2010 CAEP/ACMU Scientific Abstracts - Poster Presentations: 97-121

CAEP Abstracts

CJEM 2010;12(3):229-278

Poster presentations

97 EMERGENCY department use of Rh immune prophylaxis in early pregnancy

Sahay S, McLeod SL, Skoretz T; London Health Sciences Centre, London, ON

Introduction: Conflicting guidelines exist concerning the administration of Rh immune prophylaxis (WinRho) in first trimester complications. The objective of this study was to describe local emergency department (ED) practice regarding the administration of WinRho and determine the local obstetrical practice pattern regarding the administration of WinRho. Methods: A retrospective chart review was conducted by trained research personnel for all female, adult patients with a positive BHCG presenting to the EDs of an academic tertiary care centre with either a presenting complaint or final ED diagnosis that included abortion, miscarriage, bleeding or ectopic pregnancy. Data was gathered from a 1-year period from September 2007 to 2008. The presence of Rh typing and the administration of WinRho in the ED or urgent follow-up were recorded. Surveys were sent to consultants in obstetrics and gynecology consisting of 4 case scenarios. Each case was queried if Rh immune prophylaxis was indicated. Results: There were 1176 ED visits with a positive BHCG. Analysis of these charts resulted in 474 study visits of interest. Of these visits, only 347 (73.2%) were cross and typed. Fifty-six (16.1%) patients were identified as Rh (–), and only 35 (62.5%) were given Rh immune prophylaxis in the ED or urgent follow-up. Local physicians from obstetrics and gynecology who responded to the survey all agreed that they would give WinRho with vaginal bleeding in 11 weeks and 18 weeks, 67% would give WinRho to patients at 9 weeks gestational age and 67% would give WinRho in trauma with no bleeding. Conclusion: This study shows significant heterogeneity in the local ED practice of assessing the need for Rh immune prophylaxis in patients at risk for maternal–fetal transfusion. Education endeavours or the development of a clinical pathway may lead to improved care in this population of patients. Keywords: Rh immune prophylaxis, threatened miscarriage, health records review

98 INTEGRATION of the CanMEDS physician roles into a high fidelity human patient simulator program for Royal College of Physicians and Surgeons of Canada emergency medicine residents

Clark K; Vancouver General Hospital, University of British Columbia, Vancouver, BC

Introduction: The CanMEDS roles, essential competencies of a Canadian physician, are routinely integrated into resident training. There are no studies examining the integration of CanMEDS roles into a simulator resuscitation program for emergency medicine residents. This study evaluates the integration of the CanMEDS roles, as a basis for assessment, within a high-fidelity human patient simulator (HPS) program for Royal College of Physicians and Surgeons of Canada emergency medicine residents at the UBC. Methods: Residents and emergency physicians participated monthly in the HPS program over a 2-year period from September 2006 to June 2008. Residents acted as resuscitation team leaders. Their experiences were evaluated and debriefed using the CanMEDs physician roles as a focus of discussion. Program feedback was obtained at each session and an exit survey was completed. Outcomes included resident and facilitator perception of the integration and the utilization of the roles Medical Expert including knowledge and judgment, Communicator, Manager including Leader, Collaborator, Professional and Scholar into the simulation scenarios and debriefing sessions. Results: The final survey of 18 residents and 13 facilitators yielded a 100% response. Of respondents, 82.8% felt the CanMEDS roles could be integrated into simulation education. The following CanMEDS roles were discussed in debriefing sometimes or routinely: Medical Expert 88.8% (knowledge 100% and judgment 100%), Communicator 77.7% and Manager 66.6% (leadership 83.3%). The roles Scholar, Professional and Collaborator were not discussed as routinely. Conclusion: The CanMEDS roles Medical Expert (knowledge and judgment), Communicator and Manager (leader) are used in simulated emergency department resuscitation scenarios and can be highlighted in debriefing sessions. The roles Scholar, Professional Collaborator and Advocate require specific scenario designs to highlight their use in resuscitation. Limitations include the small sample size and the application to other education programs. Keywords: simulation training, CanMEDS, survey research

99 NIAID/FAAN criteria for the clinical diagnosis of anaphylaxis are useful in the emergency department

Kanthala AR, Campbell RL, Li JT, Hagan JB, Decker WW; Mayo Clinic College of Medicine, Rochester, MN

Introduction: We sought to determine the accuracy of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN) clinical criteria for the identification of anaphylaxis in emergency department (ED) patients. Methods: We conducted an IRB approved observational cohort study of ED patients in a tertiary care centre with approximately 80 000 ED visits annually. All patients diagnosed with allergic reactions or anaphylaxis and a random sample of patients with related diagnoses from April to July 2008 were eligible. ED medical records were reviewed to determine if patients met NIAID/FAAN criteria. Two board certified allergists subsequently and independently reviewed each record and subsequent follow-up records. The consensus diagnosis by the 2 allergists was considered the gold standard for the diagnosis of anaphylaxis. Results: Eightyeight patients constituted the validation sample. The median age was 44.5 (IQR 22.2–66.7) years, 53 (60.2%) were females and 24 (27.2%) were children less than 18 years of age. Among the 88 patients, 33 (37.5%) satisfied the NIAID/FAAN criteria for anaphylaxis. Of these 33 patients, 27 (81.8%) were diagnosed as anaphylaxis by the allergists (κ = 0.73). In the remaining 55 that did not satisfy NIAID/FAAN criteria, 5 (9.0%) were diagnosed as anaphylaxis by the allergists. The interrater agreement between the allergists was also substantial (κ = 0.75). The NIAID/FAAN clinical criteria had the following test characteristics: sensitivity 84.4% (95% CI 72%–91%), specificity 89.3% (95% CI 82%–93%), positive predictive value 81.8% (95% CI 70%–88%) and negative predictive value of 90.9% (95% CI 84%–95%). Conclusion: The NIAID/ FAAN clinical criteria for the diagnosis of anaphylaxis appear to be sensitive and specific in the ED setting. Prospective validation is needed to confirm these results. Keywords: anaphylaxis, clinical criteria, health records review

100 PNEUMONIA care: the influence of a system wide strategy to reduce ED overcrowding and improve quality of care

Rowe BH, Villa-Roel C, Willis V, Boyko D, Wing A, Lali P, Gaebert D, Bawden J, Anstett D, Crooks J, Montgomery C, Evans J, Sales A; ESSC Substudy Evaluation Group; University of Alberta, Edmonton, AB

Introduction: Pneumonia is a common emergency department (ED) presentation and wide variability in practice exists. A pneumonia care map (PCM) was implemented in 2005 in the former Capital Health region; in 2006 the Emergency Solutions and Systems Capacity (ESSC) project was implemented to address ED overcrowding. This study examined the effect of both (PCM and ESSC) on accepted quality of care markers for pneumonia in academic and community EDs. Methods: Four 6-month periods from January 2006 to December 2008 were examined (baseline, 6, 12 and 18 mo post-ESSC). A retrospective chart review was completed by trained research staff on a random selection of 600 patients/period with pneumonia to examine the quality of care. Pneumonia Severity Index (PSI) scoring, times and evidence-based care were assessed. Kruskal–Wallis and χ² statistics were used to compare different time periods. Results: Overall, 2562 patients were included and the groups were similar among the study periods. The median age was 54, more males presented and 18% were smokers. Overall, evidence of the use of the PSI in all periods was low (range 1.3%–2.6%). Most patients had a PSI class of 3 or lower. Over time, the median time to MD assessment decreased (108 v. 91 min, p < 0.001); however, time to chest xray increased (p = 0.03) and time to first antibiotic remained unchanged (4.8 v. 4.7 h). Admission occurred in approximately 45% of patients and time from triage to floor transfer increased over the study periods (24 v. 28 h, p < 0.001). Conclusion: The use of the PSI from the PCM was infrequently observed. The ESSC improves MD assessment times; however, delays in receiving chest x-rays and antibiotics persisted. Moreover, patients remain confined to the ED following admission for prolonged periods. Improvements in access to investigations and inpatient beds are required to improve the quality of care for all pneumonia patients. Keywords: pneumonia severity index, health records review, system-wide interventions

101 AIRWAY management and ALS paramedics: knowledge, skill and confidence before and after an intense airway management course

McVey J, Walker M, Jensen J, Leroux Y, Carter A; EHS Nova Scotia, Dartmouth, NS

Introduction: Airway management represents one of the core lifesaving skills in the scope of practice of the advanced life support (ALS) paramedic. The objective of this study is to determine if an intense airway management course would improve ALS paramedics’ knowledge and confidence in airway management. Methods: An intensive airway course, previously taught to physicians, was delivered to all registered ALS paramedics as part of the scheduled inservice. This before-and-after study consisted of an identical survey and exam given at the beginning and end of the 10-hour course. Participants indicated their confidence in 6 areas of airway management using a 4-point Likert scale, and completed a 20-question multiple choice exam. The sample size required to detect a 15% change on the exam was 132 subjects, and to detect a change of 0.5 on the survey, a sample size of 27 was needed. Confidence scores were compared using a Wilcoxon rank sum test, and exam scores with a paired t test. Results of an observed skills exam are presented separately. Results: A total of 301 ALS paramedics participated; 209 participants reported 6 or more years of ALS experience. Participants reported an average of 2.92 intubations in the past 12 months. The mean precourse confidence score was 2.74 and the mean postcourse confidence score was 3.39 for a difference of 0.66 (95% CI 0.61– 0.71). Postcourse exam scores improved by 4.89 (95% CI 4.58–5.20) points, from 7.71 (38.6%) to 12.606 (63.0%). Conclusion: Significant improvement in confidence and knowledge was found after paramedics completed a 10-hour airway management course. This result has implications for airway management decisions and clinical outcomes in these highacuity, time-sensitive situations. Future research includes evaluating retention of knowledge and confidence to determine continuing education requirements. Keywords: paramedic training, airway management courses, pre- poststudy design

102 IMPLEMENTATION and evaluation of a resuscitation skills simulation program for Royal College of Physicians and Surgeons of Canada emergency medicine residents

Clark K; Vancouver General Hospital, University of British Columbia, Vancouver, BC

Introduction: The benefits of simulation include direct learner observation, contextual learning and immediate feedback. The purpose of this project developed within the UBC emergency medicine residency program was to implement and evaluate a resuscitation skills program using a high fidelity human patient simulator. Methods: Residents and emergency physicians participated in the program monthly over a 2-year period from September 2006 to June 2008. Residents acted as resuscitation team leaders. Their experiences were evaluated and debriefed using the CanMEDs physician roles. Residents completed program feedback forms at the conclusion of each session. Residents and facilitators completed an exit survey. Outcomes include Likert scale ratings of the overall session, case design, reality, facilitator debriefing and teaching and perception of resuscitation skills. Results: Seventy session feedback forms were collected. Overall session ratings 98.0% (95% CI 89.1%–99.9%), case design 90.3% (95% CI 85.2%–94.0%) and reality 84.1% (95% CI 78.2%–88.9%) were consistently rated as very good (4/5) or excellent (5/5). Debriefing 92.6% (95% CI 82.1%–97.9%) and teaching 96.2% (95% CI 87.0%–99.5%) with emergency physician facilitators was consistently rated as very good (4/5) or excellent (5/5). The final survey of 18 residents and 13 facilitators yielded a 100% response. The participants felt the simulator had dedicated educator supervision, instant feedback, practical skill development and higherlevel skill development such as teamwork and critical thinking. A total of 100% (95% CI 81.5%–100%) of residents and 92.3% (95% CI 64.0%–99.8%) of facilitators stated that the ability to resuscitate an acutely ill patient improved somewhat or significantly. Conclusion: This program was rated highly by participants for many of the reasons identified in previous simulation education programs. Feedback is used for program enhancement. Limitations include the small number of participants and the application to other training programs. Keywords: simulation training, resuscitation skills, residency training

103 THE RETROSPECTIVE pre–post: a practical method to evaluate learning from an educational program

Bhanji F, Gottesman R, de Grave W, Steinert Y, Laura R, Winer LR; Montréal Children’s Hospital, Montréal, QC

Introduction: Program evaluation remains a critical, but underutilized, step in medical education. Subjective selfassessment could theoretically be a practical and inexpensive method to assess student learning but previous research has questioned students’ ability to selfassess. We compared traditional and retrospective pre–post selfassessment measures to an objective measure of learning to assess which correlated better to actual learning. Methods: A total of 47 medical students volunteered for a 4-hour pediatric resuscitation course. Subjective selfassessments were completed for the subject of interest and 2 related distracters (toxicology and fractures), preand postintervention. Students were also asked to think back, upon completing the course, and rate themselves at the onset (the “retrospective pre”). The change in traditional and retrospective preto postcourse measures was compared with the change on 22-item objectives-based multiple choice “gold-standard” exams. Results: Students’ subjective mean scores on the traditional and retrospective pre–post designs increased identically from 1.87 to 3.67/5 (p < 0.001). Their objective test scores also increased from 12.55 to 17.83 (p < 0.001). Correlations between the change in subjective and objective measures revealed a Spearman correlation of –0.02 and –0.13 for the traditional and retrospective pre–post methods. One sample t tests comparing the absolute difference between pre and post scores for distracters were expected to be 0. Traditional pre–post showed significant differences for both distracters (fracture 0.45; p < 0.001; toxicology 0.30; p < 0.01) while the retrospective pre–post showed a small difference for toxicology (0.23; p = 0.01) but not fractures (0.08; p = 0.1). Conclusion: Students accurately identified, but could not quantify, knowledge gain via traditional and retrospective subjective pre–post measures. The retrospective pre–post method of selfassessment more accurately excludes perceived change in subject matter that has not improved. Keywords: learner selfassessment, educational research, pre–post study designs

104 ADOLESCENT satisfaction in an urban pediatric emergency department

Shefrin AE, Milner RA, Goldman RD; BC Children’s Hospital, Vancouver, BC

Introduction: Adolescents are frequently cared for in pediatric emergency departments (ED). In adult populations increased levels of satisfaction are correlated with improved outcomes and utilization of health care resources. No study has focused directly on adolescents to ascertain their level of satisfaction and gather suggestions for improvement. Methods: A 33-question survey employing Likert scales and free-text was designed for this study focusing on overall satisfaction, treatment by medical and nursing staff, diagnosis and discharge instructions. The survey was administered to all eligible adolescents at discharge from the ED. Results: A total of 282 adolescents were enrolled; 92.4% of respondents rated their satisfaction as good to excellent with no differences observed by age, diagnosis and CTAS score. Almost half of respondents (45.8%) identified a desire to have more adolescent appropriate material in the waiting room and, ideally, their own waiting space. Physicians and nurses were highly regarded and trusted by their patients. However, 184 (67.3%) teenagers did not get an opportunity to meet with their physician alone. Of these, 16 (8.7%) expressed a desire to do so. Discharge diagnosis and treatment plans were understood by 232 (87.2%) of patients. Of the 161 adolescents who had attended a general hospital in the past for any reason only 11 (6.8%) preferred a general hospital ED compared with a pediatric ED. When given the opportunity to write their own responses 77 adolescents expressed a desire to have more teenage appropriate entertainment such as magazines and computers, 60 felt the wait was too long and 16 wanted a larger more comfortable waiting space. Conclusion: Adolescents were overwhelmingly satisfied with care in the pediatric ED. Medical staff should make a greater effort to meet with adolescents separate from their caregivers. Finally, institutions should strive to create a more ageappropriate ED environment for adolescents. Keywords: adolescents, pediatric emergency medicine, patient satisfaction

105 EMERGENCY physicians attitudes about routine screening for adverse drug events

Hohl CM, Brubacher JR, Joel Singer S; University of British Columbia, Vancouver, BC

Introduction: Emergency physicians (EPs) attribute 36% of ED presentations caused by adverse drug events (ADEs) to nonmedication related problems. Routine screening may improve ADE detection, documentation and treatment, but is presently not performed in most EDs because of manpower restrictions. A clinical decision rule (CDR) that flags patients at high risk for ADEs would allow clinical pharmacists to target these patients, while omitting medication optimization in lowrisk patients. Our objective was to describe EP attitudes toward routine ED-based ADE screening. Methods: We surveyed practising EPs across Canada using the membership list of the Canadian Association of Emergency Physicians (CAEP). An 18-question online survey was developed and pilot tested. An initial email invitation was sent to CAEP members. Two days later another email with a link to the online survey was sent. A reminder email was sent 1 month later. Responses were collated using descriptive statistics. Results: The response rate was 22.4%, (257/1148). Most respondents (63.6%,133/209, 95% CI 56.9%–69.9%) indicated that their patients were never evaluated by a pharmacist before discharge and 95.2% (199/209, 95% CI 91.4%–97.4%) indicated that less than 20% of discharged patients were evaluated. Admitted patients were evaluated for ADEs more often, but 62.5% (125/200, 95% CI 55.6%–68.9%) of EPs estimated that less than 20% of admitted patients were screened for ADEs in their hospital. Most respondents (58.3%, 123/211, 95% CI 51.5%–64.7%) thought that routine ED-based screening for ADEs using a CDR was a very good or excellent idea. Of individuals who thought it was only a fairly good idea (38.4%, 81/211, 95% CI 32.1%–45.1%), most were concerned about manpower implications and slowing patient flow. The median desired sensitivity for a CDR was 95% (IQR 95%–98%) for moderate, and 99% (IQR 98%–99%) for severe ADEs. Conclusion: Pharmacists do not routinely evaluate ED patients for ADEs. Most EPs thought that routine ADE screening using a CDR was a very good or excellent idea. Keywords: adverse drug events, clinical decision rule, physician acceptability

106 SEPSIS in Edmonton emergency departments: planting the SEED for reducing sepsis mortality

Bond C, Djogovic D, Bullard M, Meurer D, Villa-Roel C, Rowe BH; University of Alberta, Edmonton, Alta.

Introduction: Sepsis is a potentially life-threatening condition that requires urgent attention and management in the emergency department (ED). Evidence-based clinical guidelines for managing sepsis have been developed; however, the integration of guidelines into routine practice is often incomplete. Clinical decision support systems (CDSS) in the form of care maps may help clinicians meet guideline targets more often and rapidly. Methods: We evaluated the impact of implementing an electronic clinical practice guideline (eCPG) on the management and outcomes of patients presenting to the ED with sepsis. A retrospective case–control chart review study was performed over a 3-year period at a tertiary care, university-based, teaching hospital in Edmonton, Alta. Potentially eligible patients were identified by searching the Ambulatory Care Classification System database using ICD-10 codes and ED physician diagnoses of sepsis. Data were compared using McNemar tests (categorical data) or paired t tests (continuous data). Results: Overall, 51 cases and controls were evaluated. Due to age and sex matching, the average ages were similar between the 2 groups (62 yr) and 60% were male. Patients cared for using the eCPG were more likely to have a CVP measured (55% v. 10%, p < 0.001); however, lactate measurement, blood cultures, and other investigations were similarly ordered (all p > 0.05). The administration of antibiotics within 3 hours (63% v. 41%, p = 0.03) and vasopressors (45% v. 20%, p = 0.02) was more common in the eCPG group; however, use of steroids (29% v. 18%) and other interventions were not different between the groups (all p > 0.05). Overall, survival was high and not different between groups (82% v. 84%). Conclusion: A sepsis eCPG introduced at one hospital experienced variable use; however, patients treated by physicians using the eCPG had improved markers of quality sepsis care. Strategies to increase the utilization of eCPGs in emergency medicine appear warranted. Keywords: sepsis, clinical practice guidelines, case–control study

107 A PILOT evaluation of the effectiveness of a novel emergency medicine ultrasound curriculum for residents at a Canadian academic centre

Lee D, Woo MY, Lee CA, Frank JR; University of Ottawa, Ottawa, ON

Introduction: Emergency medicine ultrasonography (EMUS) is a new core competency of emergency medicine postgraduate training in Canada, but the effectiveness of current training curricula is not known. We evaluated the effectiveness of a novel intensive EMUS curriculum at the University of Ottawa. Methods: This pilot study analyzed existing assessment data from the first cohort of 12 emergency medicine residents to participate in a new EMUS program. All residents had a 1-day ultrasound workshop, and were then divided into 2 groups of 6 for further training. Residents in the intervention group received the initial 2-week bedside scanning course and were compared with the second cohort who did not receive the course before retesting. A multiple choice question (MCQ) exam and performance assessment (PA) tool were developed based on 4 indications (FAST, Aorta, Cardiac, Gyne) and validated by 3 experts in EMUS. Residents in the intervention group were given both tests before and after the 2 week bedside scanning course. Residents in the control group were evaluated with PA and MCQ at paired times with the intervention group. Paired comparisons were used to examine differences in assessments between the 2 groups. Results: All 12 participants completed the study. The MCQ exam scores improved for the IG (22.3 to 31.2) and little change for the CG (27 to 28.9) (p > 0.05). The PA scores CG 11.5 to 19.2, and IG 19.4 to 25.3 (p > 0.05, d = 1.43). Global rating scores CG 1.6 to 2.3, and IG 2.2 to 3.6 (score of 3 or above meets objectives) showed significant increases (p < 0.05, d = 0.72). Interrater reliability for PA and global rating were 0.95 and 0.71, respectively, using Pearson correlation coefficient. Cronbachs α for MCQ is 0.91 for Exam A and 0.87 for Exam B. Conclusion: This pilot study demonstrated the effectiveness of this novel, intensive EMUS curriculum. Other programs should consider adopting and evaluating similar models. Keywords: ultrasound training, residency training, education research

108 PLASTIC consultation in pediatric emergency department

Ang L, Millar K, Dowling S, Fraulin F, Harrop R, McPhalen D; Alberta Children’s Hospital, University of Calgary, Calgary, AB

Introduction: Consultation is a common and important aspect of emergency department (ED) care. Despite its importance, there are no studies that have assessed the agreement between emergency physicians (EPs) and consultants with regard to the perceived urgency of consultation. The primary objective was to assess the agreement between the EPs and consultants with respect to the urgency of plastic surgery referrals in a tertiary care pediatric ED. The secondary objective was to describe the type of injuries referred to plastic surgery at a tertiary care pediatric ED. Methods: This was a prospective descriptive study. Eligible patients were identified through the ED via an electronic patient tracking system. All patients who presented to the Alberta Children’s Hospital ED, 17 years of age or younger, who received pediatric plastic consultation between July and December 2009 were included in the study. At the time of consultation request, the EP filled out the study form. The rest of the form was completed by the plastic surgeon when the patient was seen. Data are then collected from the consultation form. Results: Completed data was available for 49 patients: 39 male and 10 female. Mean age was 9.7 years. Of the referrals, 10% were emergent, 55% were urgent, 32% were semiurgent while 3% were nonurgent. For the urgency of referral, the interobserver agreement (κ) between EP and plastic surgeons was 1 (95% CI 1.0–1.0). The most common injuries were fractures (56.8%), followed by burns and lacerations (11.8% each). Displaced fractures (69.0%) were more commonly referred than nondisplaced fractures. The most common injury locations were the hand (74.5%) and head/face (15.7%). Conclusion: There is excellent agreement between the emergency physicians and pediatric plastic surgeons in terms of the urgency of consultation. The most common injuries for pediatric plastic referral are hand fractures, followed by burns and lacerations. Keywords: plastic surgery, consultation patterns, pediatric emergency medicine

109 FEVER syndromic surveillance as a surrogate for pandemic H1N1 influenza in the emergency department

Bellazzini MA, Minor KD, Svenson JE; Division of Emergency Medicine, University of Wisconsin Hospital, Madison, WI

Introduction: Early detection of disease outbreaks is important to public health and emergency department preparedness. This study demonstrates the utility of using fever for syndromic surveillance for early detection of influenza-like illness (ILI) during the 2009/10 influenza pandemic. Methods: Chief complaint (CC), review of systems (ROS), discharge ICD9 code related to fever and ED temperature (T) defined as equal to or greater than 100.4°F were used as data streams. Data was collected from 11/01/08 through 11/01/09. Daily counts were converted to proportion of illness by dividing by daily total ED volume. A cumulative sum (CUSUM) algorithm using a 3 standard deviation threshold was used to generate alerts indicating aberrant fever activity. Alerts were also generated using linear regression (LM) analysis using the last 12-day proportion of fever before the day of interest. The slope of the line was used to determine the angle of rise or decline in fever activity with an alert threshold set at + 18°. Laboratory data was used to estimate the first confirmed cases of influenza during seasonal and pandemic waves. Timeliness to detection was determined by comparing syndromic surveillance alerts to the dates of laboratory confirmed influenza. Results: Alerts for fever occurred 10 days before a rise in laboratory confirmation of seasonal influenza activity using CUSUM-CC/ROS and LM-ROS. Alerts for fever occurred 11 days before a rise in laboratory confirmation of wave 1 of pandemic influenza for CUSUM-ICD/CC/T & LM-CC and 10 days prior with CUSUM-ROS & LMROS/T. Wave 2 generated alerts for fever 10 days before laboratory rise in influenza activity with LM-ROS and LM-T methods. Conclusion: Syndromic surveillance of fever may be used as a surrogate marker for influenza during the 2009/10 H1N1 influenza pandemic and may provide 10–11 days of early warning compared with laboratory confirmation of influenza activity. Keywords: syndromic surveillance, pandemic influenza, H1N1

110 FACTORS affecting medical students’ choice of emergency medicine residency training program

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

Introduction: Many career factors and personal characteristics have been associated with a medical student choosing to pursue a career in emergency medicine (EM). These include lifestyle factors such as practice flexibility and schedule as well as clinical factors such as diversity of practice and interest in a hospital-based acute care environment. The objective of this study was to determine which factors differentiate students interested in the CCFP-EM residency training stream from those interested in the FRCPC program. 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 interested in EM were asked to rank the 5 most important factors related to their choice of EM residency program from a list of 15 factors. 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, 55 (30.9%) interested in applying to the FRCPC program and the remainder unsure about which EM program they would apply to. Medical students interested in CCFP-EM ranked family life as the number 1 factor influencing residency choice followed by control over work schedule, long-term patient relationships, desire to work in a rural area and burnout prevention. FRCPC interested students ranked expertise in EM as their primary influence followed by family life, control over work schedule, subspecialization opportunities and teaching opportunities. Additionally, perceived prestige/status was ranked higher among FRCPC interested students compared with CCFP-EM interested students as a factor influencing decision-making. Conclusion: Family life and control over work schedule were ranked among the top 5 factors by both CCFP-EM and FRCPC interested groups and appear to be common priorities seen as benefits of an EM career. Keywords: residency selection, graduate medical education, CARMS

111 RELIABILITY of the 2007 CTAS guidelines: interrater agreement from a community and academic emergency department

Krause J, Fernandes CMB, McLeod S, Jewell J, Shah A, Smith B; London Health Sciences Centre, London, ON

Introduction: The Canadian Emergency Department Triage and Acuity Scale (CTAS) has been widely implemented in Canada since 1999. In 2007, an updated version of the CTAS guidelines was introduced. The objective of this study was to determine the reliability of the updated CTAS guidelines. Methods: A total of 78 triage nurses participated in the study; 53 (67.9%) nurses were from an academic teaching centre and 25 (32.1%) were from a small community emergency department. Nurses independently assigned triage scores to 10 paper-based, case scenarios consisting of vital signs, patient age, pain score and a general description of the reason for visit. For 5 scenarios, the CTAS score would have remained unchanged, while the other 5 scenarios would have been differently triaged based on the 2007 CTAS first order modifiers. Kappa statistics were used to measure interrater agreement. Results: There was a significantly higher level of agreement (κ = 0.73, 95% CI , quadratic-weighted κ = 0.85) for the 5 case scenarios which relied on the older, 2003 CTAS guidelines compared with the 5 scenarios where the 2007 guidelines would have suggested a different triage level (κ = 0.50, 95% CI 0.42–0.59, quadratic-weighted κ = 0.54). Community triage nurses had a higher level of agreement (κ = 0.80, 95% CI 0.70–0.89, quadratic-weighted κ = 0.88) for the 5 case scenarios which relied on the older guidelines compared with their colleagues at the teaching hospital (κ = 0.71, 95% CI 0.63–0.78, quadratic-weighted κ = 0.83). Similarly, for the 5 case scenarios where the 2007 CTAS guidelines would have suggested a different triage level, community nurses had a significantly higher level of agreement (κ = 0.62, 95% CI 0.48– 0.76, quadratic-weighted κ = 0.63) compared with their colleagues at the teaching hospital (κ = 0.45, 95% CI 0.35–0.56, quadratic-weighted κ = 0.50). Conclusion: The study results may be useful to develop educational materials to strengthen reliability and validity for the updated 2007 CTAS guidelines. Keywords: CTAS, reliability, interrater agreement

112 HIGH fidelity simulation to complement training in pediatric emergency medicine

Bhanji F, Stewart J; Montréal Children’s Hospital, McGill University, Montréal, QC

Introduction: Residents feel unprepared to lead the resuscitation of pediatric patients with life-threatening cardiorespiratory dysfunction. Opportunities to learn in the clinical environment are very limited yet residents are expected to graduate with these important skills. High fidelity simulation offers a unique and “safe” environment in which to practise and receive direct feedback on resuscitation performance. We incorporated a formative 2-hour high fidelity simulation workshop, focusing on crisis resource management, into the 4-week clinical pediatric emergency medicine rotation and surveyed residents on its utility. Residents also participate in 3 one-hour low-fidelity mock code sessions during the rotation — with the use of summative, objectives-based, short answer pretests to maximize learning and make the best use of instructor time. We aimed to determine if learners’ perceived ability to manage pediatric resuscitation improved by taking the workshop. Methods: Residents undertaking a pediatric emergency medicine rotation at the Montréal Children’s Hospital, between January 2009 and January 2010, were asked to complete an anonymous short questionnaire immediately following a high fidelity simulation workshop. Residents were predominantly from training programs in pediatrics, emergency medicine (FRCPC and CFPC programs), family medicine and anesthesia. Statements on the survey allowed responses of “completely agree,” “agree,” “uncertain,” “disagree” or “completely disagree.” Results: Ninety learners undertook the workshop and completed the questionnaire. All subjects believed the workshop was a positive learning experience (73 learners completely agreed and 17 agreed). More importantly, 56 learners completely agreed, and 33 agreed, they were better prepared to address a similar scenario in the ER with only 1 learner neutral to the question — no learner disagreed. Conclusion: High fidelity simulation workshops can improve learners’ perceived ability to deal with similar scenarios in the clinical setting. Keywords: high fidelity simulation, pediatric resuscitation, education research

113 TEACHING medical students to break bad news using simulation, role-play and interprofessional learning

Rocca N, McGraw R; Queen’s University School of Medicine, Kingston, ON

Introduction: Breaking bad news (BBN) is one of the most difficult tasks in medicine. Unfortunately, much evidence exists demonstrating that deficiencies in BBN are common, and that the repercussions of this communication breakdown are grave. This may be due, in part, to the previous lack of formal training in this area. This study describes an initiative by Queen’s School of Medicine to design a course introducing second year medical students to BBN Methods: A total of 100 second-year medical students and 39 thirdyear nursing students participated in the pilot program. The course consists of 2 components: an online learning module and a small group session. Students first complete the online module, where they learn the SAD NEWS protocol for BBN. During the small group session students are surprised with a simulated cardiac arrest to immediately engage the learners. Following the unsuccessful resuscitation of the high fidelity mannequin, a clinician demonstrates a BBN interview with a standardized patient (SP). Students then role-play a BBN interview with a SP and receive structured feedback. Following the small group session, students complete a survey evaluating the course. Results: Evaluations showed that 93.3% of students agreed or strongly agreed that the session provided them with a clear and stepwise approach to BBN and 88.9% agreed or strongly agreed that the SP interview was a realistic and emotional experience. Finally, 73.3% of students agreed or strongly agreed that the cardiac arrest simulation helped them to realize some of the effects of their own emotions while BBN to a patient. Conclusion: This program used an innovative integration of an online educational tool, interprofessional small group learning, SP role-play, and high fidelity simulation to achieve its goal of teaching medical students to break bad news effectively and compassionately. An overwhelming majority of students found the session an effective and enjoyable way to learn the difficult skill of BBN. Keywords: breaking bad news, interprofessional learning, simulation training

114 THE RADIATION casualty assessment tool: a new tool for the emergency department management of radiation disasters

Jarvis C, Wilkinson D; Queen Elizabeth II Health Sciences Centre, Halifax, NS

Introduction: Few Canadian emergency departments (EDs) consider themselves prepared for a disaster involving radiation. To address this gap we developed a tool designed to provide background information to guide decision-making, highlight the clinical biodosimetry measures available acutely, and facilitate documenting important clinical information obtained during the history and physical exam. Methods: The initial version of the Radiation Casualty Assessment Tool (RCAT) was developed following a live exercise, MEDNEREX, which was held in the emergency department of the Queen Elizabeth II Health Sciences Centre in Halifax in October 2006. The tool was integrated into a 2-day course called METER (Medical Emergency Treatment for Exposure to Radiation). The course was given a total of 9 times over the following 2 years. At each course, the tool was presented, along with didactic presentations on radiation medicine, followed by a workshop during which participants were required to use the tool to manage cases. At 5 of those courses, questionnaires were completed by course participants to provide feedback on the utility of the Tool. These suggestions were incorporated into subsequent revisions of the tool. Results: A total of 62 questionnaires were returned from approximately 225 participants during 5 METER courses. The questionnaires did not identify the role of the respondent (i.e., whether they were a paramedic, ED clinical staff, Public Health or administration). The overall response score was 4.1 (on a scale of 1–5, with 1 being negative, 5 being positive). The score tended to improve with each revision of the tool. Conclusion: The Radiation Casualty Assessment Tool received high scores in terms of ease of use and usefulness for ED staff when assessing casualties during workshops involving radiation cases. Use of this tool may help address a lack of preparedness at many EDs for managing radiation disasters. Keywords: disaster medicine, Radiation Casualty Assessment Tool

115 COMPARISON of physician assessment of pretest probability of heart failure to decision tools: experience within one regional health authority

Graham TAD, Villa-Roel C, Cembrowski G, Ezekowitz JA, Chan MC, Blakney G, Bullard MJ, Kozan DC, Rowe BH; University of Alberta, Edmonton, AB

Introduction: Heart failure (HF) is a common presentation to the emergency department (ED) and clinical diagnosis can be a difficult. Tools such as the PRIDE scoring system and serum brain natriuretic peptide (BNP) have been proposed alone or in combination to improve diagnostic accuracy for ED patients with dyspnea. This study evaluated the accuracy of physician assessment to other methods for patients with suspected HF. Methods: Prior to ordering a BNP, physicians at 5 hospitals were required to complete a simple, intranetor paper-based form that documented the following: ordering physician, signs and symptoms of HF, treatment, pretest probability (PTP) of HF and risk of death within 30 days. Enforcement of form completion was assigned to ward clerks. Patients with high (> 50%), moderate (15%–50%) and low (< 15%) PTP assessed by an ED physician were compared with calculated PRIDE scores and BNP, and the combination of both. Data are presented as proportions and median with interquartile ranges (IQRs); groups were compared using ANOVA. Results: Of 2780 BNP tests ordered, 1119 (40.2%, 95% CI 38.1%–1.8%) forms were completed. Overall, 807 (72%) were completed by ED physicians and included in this analysis. BNP was ordered in 45 (5.6%) patients whose HF PTP was low, 398 (49.3%) patients whose PTP was moderate, and 351 (43.5%) patients whose PTP was high. The median (IQR) PRIDE scores for low, moderate and high PTP were 4 (1, 7), 5 (4, 8), and 8 (6, 11), respectively (p < 0.001). The median PRIDE scores (without BNP) for low, moderate and high PTP were 2.5 (1, 4), 4 (3, 6), and 6 (4, 7), respectively (p < 0.001). The median (IQR) BNP levels for low, moderate and high PTP were 127.5 (68, 426), 377 (148, 1025) and 700 (316, 1498), respectively (p < 0.001). Conclusion: Compliance with BNP ordering was low. Physician PTP estimates were strongly associated with PRIDE score and BNP results. Despite recommendations, approximately 50% of BNP tests could be eliminated; the use of a PRIDE scoring system could assist ED physicians in BNP ordering. Keywords: brain natriuretic peptide, PRIDE scoring system, heart failure

116 PREDICTORS of prolonged length of emergency department stay for CTAS level 1–3 patients

Grafstein E, Stenstrom R, Cheng AL, Scheuermeyer F; University of British Columbia, Vancouver, BC

Introduction: Emergency department (ED) length of stay (LOS) is an important performance indicator and increased ED LOS may worsen ED crowding and access block. A pay for performance model was created for regional EDs and provides incentive for both high and low acuity patients that are discharged within target times. The purpose of this study was to identify predictors of prolonged ED LOS (> 4 h) in high acuity (CTAS1, 2 or 3) patients who were discharged home. Methods: This was an administrative database study undertaken from Feb. 1 to Dec. 1, 2009, in a tertiary care ED with greater than 60 000 visits per year. Patients triaged as CTAS 1–3 who were discharged home from the ED without spending time in our observation unit were included. Age, gender, arrival mode, arrival time (hour of day and day of week), triage level and location, time-to-MD assessment and all orders (laboratory, imaging, medication, ECG and consults) were extracted from the ED administrative database. Predictors of prolonged ED LOS were evaluated with multivariable logistic regression. Results: A total of 17 483 CTAS 1–3 patient visits occurred; 4964 (28.4%) had an LOS greater than 4 hours. The odds ratio (OR) for prolonged ED LOS was 4.61 (95% CI 4.1–5.26) if patients had any orders and 1.8 (1.67–1.95) if they arrived by ambulance, 1.59 (1.41–1.75) for CTAS 1–3, 4.53 (4.1–5.0) if a consult was ordered, 4.06 (3.68–4.47) if a CBC was ordered, 2.08 (1.92–2.25) for any imaging, 1.82 (1.68–1.97) if medication was ordered, 1.49 (1.43–1.55) for each 30minute increase in time to MD assessment and 1.96 (1.77–2.16) if the patient was first triaged to the acute versus fasttrack area. Conclusion: There are several independent predictors of prolonged ED LOS. These can broadly be grouped as patient specific (arrival mode, acuity level) or process specific factors (orders, consultation, CBC, imaging, location of patient placement in ED, medications given and time to MD assessment). The latter are potentially amenable to QI improvement initiatives. Keywords: administrative database study, ED length of stay

117 CRISIS resources for emergency workers (CREW), Phase II: results from a pilot study and simulation-based crisis resource management course for emergency medicine residents

Hicks CM, Bandiera GW, Kiss A, Denny CJ; St. Michael’s Hospital, Toronto, ON

Introduction: Resuscitation of a critically ill patient in the emergency department (ED) requires the coordinated efforts of an interdisciplinary team. Although effective aviation-based team training strategies are taught in other medical domains, there is currently no formal Crisis Resource Management (CRM) curriculum for Canadian emergency medicine (EM) trainees. We describe the piloting and multilevel evaluation of a novel, simulation-based CRM curriculum for EM residents, the CREW curriculum. Methods: Curriculum development was informed by a formal needs assessment survey of key EM stakeholders (CREW I). We constructed a 1-day CRM course using a blend of lecture, simulation scenarios and focused debriefing sessions facilitated by trained instructors. A subset of 10 residents was recruited to participate in a simulation-based assessment to evaluate if the CREW course improves resident performance in standardized preand postcourse scenarios; these were videotaped and scored by 2 blinded reviewers using a previously validated scale, the Ottawa CRM Global Rating Scale (GRS). To measure attitudinal shifts regarding CRM behaviours, residents completed the Human Factors Attitude Survey (HFAS) both preand posttraining, as well a postcourse survey. Results: Resident postcourse survey responses were highly favourable. The majority reported that CREW training will influence their practice and has the potential to reduce error and improve patient safety. Suggested areas for improvement include interdisciplinary training and shortening the length of instruction. Statistical analysis of the Ottawa GRS and HFAS did not demonstrate a significant difference in preand postcourse scores. Conclusion: EM residents find simulation-based CRM instruction to be highly effective and relevant to their practice. Future efforts should focus on interdisciplinary modes of EM team training and recruiting a larger sample size for pre–post comparison. Keywords: simulation training, residency training, survey study

118 ABUSIVE versus nonabusive head injury in children: a systematic review

Piteau SJ, Ward M, Barrowman N, Plint AC; Queen’s University, Kingston, ON

Introduction: Abusive head injury is the leading cause of traumatic death in infancy. Studies have shown that up to one-third of abusive head injury is initially misdiagnosed as accidental by emergency department (ED) physicians. By identifying characteristic clinical and radiological features of abusive and nonabusive traumatic head injury we may be able to improve recognition of abuse by ED physicians. Methods: We searched electronic databases, Cochrane Library, conference proceedings, and reference lists to identify all comparative studies of children aged 6 years or younger with abusive or nonabusive head injury. Only studies in which children were admitted to hospital and that compared historical features, physical exam features or imaging findings were eligible. Results: A total of 485 citations were identified and 29 studies were included in the review. There was variability in the methods by which head injuries were deemed to be abusive — 1 study used determination by single MD, 1 required admission of abuse, 5 relied on multidisciplinary assessment, 6 relied on discharge diagnosis and 16 used a combination of criteria (e.g., witnessed abuse, history inconsistent with developmental stage). Inconsistency in the definition and reporting of clinical and imaging characteristics as well as high statistical heterogeneity presented challenges to meta-analysis. Notwithstanding these important limitations, there were 3 characteristics where odds ratios (ORs) for abusive versus nonabusive head injuries could be combined: subdural hemorrhage (pooled OR 10.5, 95% CI 7.2 to 15.2, 19 studies), metaphyseal fractures (12.7, 95% CI 2.9 to 55.3, 3 studies), and long bone fractures (3.7, 95% CI 1.8 to 7.7, 8 studies). Conclusion: This systematic review highlights the need within the child abuse research literature for greater consistency in the criteria used to identify head injuries as abusive or nonabusive and for greater consistency in examining and defining characteristics that may be associated with these injuries. Keywords: child abuse, head trauma, systematic review

119 QUEPASA: the Quebec panic attack screening aid for emergency department patients with unexplained chest pain

Foldes-Busque G, Fleet R, Chauny J, Poitras J, Marchand A, Belleville G, Diodati JG, Pelland M, Lessard M; CHAU Hôtel-Dieu de Lévis, Lévis, QC

Introduction: The objective of the present study was to develop and validate a screening questionnaire for panic-like anxiety in emergency department (ED) patients with unexplained chest pain (UCP). Methods: This multicentre study included 507 consecutive ED patients randomly assigned to the development condition (n = 201) or the validation condition (n = 306). In the development condition, logistic regression analyses were conducted to determine which of the socio-demographic, medical and questionnaire response variables best predicted presence of panic-like anxiety. The selected predictors were used to develop and validate a screening questionnaire. Results: The 4-item Quebec Panic Attack Screening Aid (QUEPASA) screened panic-like anxiety with a sensitivity of 63.9% (95% CI 53%–73%) and a specificity of 81.2% (95% CI 72%–88%) in the development phase. Sensitivity and specificity were 54.6% (95% CI 46%–63%) and 82.3% (95% CI 76%–87%), respectively, in the validation phase. Comparative analyses revealed that the QUEPASA was 6–10 times more sensitive to detect panic-like anxiety than ED physicians. Conclusion: The QUEPASA has the potential to improve identification of panic-like anxiety in patients who consult in the ED for UCP. Prospective validation and impact analysis are required before clinical implementation. Keywords: chest pain, panic disorder, screening aids

120 KETAMINE–propofol compared with propofol for procedural sedation in the emergency department

Church K, Mosdossy G, Shah A, McLeod S, Lehnhardt K, Peddle M, McRae A; London Health Sciences Centre, University of Western Ontario, London, ON

Introduction: Propofol (P) and ketamine (K) are 2 commonly used agents in procedural sedation. The objective of this open-label pilot study was to compare time to recovery, total sedation time, complications, adverse events (AEs) and satisfaction scores when ketamine– propofol (KP) was used compared with P for ED procedural sedation. Methods: This prospective observational trial included adults (≥ 18 yr) presenting to an academic ED requiring procedural sedation. Physicians were assigned to use either KP or P for all procedural sedations performed over the study duration. KP patients received an initial dose of K 0.5 mg/kg and P 0.5mg/kg IV at time zero, followed by additional titrated doses of P 0.25–0.5 mg/kg IV administered every 60 seconds as needed to reach a predetermined sedation score. P patients received an initial dose of P 0.5 mg/kg IV, followed by additional titrated doses of P 0.25–0.5 mg/kg IV administered every 60 seconds as required. Oxygen was administered only as an intervention for hypoxia, and was not given preprocedurally. Results: Forty patients (21 KP, 19 P) were enrolled (July–September 2009). Mean recovery time in the KP group (7.7 min, 95% CI 5.9–9.5) was not different compared with the P group (8.5 min, 95% CI 6.1–10.9). Total sedation time in the KP group (14.5 min, 95% CI 11.5–17.5) was also not different compared with the P group (12.7 min, 95% CI 10.5–14.9). Thirteen (61.9%) patients in the KP group experienced intraprocedural AEs compared with 6 (31.6) in the P group (p = 0.07). Postprocedural AEs (nausea/ vomiting, emergence reaction) were not different between the 2 groups (KP 3/21, P 2/19). There was no difference in patient, nurse or physician satisfaction scores. Conclusion: This small data set demonstrated the feasibility of sedation with KP and P regimens in adults who did not receive preprocedural oxygenation. Data gathered from this pilot study will be used to generate hypotheses for a future multicentred, randomized controlled trial involving K and P. Keywords: ketamine propofol, procedural sedation, pilot studies

121 THE INFLUENCE of a system-wide strategy to reduce emergency department overcrowding on COPD care

Rowe BH, Villa-Roel C, Willis V, Boyko D, Wing A, Lali P, Gaebert D, Bawden J, Anstett D, Crooks J, Montgomery C, Evans J, Sales A; ESSC Substudy Evaluation Group; University of Alberta, Edmonton, AB

Introduction: Emergency department (ED) overcrowding is one of the most pressing health care issues in developed countries. In 2006, the former Capital Health (CH) region implemented the Emergency Solutions and System Capacity (ESSC) project to address ED overcrowding and patientflow issues. This study examined the effect of the ESSC on accepted quality of care markers for acute COPD at academic and community EDs. Methods: Four 6-month periods from January 2006 to December 2008 were examined (baseline, 6, 12 and 18 mo postintervention). Retrospective chart reviews were completed by trained research staff on a random selection of 400 patients/period with COPD to examine the quality of care. The outcomes were time to assessment and evidence-based care. Kruskal–Wallis and χ² statistics were used to compare different time periods. Results: Overall, 1933 patients were included and the groups were similar among the study periods. The median age was 71 years, more males presented (51%) and 26% were smokers. The median time to care decreased (83 v. 70 min, p = 0.001) over the study periods. Median time from triage to first corticosteroid (p = 0.22) and antibiotic (0.90) administration were unchanged. Approximately 50% of all patients seen in this region are admitted with COPD and the time from triage to admission increased over the study from 22 hours to 29 hours (p < 0.001). Time to discharge remained unchanged (6.5 h). Conclusion: The ESSC improved ED throughput for patients with COPD marginally; however, ED output, particularly for admitted patients remains problematic and increasing delays were observed. Additional interventions are required to ensure COPD patients receive appropriate care during exacerbations. Keywords: system-wide interventions, COPD, emergency crowding