2016 Academic Section Proceedings
CAEP 2016 Academic Symposium on Education Scholarship: Training our Future Clinician Educators in Emergency Medicine
- Robert A. Woods, Jennifer D. Artz, Benoit Carrière, Simon Field, James Huffman, Sandy L. Dong, Farhan Bhanji, Stella Yiu, Sheila Smith, Rose Mengual, Chris Hicks, Jason Frank
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S1-S8
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Objective
To develop consensus recommendations for training future clinician educators (CEs) in emergency medicine (EM).
MethodsA panel of EM education leaders was assembled from across Canada and met regularly by teleconference over the course of 1 year. Recommendations for CE training were drafted based on the panel’s experience, a literature review, and a survey of current and past EM education leaders in Canada. Feedback was sought from attendees at the Canadian Association of Emergency Physicians (CAEP) annual academic symposium. Recommendations were distributed to the society’s Academic Section for further feedback and updated by a consensus of the expert panel.
ResultsRecommendations were categorized for one of three audiences: 1) Future CEs; 2) Academic departments and divisions (AD&D) that support training to fulfill their education leadership goals; and 3) The CAEP Academic Section. Advanced medical education training is recommended for any emergency physician or resident who pursues an education leadership role. Individuals should seek out mentorship in making decisions about career opportunities and training options. AD&D should regularly perform a needs assessment of their future CE needs and identify and encourage potential individuals who fulfill education leadership roles. AD&D should develop training opportunities at their institution, provide support to complete this training, and advocate for the recognition of education scholarship in their institutional promotions process. The CAEP Academic Section should support mentorship of future CEs on a national scale.
ConclusionThese recommendations serve as a framework for training and supporting the next generation of Canadian EM medical educators.
CAEP 2016 Academic Symposium: A Writer’s Guide to Key Steps in Producing Quality Medical Education Scholarship
- Teresa M. Chan, Brent Thoma, Andrew Koch Hall, Aleisha Murnaghan, Daniel K. Ting, Carly Hagel, Kristen Weersink, Paola Camorlinga, Jill McEwen, Farhan Bhanji, Jonathan Sherbino
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S9-S15
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A key skill for successful clinician educators is the effective dissemination of scholarly innovations and research. Although there are many ways to disseminate scholarship, the most accepted and rewarded form of educational scholarship is publication in peer-reviewed journals.
This paper provides direction for emergency medicine (EM) educators interested in publishing their scholarship via traditional peer-reviewed avenues. It builds upon four literature reviews that aggregated recommendations for writing and publishing high-quality quantitative and qualitative research, innovations, and reviews. Based on the findings from these literature reviews, the recommendations were prioritized for importance and relevance to novice clinician educators by a broad community of medical educators.
The top items from the expert vetting process were presented to the 2016 Canadian Association of Emergency Physicians (CAEP) Academic Symposium Consensus Conference on Education Scholarship. This community of EM educators identified the highest yield recommendations for junior medical education scholars. This manuscript elaborates upon the top recommendations identified through this consensus-building process.
CAEP 2016 Academic Symposium: How to have an impact as an emergency medicine educator and scholar
- Jason R. Frank, Warren J. Cheung, Jonathan Sherbino, Robert Primavesi, Robert A. Woods, Glen Bandiera, Constance LeBlanc
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- 15 May 2017, pp. S16-S21
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Background
In a time of major medical education transformation, emergency medicine (EM) needs to nurture education scholars who will influence EM education practice. However, the essential ingredients to ensure a career with impact in EM education are not clear.
ObjectiveTo describe how to prepare EM educators for a high-impact career.
MethodsThe Canadian Association of Emergency Physicians (CAEP) Academic Section commissioned an “Education Impact” working group (IWG) to guide the creation of consensus recommendations from the EM community. EM educators from across Canada were initially recruited from the networks of the IWG members, and additional educators were recruited via snowball sampling. “High impact educators” were nominated by this network. The high impact educators were then interviewed using a structured question guide. These interviews were transcribed and coded for themes using qualitative methods. The process continued until no new themes were identified. Proposed themes and recommendations were presented to the EM community at the CAEP 2016 Academic Symposium. Feedback was then incorporated into a final set of recommendations.
ResultsFifty-five (71%) of 77 of identified Canadian EM educators participated, and 170 names of high impact educators were submitted and ranked by frequency. The IWG achieved sufficiency of themes after nine interviews. Five recommendations were made: 1) EM educators can pursue a high impact career by leveraging either traditional or innovative career pathways; 2) EM educators starting their education careers should have multiple senior mentors; 3) Early-career EM educators should immerse themselves in their area of interest and cultivate a community of practice, not limited to EM; 4) Every academic EM department and EM teaching site should have access to an EM educator with protected time and recognition for their EM education scholarship; and 5) Educators at all stages should continuously compile an impact portfolio.
ConclusionsWe describe a unique set of recommendations to develop educators who will influence EM, derived from a consensus from the EM community. EM leaders, educators, and aspiring educational scholars should consider how to implement this guide towards enhancing our specialty’s educational mission.
Message from Research Committee Chair
CAEP/ACMU 2017 Scientific Abstracts, June 3rd to June 7th, 2017, Whistler, British Columbia
- Jeff Perry
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- Published online by Cambridge University Press:
- 15 May 2017, p. S22
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Research Awards
CAEP/ACMU 2017 Research Abstract Awards
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S23-S25
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Plenary Oral Presentations
PL01: Creation of the Canadian Heart Failure Risk Scale for acute heart failure patients
- I.G. Stiell, C.M. Clement, J.J. Perry, R.J. Brison, A. McRae, B.H. Rowe, B. Borgundvaag, S. Aaron, L. Mielneczuk, L. Calder, J. Brinkhurst, A. Forster, G.A. Wells
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- 15 May 2017, p. S26
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Introduction: Acute heart failure (AHF) is a common, serious condition that frequently results in morbidity and death and is a leading cause for hospital admissions. There is little evidence to guide ED physician disposition decisions for AHF patients. We sought to create a risk-stratification tool for use by ED physicians to determine which AHF patients are at high risk for poor outcomes. Methods: We conducted a prospective cohort study in 9 tertiary hospital EDs and enrolled adult patients presenting with shortness of breath due to AHF. Patients were assessed for standardized clinical and laboratory variables and then followed to determine short-term serious outcome (SSO), defined as death, intubation, myocardial infarction, or relapse requiring admission within 14 days. We identified predictors of SSO by stepwise logistic regression and then rounded beta coefficients to create a risk scale. Results: We enrolled 1,733 patients with mean age 77.1 years, male 54.5%, and initially admitted 50.1%. SSOs occurred in 202 (11.7%) cases (14.0% in those admitted and 9.3% in those discharged from the ED). We created the CHFRS consisting of:1. Initial Assessment a) History of valvular heart disease b) On anti-arrhythmic c) Arrival heart rate ≥ 110d) Treated with non-invasive ventilation2. Investigations a) Urea >12 mmol/L or Cr>150 µmol/L b) Serum CO2>35 mmol/L or pCO2 >60 mmHg (VBG or ABG) c) Troponin >5x Upper Reference Level 3. Fails reassessment after ED treatment:(i) Resting vital signs abnormal, (SaO2 <90% on room air or usual O2, or HR >110, or RR >28); OR(ii) Unable to complete 3-minute walk test. The risk of SSO varied from 5.0% for a score of 0, to 77.4% for a score of 9. Discrimination between SSO and no SSO cases was good with an area under the ROC curve of 0.70 (95% CI 0.66-0.74). There was good calibration between the observed and expected probability of SSO and internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. Conclusion: We have created the CHFRS tool which consists of 8 simple variables and which estimates the short-term risk of SSOs in AHF patients. CHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients. This will ultimately lead to better safety for patients and more efficient use of hospital resources.
PL02: Derivation and validation of a feasible emergency department specific frailty index to predict adverse outcomes
- A. Brousseau, E. Dent, R.E. Hubbard, D. Melady, M. Émond, E. Mercier, A. Costa
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- 15 May 2017, p. S26
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Introduction: Frailty is an overarching concept in geriatric medicine. However its utility in the emergency department (ED) was not well understood. Objectives were to derive and validate an ED specific frailty index (FI-ED), using a cumulative deficits model; and to evaluate its ability to predict adverse outcomes. Methods: This was a large multinational prospective cohort study using data from: The Management of Older Persons in Emergency Departments (MOPED) and the interRAI study. The FI-ED was derived from the Canadian sample and validated in the multinational sample. Inclusion criteria were all patients ≥75 years old presenting to an ED. The FI-ED used 24 variables identified in the interRAI ED-Contact Assessment tool, a brief focussed geriatric assessment. Its ability to predict adverse outcomes were analysed by logistic regression with odds ratio (OR). Results: There were 3903 participants: 2153 in the derivation sample and 1750 in the validation sample. In the derivation sample, increasing FI-ED was significantly associated with admission (OR 1.43 [95% CI 1.34-1.52]), death in hospital (OR 1.55 [1.38-1.73]), prolonged hospital stay (OR 1.37 [1.22-1.54]), needs for Comprehensive Geriatric Assessment (OR 1.51 [1.41-1.60]) and discharge to long-term care (OR 1.30 [1.16-1.47]). In the validation sample, results were similar except for long-term care disposition (OR 0.84 [0.75 0.85]). Conclusion: The FI-ED conformed to characteristics previously reported in other geriatric populations. It was accurately derived and validated from a brief geriatric assessment feasible in the ED and can be used to predict adverse outcomes.
PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation
- C. Vaillancourt, M. Charette, J.E. Sinclair, J. Maloney, R. Dionne, P. Kelly, G.A. Wells, I.G. Stiell
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S26-S27
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Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.
PL04: Initial serum lactate predicts deterioration in emergency department patients with sepsis
- S.M. Fernando, D.P. Barnaby, C.L. Herry, A.J. Seely
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- Published online by Cambridge University Press:
- 15 May 2017, p. S27
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Introduction: Early Emergency Department (ED) identification of septic patients at risk of subsequent deterioration is necessary in order to optimize disposition. High-risk patients admitted directly from the ED to the ICU have better outcomes than those admitted to the floor first. Initial ED serum lactate level has been associated with 28-day mortality in admitted patients, but there is little evidence on its use in predicting short-term deterioration. Furthermore, it is unclear whether the addition of respiratory rate (RR) to lactate would create a stronger predictive model of deterioration than either alone. Methods: Prospective cohort study of ED patients (age ≥18) screened and treated for sepsis (defined as physician suspicion of infection and 2 or more of the SIRS criteria). Lactate and vital signs were obtained within 2 hours of ED arrival. Main outcome was deterioration (defined as any of the following: death; ICU admission >24 hours; Intubation; Vasoactive medications for >1 hour; or Non-invasive positive pressure ventilation for >1 hour) within 72 hours. Patients meeting an endpoint within 1 hour of arrival were excluded. Discharged patients were contacted at 72 hours to ensure that they had not met the endpoint or presented to another institution. Results: 985 patients presenting to either of two urban high-volume EDs were enrolled, of whom 84 (8.5%) met the primary outcome. Initial serum lactate ≥ 4.0 had a specificity of 97.4% (95% CI, 94.1-100%), but a sensitivity of 27.4% (95% CI, 17-8-36.9%) for predicting deterioration. Of patients with a lactate ≥ 4.0, 4 (8.7%) were discharged home, and did not reach an endpoint at 72 hours. Lactate <2.0 had a sensitivity of 95.5% (95% CI: 93.4-97.1%) and specificity of 84.5% (95% CI: 80.4-88.6%) for ruling out 72-hour deterioration. Of patients with a lactate <2.0, 224 (56.1%) were discharged home. Combining lactate with RR (AUC: 0.72, 95% CI: 0.66-0.79) did not yield better predictive capability than lactate alone (AUC: 0.70, 95% CI: 0.64-0.76). Conclusion: Initial ED lactate is predictive of deterioration within 72 hours in patients with sepsis. The combination of lactate and RR was not more predictive of deterioration than lactate alone. This suggests that serum lactate has a role in predicting deterioration in patients with sepsis, and has utility in determining disposition.
Oral Presentations
LO01: Prevalence of pulmonary embolism among Canadian emergency department patients with syncope: a multicenter prospective cohort study
- V. Thiruganasambandamoorthy, M. Sivilotti, A. McRae, M.A. Mukarram, S. Kim, B.H. Rowe, L. Huang
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- Published online by Cambridge University Press:
- 15 May 2017, p. S27
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Introduction: A recent cross-sectional study reported a 17.3% prevalence of pulmonary embolism (PE) among patients with syncope. However, the study had several flaws including spectrum and work-up bias with over-diagnosis due to excessive investigations. We sought to evaluate the prevalence of PE among Canadian emergency department (ED) patients presenting with syncope. Methods: We enrolled adults with syncope at 5 EDs and collected demographics, proportion of patients evaluated for suspected PE, their Wells PE score values and results of investigations [d-dimer, computed angiography (CT) of chest or ventilation-perfusion (VQ) scan]. 30-day adjudicated outcome included diagnosis of PE requiring treatment. We used descriptive statistics to report the results. Results: 4,739 patients [mean age 54.3 years, 54.4% females, and 587 (12.4%) hospitalized] were enrolled. 323 patients (6.8%) had further evaluation and investigations performed for suspected PE: 255 patients had D-dimer performed, 140 had CT chest and 17 had VQ performed. Of the 323 patients, 300 patients were low risk (Wells score ≤4) and 23 were high-risk (score >4). A total of 16 patients (0.3%) in the study cohort were diagnosed with PE: 10 patients were diagnosed in the ED, 5 patients were diagnosed while hospitalized as inpatient, and 1 patient was diagnosed on a return ED visit. Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among those hospitalized for syncope. Conclusion: Our study shows that the prevalence of PE is very low among all patients presenting to the ED with syncope. The prevalence is also very low among those hospitalized for syncope than previously reported. While PE should be suspected and further investigations performed among syncope patients if clinically appropriate, caution should also be taken against indiscriminate over-investigations for PE.
LO02: Heart failure and palliative care in the emergency department
- M. Lipinski, D. Eagles, L.M. Fischer, L. Mielneczuk, I.G. Stiell
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S27-S28
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Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.
LO03: Application and usefulness of outpatient cardiac testing among emergency department patients with syncope
- O. Cook, M.A. Mukarram, S. Kim, K. Arcot, M. Taljaard, M. Sivilotti, B.H. Rowe, V. Thiruganasambandamoorthy
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- 15 May 2017, p. S28
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Introduction: 2.6% of emergency department (ED) syncope patients will have underlying cardiac serious conditions (e.g. arrhythmia, serious structural heart disease) identified within 30-days of disposition. If those at risk are discharged home, outpatient cardiac testing can detect underlying arrhythmias and structural heart disease, and thereby improve patient safety. We describe the frequency of outpatient referrals for cardiac testing and the proportion of cardiac serious adverse events (SAE) among high risk and non-high (low and medium) risk ED syncope patients, as defined by the Canadian Syncope Risk Score (CSRS). Methods: We conducted a multicenter prospective cohort study to enroll adult syncope patients across five large tertiary care EDs. We collected demographics, medical history, disposition, CSRS value, outpatient referrals and testing results (holter, echocardiography), and cardiac SAE. Adjudicated 30-day SAE included death due to unknown cause, myocardial infarction, arrhythmia, and structural heart disease. We used descriptive analysis. Results: Of 4,064 enrolled patients, a total of 955 patients (23%) received an outpatient referral (mean age 57.7 years, 52.1% female). Of the 299 patients (7%) hospitalized, 154 received outpatient cardiac testing after discharge. Among the 3,765 patients discharged home from the ED, 40% of the non-high risk patients (305/756) and 56% of the high risk patients (25/45) received outpatient cardiac testing. Of all patients who received outpatient cardiac testing, 4 patients (0.8%) had serious cardiac conditions identified and all were arrhythmias. Among those with no cardiac testing, 5 patients (0.9%) suffered cardiac SAE (80% arrhythmias) outside the hospital. Of the 20 (44%) high risk patients who did not receive outpatient cardiac testing, 2 (10%) patients suffered arrhythmias outside the hospital. While among the 451 non-high risk patients, only 0.8% suffered arrhythmia outside the hospital. Conclusion: Outpatient cardiac testing among ED syncope patients is largely underutilized, especially among high risk patients. Better guidelines for outpatient cardiac testing are needed, as current practice is highly variable and mismatched with patient risk.
LO04: Very low concentrations of high-sensitivity troponin T at presentation can rapidly exclude acute myocardial infarction in a significant proportion of ED chest pain patients
- J. Andruchow, A. McRae, T. Abedin, D. Wang, E. Lang, G. Innes
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- 15 May 2017, p. S28
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Introduction: Chest pain is one of the most common presenting complaints to emergency departments (EDs) across the world, and the exclusion of acute myocardial infarction (AMI) using troponin testing is central to the care of many of these patients. Testing strategies using conventional troponin assays require repeat testing over many hours to avoid missed diagnoses. This study aims to validate the ability of very low concentrations of troponin at presentation to exclude AMI in ED chest pain patients. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. Relevant outcomes were obtained from administrative data. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). The study was REB approved. Results: A total of 1,016 patients were enrolled from August 2014-September 2016, of which 174 (17.1%) patients had an initial troponin below the limit of blank (<3 ng/L) and 369 (36.3%) had a level below the limit of detection (<5 ng/L). The sensitivity and negative predictive value (NPV) of a troponin below limit of blank (<3 ng/L) for 30-day AMI were 100% (95% CI 89.3%-100%) and 100% (95% CI 97.8-100%), respectively. The sensitivity and NPV of a troponin below limit of detection (<5 ng/L) for 30-day AMI were 93.8% (95% CI 80.0-98.3%) and 99.5% (95% CI 98.1-99.9%) respectively. Sensitivity for 30-day MACE at both cutoffs was lower: 96.1% (95% CI 92.5-98.0%) for <3 ng/L, and 88.4% (95% CI 83.3-92.1%) for <5 ng/L, respectively. Conclusion: A high sensitivity troponin T result below the limit of blank is highly sensitive at excluding AMI and identifies patients at reasonably low risk of 30-day MACE. A result below the limit of detection will identify a larger population of patients as low risk but has a greater risk of missed AMI and MACE.
LO05: In patients presenting to the ED with STEMI, is the provision of morphine associated with worse patient outcomes?
- D. Barbic, F.X. Scheuermeyer, Q. Salehmohamed, B. Kim, S. Barbic, T. Kawano, B.E. Grunau, J. Christenson
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S28-S29
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Introduction: ST-elevation myocardial infarction (STEMI) presenting to the ED is a significant health burden. The provision of IV morphine with doses titrated to provide comfort is recommended in the AHA STEMI Guidelines, yet there is limited evidence of safety in this setting. The primary objective of this study was to measure potential harm associated with the provision of IV morphine in STEMI patients presenting to the ED. Methods: This was a two centre retrospective chart review from an urban, inner city, academic ED with an annual census of 85,000 visits, and an affiliated community hospital with 35,000 annual visits. Consecutive patients from April 2009 to January 2015 presenting to the 2 EDs with a diagnosis of STEMI were identified in the ED database. Eight trained research assistants, blinded to the study hypothesis, used standardized data collection templates. The primary investigator double collected 20% of all data to ensure completeness and accuracy. Results: We included 311 patients with STEMI (124 received morphine [M]; 187 no morphine [nM]). The ages of the two groups were similar (mean 64 yrs [M] & 67 yrs [nM]; median 63 yrs [M] & 66 yrs [nM]; IQR 45-81 [M] and 45.5-86.5 [nM]); as were the proportion of female patients (21.0% [M] & 23.5% [nM]. The pre-STEMI Charlson comorbidity scores (mean 2.6), median time to first ECG (11 min [M] & 16 min [nM]), and mean time-to-needle for PCI (96.8 min [M] & 92.0 min [nM]) were similar between groups. The mean CCU length of stay (LOS) (9.3 days vs 6.3 days) and hospital LOS (7.4 days vs 4.6 days) were longer for patients receiving morphine than those not receiving morphine. Rates of congestive heart failure, acute kidney injury and cardiac arrest in hospital were unchanged between the groups. Unadjusted mortality was similar (10.5% [M] vs 13.3% [nM]) between groups. Binary logistic regression controlling for age, Charlson score, first and peak troponin values demonstrated an association between receiving morphine in the ED and an increased risk of death at 30 days (OR 8.1; 95% CI 7.1.-9.1). Conclusion: The provision of morphine to patients with STEMI in the ED may be associated with increased CCU and hospital LOS. When controlling for age, pre-STEMI Charlson score, first and peak troponin values, receiving morphine was associated with an increased risk of death at 30 days. Further research to elucidate this association is warranted.
LO06: Role of the age adjusted D-dimer in suspected deep venous thrombosis
- P. Reardon, S. Patrick, M. Taljaard, K. Thavorn, M.A. Mukarram, S. Kim, G. Le Gal, V. Thiruganasambandamoorthy
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- Published online by Cambridge University Press:
- 15 May 2017, p. S29
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Introduction: It is well established that a negative D-dimer will reliably rule out thromboembolism in selected low risk patients. Multiple modified D-dimer cutoffs have been suggested for older patients to improve diagnostic specificity. However, these approaches are better established for pulmonary embolism than for deep venous thrombosis (DVT). This study will evaluate the diagnostic performance of previously suggested D-dimer cutoffs for low risk DVT patients in the ED, and assess for a novel cutoff with improved performance. Methods: This health records review included patients >50 years with suspected DVT who were low-risk and had a D-dimer performed. Our analysis evaluated the diagnostic accuracy of D-dimer cutoffs of 500 and the age adjusted (age x 10) rule for patients >50 years; and 750, and 1,000 cutoffs for patients >60 years. 30-day outcome was a diagnosis of DVT. We also assessed the diagnostic accuracy for a novel cutoff (age x 12.5). Results: 1,000 patients (mean age 68 years; 59% female) were included. Of these, 110 patients (11%) were diagnosed with DVT. The conventional cutoff of <500 µg/L demonstrated a sensitivity of 99.1% (95% CI 95.0-99.9) and a specificity of 36.4% (95% CI 33.2-39.7). For patients >60 years, the absolute cutoffs of 750 and 1,000 showed sensitivity of 98.7% (95% CI, 92.9, 99.9), and the specificity increased to 48.6% (95% CI, 44.5-52.8%) and 62.1% (95% CI, 58.1-66.1%) respectively. For all study patients, age adjusted D-dimer demonstrated a sensitivity of 99.1% (95% CI 95.0-99.9) and a specificity of 51.2% (95% CI, 47.9-54.6). A novel age adjusted cutoff (age x 12.5) for patients >50, demonstrated a sensitivity of 97.3% (95% CI 92.2-99.4) and a specificity of 61.2% (95% CI 58.0-64.5). When compared to conventional cutoff, the age adjusted cutoffs (age x 10 and age x 12.5) would have resulted in an absolute decrease in further investigations of 13.1% and 22.2%, respectively, with false negative rates of 0.1% and 0.3%. Conclusion: Among older patients with suspected DVT and low clinical probability, the age adjusted D-dimer increases the proportion of patients among whom DVT can be ruled out. A novel cutoff (age x 12.5) demonstrated improved specificity. Future large scale prospective studies are needed to confirm this finding and to explore the cost savings of these approaches.
LO07: Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial
- M. Peach, J. Milne, D. Lewis, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, J. Fraser, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D.J. van Hoving, D. Fredericks, L. Taylor, T. Dahn, S.T. Hurley, K. MacSween, C. Cox, L. Richardson, O. Loubani, G. Stoica, S. Hunter, P. Olszynski, P.R. Atkinson
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- 15 May 2017, p. S29
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Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.
LO08: Effect of an intact “chain of survival” sequence on survival to discharge from out-of-hospital cardiac arrest
- D.L. Andrusiek, R.B. Abu-Laban, J.M. Tallon, S. Sheps, K. Joseph
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- Published online by Cambridge University Press:
- 15 May 2017, p. S30
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Introduction: The “chain of survival” is a 5-link theoretical construct that has been central to cardiac arrest resuscitation for over 40 years. Although the role of each link has been extensively studied, little is known about the impact of performing the chain of survival in sequence. The purpose of this study was to estimate the proportion of out-of-hospital cardiac arrest (OHCA) responses by Emergency Medical Services (EMS) that had an intact chain of survival sequence response, and the effect of this on survival to hospital discharge. Methods: We conducted a prospective cohort study of adult (>age 20 years) OHCA patients using data collected between 2005-2007 by the Resuscitation Outcomes Consortium (ROC). ROC is a research network involving 10 research sites and 264 EMS agencies across North America. Using routinely collected data, we coded cases as receiving an intact or non-intact chain of survival sequence based on EMS cardio pulmonary resuscitation (CPR), rhythm analysis or defibrillation, epinephrine administration or endotracheal intubation, and transport to a hospital with an electrophysiology lab or percutaneous coronary intervention capability, contingent on the patient’s condition when EMS arrived. Multiple variable logistic regression was performed, adjusting for known (Utstein) survival predictors, to estimate the independent effect of intact chain of survival sequence on survival to hospital discharge. REB approval was obtained. Results: We enrolled12,821 OHCA cases, of which, 29.4% (n=3,773) had an intact chain of survival and 7.6% (n=972) survived to hospital discharge. Cases with an intact chain of survival were younger, and more likely to arrest in public, receive bystander CPR, occur in the USA and specific ROC sites, and had faster EMS response times. The adjusted odds ratio of survival to hospital discharge with an intact chain of survival sequence was 2.4 (95% CI: 2.1-2.8). A sensitivity analysis of 4,056 cases with known timing of endotracheal intubation found a similar adjusted odds ratio of 2.1 (95% CI: 1.6-2.8). Conclusion: Our results indicate that OCHA resuscitation with an intact chain of survival occurs in approximately 1/3 of cases, and results in over a two-fold increase in the odds of surviving to hospital discharge. Initiatives to improve EMS teamwork and increase the proportion of OHCA resuscitation with an intact chain of survival appear to be warranted.
LO09: Assessing the ability of emergency department patients to self-triage by using an electronic questionnaire: a pilot study
- S. Trivedi, J. Littmann, P. Kapur, M. Betz, J. Stempien
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- Published online by Cambridge University Press:
- 15 May 2017, p. S30
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Introduction: The process of triage is used to prioritize the care of patients arriving in the emergency department (ED). To our knowledge, self-triage has not been previously studied in the general emergency department (ED) setting. In an attempt to test the feasibility of implementing this in the ED, we sought to assess the ability of ED patients to triage themselves using an electronic questionnaire. Methods: This was a prospective observational study. An iPad-based questionnaire was designed with a series of ‘yes’ or ‘no’ answers related to common chief complaints. A score corresponding to a Canadian Triage and Acuity Scale (CTAS) category was assigned based on their answers, without the knowledge of patients or ED staff. These scores were subsequently compared to the official CTAS score assigned by triage nurses. A convenience sample of ambulatory patients arriving at the ED were enrolled over a four week period. Patients arriving by ambulance were excluded. We also sought to assess patients’ ability to predict their ultimate disposition. Results: A total of 492 patients were enrolled. The mean age of enrolled patients was 43.9. Of enrolled patients, 56 (11.4%) were under 20 years old, 168 (34.1%) between ages 20-39, 116 (23.6%) between ages 40-59 and 152 (30.9%) older than 60 years. We had 245 (49.8%) patients identify as male. Patient-determined CTAS scores were as follows: 146 CTAS 1 (26.7%), 66 CTAS 2 (13.4%), 176 CTAS 3 (35.8%) and 104 CTAS 4 and 5 (21.1%). Formal triage CTAS scores were: 47 CTAS 2 (9.6%), 155 CTAS 3 (31.5%), and 290 CTAS 4 and 5 (59%). With our survey tool, 22.2% of patients matched their official triage scores. We found that that 69.9% of participants over-estimated their CTAS score while 7.9% underestimated it. Two hundred and three patients (41.3%) felt that they needed to be admitted. In fact, 73 patients (17.3%) were admitted to hospital. Conclusion: Using an electronic questionnaire, ambulatory patients frequently overestimated the acuity of their presenting complaint. Patients were also not unable to accurately predict their disposition. Further study of different approaches to self-triage is needed before possible implementation in EDs.
LO10: Quantity of opioid to prescribe for acute pain to limit misuse after emergency department discharge
- R. Daoust, J. Paquet, E. Piette, J. Morris, A. Cournoyer, M. Émond, S. Gosselin, J.S. Lee, G. Lavigne, J. Chauny
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- Published online by Cambridge University Press:
- 15 May 2017, pp. S30-S31
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Introduction: A 2008 survey found that 1.9% of the entire US population was using prescription pain medication non-medically and that 56% obtained them from a friend or relatives. Diversion of pain medication may occur when a portion of the prescription is unused for pain relief after an ED visit. We hypothesized that at least 10 pills (~40%) of an opioid prescription 2 weeks after an ED visit, will not be consumed and become available for potential misuse. Objective: Determine the quantity of unused opioids pills for common acute pain diagnoses, 2 weeks after an ED visit for acute pain. Methods: Prospective observational cohort study of consecutive ED patients from a tertiary academic urban hospital with 60,000 ED visits annually. Inclusion criteria: aged ≥18 years, acute pain conditions present ≤2 weeks, pain intensity at triage of ≥4 (on a 0-10 numeric rating scale; NRS), and discharged with a new opioid prescription. ED physicians identified (24/7) eligible patients. They recorded the pain complaint/location, the final diagnosis, the quantity and type of prescribed pain medication. Discharged patients completed paper or electronic 14-day diary (REDCap database) to document their pain medication consumption. As a mitigation strategy, they were also contacted by phone at 2 weeks for the same information. A paired t-test was used to test the difference between the amounts of opioids prescribed and consumed. Results: 350 patients were recruited. Mean age 50 (SD ±16) and 54.2% were men. Painful diagnosis: fracture (18.2%), acute back pain (15.3%), renal colic (15.3%), Sprain (excluding back/neck pain) (6.9%), Contusion (6.4%), acute neck pain (5.8%), abdominal pain (4.9%), and other (27.2%). Opioids prescribed: oxycodone (47%), morphine (37%) and hydromorphone (16%). Means quantity of opioid pills prescribed: 24 (IC95%: 23-26). Filled opioid prescription: 92%. Means quantity of opioid pills consumed: 8 (IC95%: 7-9). Means quantity of unused opioids pills: 16. Opioid pills available for misuse in our cohort: 5,600 pills. Conclusion: After an ED visit for acute pain a significant portion of opioids prescribed is unused and available for misuse. A large pragmatic study should be done to confirm that an opioid prescription strategy based on our results will limit unused opioid pills while maintaining pain relief.
LO11: Opiate prescribing in Ontario emergency departments
- B. Borgundvaag, W. Khuu, S.L. McLeod, T. Gomes
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- Published online by Cambridge University Press:
- 15 May 2017, p. S31
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Introduction: Increased prescribing of high potency opioids has been associated with increasing opioid addiction and linked to serious adverse outcomes including misuse, diversion, overdose and death. Problems related to opioids are a major Canadian public health concern yet few data are available on prescribing in most Canadian provinces. The objective of this study was to describe opioid prescribing in Ontario EDs and patient harms associated with this practice. Methods: We conducted a population-based cohort study among Ontario residents aged 15-64 years who were eligible for public drug coverage between April 2008 and March 2012. Using administrative databases, we identified patients with no opioid use in the past 12 months who received a prescription opioid from an emergency or family physician. Patients were followed for 2 years following their index prescription. The primary outcome was hospital admission for opioid toxicity and secondary outcome was dose-escalation exceeding 200 mg morphine equivalents (MEQ). Results: Of the 77,270 unique patients included, 33,492 (43.3%) and 43,778 (56.7%) prescriptions were issued by emergency physician (EP) and family physicians (FP), respectively. FP patients were older (45.9 vs 41.2 yr, MSD 0.35), had fewer ED visits (0.9 vs 2.3, MSD 0.46), and more FP visits (11.5 vs 8.7 MSD 0.31) in the year prior to their index visit. For combination products, EPs were more likely to prescribe oxycodone compared to FPs (37.2% vs 16.7%, Δ 20.5, 95% CI: 19.9, 21.2). For single agent products, EPs were more likely to prescribe hydromorphone compared to FPs (44.5% vs 21.7%, Δ 22.8, 95% CI: 20.4, 25.2). FPs were more likely to prescribe codeine either as a combination or single agent formulation. EP prescriptions led to significantly more hospital admissions for opioid toxicity (0.5% vs 0.3%, Δ 0.2, 95% CI: 0.1, 0.3), while FP prescriptions more often resulted in dose escalation beyond 200 mg MEQs (0.1% vs 0.7%, Δ 0.6, 95% CI: 0.4, 0.7). Conclusion: A large percentage of opioid-naïve patients receive an initial opiate prescription in the ED, where the use of high potency opioids is much more common, with 1/200 of these patients subsequently hospitalized for opioid toxicity. Creation of a physician accessible provincial registry would be useful to monitor opioid prescribing and dispensing, inform clinical practice, and identify patients at high-risk who may benefit from early interventions.