibiotic administration and hospital admission for the majority of cases. However, almost one-third of patients with pneumonia may not be treated according to the guidelines and may reflect an area of continuing medical education for rural ED physicians. Keywords: community-acquired pneumonia, rural emergency medicine, descriptive analysis

155 PHYSICIAN efficiency is no different between credentialed and noncredentialed emergency physicians in emergency medicine ultrasonography

Woo MY, Gatien M; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON

Introduction: The impact of emergency medicine ultrasonography (EMUS) on physician efficiency (PE) is unknown but is perceived as a barrier to performing EMUS. The objective of this study was to determine physician efficiency based on credentialing criteria in EMUS. Methods: Anonymous PE audits that are performed on a regular basis at a tertiary care urban academic emergency department were reviewed. Target number of patients seen per hour was calculated for each physician based on the type and number of shifts completed during the audit period (urgent care v. observation v. resuscitation and weekday v. weekends and nights). This was then compared with the average number of patients that would have been seen for that particular distribution of shifts by the average physician. PE was compared relative to being above or below the individualized target number. Those physicians within 10% of their target number were considered average. Physicians were then stratified based on their EMUS credentialing level (level 0: no experience; level 1: at least an introductory US course; level 2: credentialed). Descriptive statistics were used. Results: Fortyfour emergency physicians (EPs) were audited in September 2008 and January 2009. The overall average number of patients seen per hour was 2.51 (September 2008) and 2.48 (January 2009). EPs were stratified according to efficiency (below, average, above) and credentialing (level 0,1,2). There were 7, 24 and 13 EPs credentialed at levels 0, 1 and 2, respectively. September 2008 EPs at each level 0, 1 and 2 were considered average efficiency of 29%, 54% and 92%, respectively. There was little difference for January 2009 with average efficiency of 100%, 79% and 92% for levels 0, 1 and 2, respectively. Conclusion: There is little difference in physician efficiency based on EMUS credentialing levels and over time between EMUS credentialing levels. The perception of decrease in physician efficiency with EMUS should not be a barrier to EMUS credentialing. Keywords: emergency ultrasound, physician efficiency, credentialling

156 AN EXPERIENCE in patient advocacy by rural emergency physicians after major services cuts: the case of Nelson, BC

Fleet R, Plant J, Ness R, Moola S; Université Laval, Québec City, QC, CHAU Hôtel Dieu de Lévis, Lévis, QC

Introduction: Government’s efforts at cost containment through regionalization may lead to reduced emergency support services increasing patient risks while stretching the limits of the Canadian Health Care Act. Front-line emergency physicians may feel compelled to advocate for their patients. Few published reports on physician advocacy experiences pertaining to rural EDs exist. Methods: A qualitative case report by former ED physicians and local obstetricians/gynecologists describing advocacy experience at Kootenay Lake Hospital in Nelson, BC. In 2002, the BC government eliminated the general surgical program and closed the ICU. Since then, over 6000 patients travel yearly for specialty care and CT to the closest regional hospital in Trail, BC, 73 km away (1 h, 14 min). Results: Since July 2008, the regional hospital has been unable to provide ICU coverage on average 10 days per month. The closest ICU is then in Kelowna, (447 km) or Vancouver (662 km). The situation has led to increased transfer times with associated adverse events. We repeatedly informed health authorities of the potential hazards and proposed solutions. As these issues were not even considered through administrative channels, and, with unanimous support of the medical staff, we publicly exposed the situation. The details, risks and benefits of this process will be discussed. Ultimately, the situation has contributed to reduced morale and resignation of several fulltime ED physicians. To date, few improvements have materialized, and KLH remains with the only ED its size in BC (12 000 visits/yr) serving a population of 30 000 without a CT, surgeon and adequate regional ICU coverage. Conclusion: Patient advocacy can be a complex, timeconsuming experience with mitigated results. We still urge EP to use their expertise to better inform health authorities as well as the general public when administrative decisions compromise emergency care. We call on interested professional organizations and academic centres to provide objective review of the situation. Keywords: rural emergency medicine, patient advocacy, service cuts

157 RETROSPECTIVE analysis of medevacs to the emergency department in Yellowknife

Hoechsmann A; Stanton Territorial Health Authority, Yellowknife, NT

Introduction: The Northwest Territories has a geographic area roughly the size of Ontario with less than 0.5% of Ontario’s population. Providing high quality emergency health care in this enormous and vastly unpopulated region requires a substantial portion of the Territorial Ministry of Health’s budget spent on medical travel, disproportionately on medevacs (urgent aeromedical evacuations). The purpose of this study is to identify those demographic and basic clinical criteria that are associated with the need for medevacs. Methods: Specific data from medevacs and scheduled flights (delayed urgent repatriation) from remote communities within the Northwest Territories to the emergency department in Yellowknife from April 2006 to August 2009 were reviewed. The following criteria were recorded for each patient: age of the patient, location of sending practitioner and accepting hospital, nature of illness/injury, time of day of call, nurse versus physician sending patient. To compare the 2 groups, statistical analysis was performed using ANOVA for quantitative data and a χ² test for qualitative data. Results: A total of 1215 medevacs and 755 scheduled flights to the Stanton Territorial Emergency Department were performed during the study period. Several characteristics were identified that are more strongly associated with medevacs: older age, internal medicine required and patient location. Other factors are more strongly associated with delayed urgent repatriations: orthopedic or plastic surgery patients. All criteria are presented in table form with their respective odds ratios. Conclusion: This study identifies criteria most strongly positively associated and negatively associated with medevacs. These criteria will assist in improving the decision-making process with respect to medevacs. Combining some of these criteria with particular clinical factors could form the basis for derivation of a robust decision rule to assist in the decision process. Keywords: medical evacuation, rural emergency medicine, retrospective review

158 ELDERLY perceptions as to why they come to the emergency department by ambulance while emergency physicians judge it unnecessary

Dallaire CD, Aubin KA, Poitras J; Hôtel-Dieu de Lévis, Lévis, QC, Université Laval, Québec City, QC

Introduction: According to the literature, 35% to 68% of elderly persons’ ambulance transports are deemed unnecessary by health professionals, but few studies researched why those persons choose to come by ambulance to the emergency department (ED). This study aimed at identifying predisposing and facilitating factors bringing the elderly to request ambulance transport. Methods: Our qualitative study included patients 65 years or older transported by ambulance to the ED at their request and whose transport was judged unnecessary by the attending EP. Information about the project was largely distributed to our EP and a phone number was posted in working areas soliciting EP to call for a research assistant if they cared for such a case. Recruitment was performed over a 2-week period, Monday to Friday, from 8:00 am to 4:00 pm. A 30-minute semistructured interview was conducted with the patient at the moment of discharge to collect information about predisposing and facilitating factors having led to the decision to call for an ambulance. Results: During the study, 8 unnecessary transports were reported and 1 woman and 4 men agreed to be interviewed. One patient was 68 years old and 4 were aged from 82 to 87. The major predisposing factor to the decision to call for an ambulance was the patient’s own perception of a worsening health condition. Other factors included mobility issues and the distance patients had to travel, which varied from 16 to 65 km. Conclusion: This small interview-based study suggests that perception of a worsening health condition and transport issues play an important role in the use of ambulance in our elderly population. In order to formerly address those issues, larger population-based studies with systematic evaluation of contributive factors are warranted. Keywords: geriatrics, prehospital transport, ED misuse

159 INIMAPA: investigation by medical imaging in patients with acute appendicitis

Robert S, Le Sage N, Blanchet M, Tran C ; Université Laval, Québec City, QC

Introduction: The increasing use of imaging in the assessment of abdominal pain has improved the diagnostic performance, but many doubts persist about the consequences of the widespread use of these modalities. The aim of our study is to evaluate the impact of radiological imaging modalities on treatment delays in patients with proven acute appendicitis and to detail many time intervals from the patient’s arrival in the ED to the operating room. Methods: Retrospective study in 230 patients with diagnosis of acute appendicitis, grouped according to their imaging modality: clinical assessment only, ultrasound or CT scan. The time between the patient’s arrival and the following events was analyzed: medical assessment, radiological investigation, obtaining imaging results, phone call to the surgeon, consultation by the surgical team and beginning of surgery. Different clinical data were also noted. Results: The median total time (h) for patients with clinical assessment only was 5.6 hours, though it was 9.9 hours for the CT scan group and 11.6 hours for the ultrasound group. The delays of assessment by the emergency physician were clinically similar in all groups and were, respectively 0.8 hours, 0.8 hours and 0.6 hours (p = 0.04). The time devoted to the radiological assessment was 3.8 hours for the CT scan and 3.4 hours for the ultrasound (p < 0.0001). The delay from the surgical consultation was significantly longer for the CT scan and ultrasound groups, compared with the clinical assessment only (respectively, 5.1 h, 4.8 h and 2.2 h) (p < 0.0001)). Conclusion: In this study, the use of CT scan and ultrasound imaging was associated to longer delays before the surgery for the acute appendicitis. On the other hand, the elongation of these delays does not seem entirely due to the time required by the imaging procedure itself. Keywords: abdominal pain, imaging strategies, throughput analysis

160 INNOVATED pediatric chest tube insertion bench model simulation: the usability of the pilot model

Al-Qadhi S, Constas N, Corrin M, Pirie J; Hospital for Sick Children, Toronto, ON

Introduction: Acute morbidities of chest tube insertion (CTI) are directly related to poor acquisition of key tasks, specifically psychomotor and visual–spatial skills. Pediatric emergency practitioners infrequently perform this procedure and previous teaching models have been limiting and do not completely address their learning needs. A curriculum based simulation bench model was developed and piloted on pediatric residents and emergency fellows. Methods: Physicians in pediatric surgery and critical care were asked to identify the most challenging steps in the insertion of a chest tube based on the ATLS procedural checklist for CTI. As a part of quality improvement project, a model was developed which addressed these steps as well as the traditional components of CTI. The pediatric CTI simulation bench model was piloted for 2 procedural training sessions at the Hospital for Sick Children, in 2008 and 2009. Participants’ self reported attitudes toward the usability of the model as a task trainer were captured using a 5-point Likert score. Results: The survey response rate was 75% (24 of 32 participants). Of the respondents, 90% recommended this model for skills training, 79% voted that it was better or superior to previous models, and 87.5% reported improvement the 2 challenging steps dissecting the intercostal space and tube positioning in the thoracic cavity. Respondents either agreed or strongly agreed that they now have the knowledge (95%) and are comfortable performing CTI for life saving purposes (83%). Conclusion: Pediatric trainees found the CTI Pediatric Model to be a usable teaching tool which was highly recommended, superior to previous models, and improved their comfort with the procedure. Further studies to validate the model are needed. Keywords: chest tube insertion, simulation training, pediatric emergency medicine

161 EXPERIENCE of a tertiary pediatric emergency department responding to a pandemic H1N1 influenza surge

Farion KJ, Wright M, Poirier S, MacKelvie J, Dalgleish D, Voskamp D, Yoxon H, MacLeod T; Children’s Hospital of Eastern Ontario, Ottawa, ON

Introduction: Surges of the new pandemic H1N1 influenza virus activity impacted our tertiary care pediatric emergency department (ED) (2008 census 53 667) during the spring of 2009, with a more significant second wave in the fall. Despite modifications to our hospital pandemic response plan following the first wave, considerable real-time adaptation and deviation from the plan were required during the second wave to maintain timely service. Methods: Electronic institutional databases were used to track the impact of the wave 2 influenza surge as it evolved. This allowed daily, and sometimes hourly, adjustments to the pandemic response in conjunction with regional and institutional responses. Results: During the period from Oct. 14 to Nov. 15, 2009, we saw a 50% increase in patient census (compared with 2008) with a peak day of 353 patients (143% increase). Fifty-one percent of patients required isolation for febrile respiratory illness (FRI) (peak 71%) and 28% met the definition of influenza-like illness (ILI) (peak 42%). Original plans called for a second ED space to maintain services for nonpandemic patients. The large volume of patients with mild H1N1 disease severity led us to implement an independent 24/7 FRI clinic in a clinical area adjacent to the ED. This was staffed by ED and non-ED personnel redeployed from the hospital. ED leadership met daily to evaluate and adjust our pandemic response. Justintime education, treatment algorithms, rapid assessment forms and preprinted orders were quickly developed and implemented to maximize efficiency and standardize workflow processes. These interventions allowed us to maintain and even improve waittime indicators despite this unprecedented surge. Conclusion: Real-time adaptation and modification of the hospital pandemic response plan is required to deal with prolonged surges in volume/acuity. Lessons learned can be applied to future surges or mass-causality events. ED redevelopment should consider the ability to rapidly expand operations into adjacent space. Keywords: H1N1, pandemic influenza, administrative database research

162 DIAGNOSTIC approach to pulmonary embolism in a rural emergency department

Ballantine M, Bhimani M, Milne K; Division of Emergency Medicine, Schulich School of Medicine, University of Western Ontario, London, ON

Introduction: Pulmonary embolism (PE) is a serious condition with mortality estimates of up to 7.9%. No study has examined the management of PE and accessibility to the main imaging modalities for diagnosing PE, namely VQ scan and CT pulmonary angiogram, in Canadian rural emergency departments (EDs). We sought to investigate the diagnosis of PE, how long it took to access imaging and the diagnostic utility of each imaging modality in a rural ED. Methods: A retrospective chart-review was completed to determine the investigations performed and treatments initiated in the management of suspected PE in a small 20 bed rural hospital. Results: Fortyseven cases were reviewed from a 5-year period. Of these, 82.98% had a D-dimer ordered, 25.53% had a leg ultrasound ordered, 31.91% and 40.43% had either a VQ or CT scan ordered during the initial ER visit, and 14.89% received both a VQ and CT at some point during the workup. Thirteen patients (27.6%) were positive for pulmonary embolus with 12 of the positive tests diagnosed by CT scan. The mean time to receive either a VQ or CT scan was 1.58 and 1.59 days, respectively. Low molecular weight heparin was initiated in 82.98% of cases. Conclusion: These results conclude that in one rural ED, patients with suspected PE were subjected to equally short delays in receiving either a VQ or CT scan and that CT scan is diagnosing more PE than VQ scan. There may be overreliance on D-dimer testing in rural centres, compared with quoted averages, irrespective of Wells score. Leg Dopplers were not used any more frequently than CT or VQ in aiding the diagnosis. Anticoagulation was started in the majority of patients empirically. Future research could seek to replicate these results in similar rural EDs across the country. Keywords: pulmonary embolism, rural emergency medicine, diagnostic evaluation

163 ARE narcotics harmful in the treatment of acute pulmonary edema? A critically appraised topic

Berger PE, Archambault P, Poitras J; Laval University, Québec City, QC

Introduction: Acute cardiogenic pulmonary edema (ACPE) is a common diagnosis in the emergency department and use of narcotics like morphine is common. With a 3 parts question, we ask: In adults with ACPE, does administration of narcotics increase mortality or intubation? Methods: We searched databases MEDLINE, Embase and Cochrane with keywords. We included English articles with human subjects, in-hospital setting about treatment with any opioid in ACPE. All investigation type were included. Our primary outcome was mortality or intubation, but we analyzed any other outcome. We excluded animals subjects an prehospital setting studies. Results: We found 974 titles, of which 4 articles were relevant, 3 retrospective studies and 1 randomized controlled trial. The only narcotic studied was morphine. All retrospective studies showed a trend to an increase mortality in patients with ACPE treated with morphine. In the most important retrospective study, the ADHERE study, number needed to harm is 10 for mortality outcome. Many methodology problems were found in each paper, and important selection biais were found. No information about morphine doses were available. The randomized controlled trial didn’t analyzed mortality outcome. Conclusion: In retrospective studies, narcotic treatment in ACPE seems to be associated with potential harm. Keywords: narcotics, pulmonary edema, critically appraised topic

164 A NOVEL approach to case presentations in academic emergency medicine

Poitras J, O’Grady J, Archambault P; Hôtel-Dieu de Lévis, Lévis, QC, Université Laval, Québec City, QC

Introduction: Case presentations in academic emergency medicine (AEM) are popular as they appeal to our taste for stories and offer better retention than formal teaching. Furthermore, it is possible to find interesting elements in any case, either on an expertise level or another CanMEDS competency. Traditionally, case presentations happen a posteriori with a witness revealing symptoms and signs in a stepwise manner, trying to reproduce the clinical encounter and give the participants the impression they were present, formulating the same questions as the clinical team. Such a task is arduous since it happens out of context and patients are not duplicable on slides. Furthermore, interesting cases present every minute in our crowded emergency departments (EDs), a singularity of AEM. In this study, we postulated that a new approach to case presentation sessions using videoconferencing and wireless technology to generate and search clinical questions would be appreciated. Methods: Wireless technology in Université Laval (UL) conference rooms allowed participating emergency physicians (EPs) and residents to use computers and handheld devices to search the UL library and the Web during the session. Videoconferencing linked participants to an actual ED as they assisted live to the history and examination of a real consenting ED patient, for whom clinical questions were formulated and searched. Pre- and postevaluation questionnaires were distributed. Results: Questionnaires were answered by 60 participants and showed that the session was appreciated for its use of new technologies, for its lively participation and for its incentive to generate live clinical questions and instant answers. Most participants tried at least one new information resource during the session. Conclusion: This new approach to case presentations leads to improved transmission of clinical information and opens the possibility to teach EP how to search informational resources during a clinical shift in the ED. Keywords: case presentations, videoconferencing, distance learning

165 ACCREDITATION Canada survey results and new standards content for emergency health services

Bonacci A, Cyr-Hansen M; Accreditation Canada, Ottawa, ON

Introduction: As part of Accreditation Canada’s broader set of Emergency Health Services Standards; comprising emergency department, trauma and emergency medical services; all of these standards were developed in response to an expressed need by health services organizations to assess themselves against a national set of standards. The presentation will outline the analysis of results emergency department survey data as well as emergency medical services survey data. The focus of the analysis will be specific to where emergency medical services are linked with emergency department. There are a number of occasions where emergency health services providers interface with the emergency department and vice versa. The presentation will also include a brief overview of new content in the emergency department standards related to organ and tissue donation. Methods: Emergency department survey data will be retrieved from surveys that occur between January 2009 and April 2010, and emergency medical services survey data will be retrieved from surveys that occur between January and April 2010. Since the Emergency Medical Services Standards have only been rolled for organizations that have a survey in January 2010 or later, only a few months of survey data will be available for emergency medical services. Results: The results will outline trends in terms of strengths and areas for improvement in organizations where emergency medical services interfaces with the emergency department. Conclusion: The implications of doing an analysis of survey results will improve understanding of the application of the 2009 emergency department standards as well as 2010 Emergency Medical Services Standards in organizations that provide these services, and how these service areas are linked. Keywords: emergency medical services, accreditation, performance standards

166 PREHOSPITAL analgesia: a novel approach that conforms to Canadian law

Poitras J, Tanguay A, Maire S, Lapointe J; Hôtel-Dieu de Lévis, Lévis, QC, Université Laval, Québec City, QC

Introduction: In Quebec’s prehospital system, narcotics cannot be administered by paramedics to transported patients with regard to the Collège des médecins du Québec (CMQ) interpretation of Canadian law. Since 2006, the Chaudières–Appalaches Health Region disposes of system wide prehospital communications and a base hospital (BH) that allows transmission of voice communication, monitoring and electrocardiographic (ECG) data from ambulances, with 24 hours a day, 7 days a week support from BH nurses and emergency physicians (EPs). Methods: By ways of BH and wireless technology we conceived a dispensation system acceptable to the CMQ for EPs to prescribe narcotics to patients transported by ambulance. Results: The protocol is initiated when a paramedic caring for a suffering patient X contacts a BH nurse who confirms inclusion/exclusion criteria and relays the communication to an EP. While the protocol is running, patient X is monitored and clinical and voice data are continuously transmitted and recorded. The EP individually prescribes a narcotic (Sublimaze 200 µg s/c) to patient X. The 42 ambulances of the region are equipped with a narcotic locked case whose electronic combination is unique and changes with activation. The combination is computer generated for each patient by the BH and allows for the controlled prescription of a single dose to a given individual (a CMQ imperative). Once the narcotic case has been used, it is exchanged with a new one at the hospital. Conclusion: BH and wireless technology allow this important development for Quebec’s patients as huge numbers could gain from prehospital analgesia, pain being present in many emergency situations. Such a use of technology has system wide impacts and fosters benefits on morbidity that are potentially much larger than those obtained from ECG transmission and myocardial infarction treatment regionalization. Keywords: prehospital analgesia, medical direction, medicolegal considerations