Introduction: In the province of Québec, roughly 20% of the population lives in rural areas. Rural emergency departments (EDs) face different challenges than their urban counterparts. Yet, few studies have sought to understand these challenges. This study aims to survey Québec’s emergency physicians to: 1) identify problems specific to rural EDs, 2) find solutions for improving accessibility and quality of care offered in rural regions and, 3) rank solutions in order of priority. These results will allow data triangulation with other of our studies that seek to identify challenges faced by rural EDs and potential solutions. Methods: During the 2016 annual conference of the Québec Emergency Physicians’ Association, we asked physicians and residents (including those from urban EDs), to complete a survey about the challenges faced by rural EDs. The survey contained two sections. The first took the form of open-ended questions in which respondents could write three challenges about accessibility and quality of care in rural EDs (objective 1) and three solutions to address these challenges (objective 2). The second section listed 11 potential solutions identified in our previous study. The solutions were ranked based on their priority level on a five-point Likert scale that ranged from “not a priority” to “an absolute priority” (objective 3). We added the total number of points for each solution and produced a ranking list. Results: Ninety-one physicians out of the 417 at the conference completed the survey; 58% came from urban EDs and 42% from rural EDs. Open-ended questions suggest that access to specialists and interfacility transfers are the principal challenges faced by rural EDs. The top five solutions identified as the highest priorities were: 1) care protocols, 2) improvement of interfacility transfers, 3) training with simulators, 4) targeted ultrasound and, 5) implementation of staff retention and recruitment strategies. Conclusion: This study is relevant and useful as roughly a quarter of attendants at the conference spontaneously volunteered to help identify and prioritize solutions to foster the accessibility and quality of care in rural EDs. Furthermore, it represents a stepping stone for our recently-launched wide-scope study, Urgences Rurales 360, that aims to explore problems faced by every of the 28 rural EDs in Québec and the solutions that could be implemented to resolve them.

Introduction: In the last year, Canada published its Strategy for Patient-Oriented Research (SPOR) to ensure that patients receive the right treatment at the right time. Approximately, one in five Canadians will experience a mental illness in their life time, with many presenting to the Emergency Department (ED) as their entry point into the system. In order to improve patient outcomes and focus on patient-identified priorities, the aim of this study was to identify the short-term goals of patients with an acute mental health complaint (AMHC) presenting to the ED. Methods: We prospectively recruited a convenience sample of patients presenting to an inner city, academic ED with an annual census of 85,000 visits. Patients provided written informed consent and completed a survey package that included questions about employment intentions and short-term life goals. We collated the goals and used a content analysis to summarize the frequency of themes that emerged. Results: This study reports on the preliminary data from 108 of the targeted 200 patients (mean age 39.7 ±13.6 years; 65% male). A total of 75% of participants reported being unemployed, 84% of whom reported that they would like to gain some form of employment in the near future. Over half the sample (52%) identified that they were not satisfied with their current housing situation. In addition to improving housing and obtaining work, improving mental health (n=34), improving relationships with family or friends (n=27), going back to school (n=22) and managing addiction problems (n=20) were identified as the most common short-term goals. Other goals/priorities included improving physical health, traveling, exercising, and eating better. Conclusion: This study provides new information about the priorities of adults presenting with AMHC to the ED. It also offers insight into how to collaborate with patients to build sustainable, accessible, and coordinated care pathways that can bring about positive changes in their lives. This information can be used to compliment current care for mental health problems, ensuring greater quality, accountability, and continuity of care for this vulnerable patient group.

Introduction: Palliative care is a broad approach to care for patients with serious or life-threatening illnesses. This includes relief of symptoms, such as pain, that interfere with a patient’s quality of life. It therefore falls firmly within the realm of emergency medicine (EM). 94% of emergency physicians report a need for education in dealing with death and dying. Nevertheless, there are no generally agreed upon competencies for Canadian EM residents with regard to palliative care and end of life care in the emergency department (ED). We performed a cross-sectional study of Canadian EM residency programs to measure the existing curricula in palliative and end of life care. Our primary outcome was the prevalence of structured educational programs for palliative and end of life care. Methods: An e-survey was e-mailed to all program directors of both CCFP(EM) and EM post-graduate training programs countrywide, using FluidSurveysTM. It included questions regarding current palliative and end of life care curricula from formal rotations to seminars and online modules. The survey was developed in consultation with the author group including specialists in education, palliative care medicine, emergency medicine, and medical education. Hired translators were employed to include French speaking programs in Canada. This study had ethical approval: Interior Health REB and UBC CREB certificate 2016-17-026-H. Results: The survey was open from October 12th to December 19th, 2016. During that time, we received 26 responses including 5 French speaking programs, for a response rate of 72.2%. The primary outcome was present in 38.5% of programs. There was no difference between FRCP and CCFP(EM) programs in the occurrence of the primary outcome (p=1; Fisher’s Exact Text). However, CCFP(EM) program directors commented that many of their residents had completed palliative care rotations in their family medicine training. The largest barriers to education included time (84.6%), curriculum development (80.8%), and availability of instructors (50.0%). Conclusion: Our preliminary analysis shows that few Canadian post-graduate EM programs have a structured educational program pertaining to palliative and end of life care. Current barriers to education that can be addressed in future curricular initiatives include lack of time, curriculum development, and instructor availability.

Introduction/Innovation Concept: In 2015, the Royal College of Physicians and Surgeons of Canada set out to redefine the CanMEDS roles including replacement of the “manager” role to that of the “leader”. This was to highlight the fact that skills in leadership are crucially important as ongoing health care improvement occurs. This educational innovation was born out of a need for formal education in leadership and administration in post graduate emergency medicine training. Methods: Few post graduate emergency medicine training programs in Canada have leadership and administrative curricula involving either longitudinal or discrete 4 week rotations. We sought to create an evidence based leadership and administrative experience based on the CanMEDS roles. We adapted components of pre-existing rotations from other universities and selected competencies from Thoma et al in order to compile a list of objectives. This was coupled with a reading list, various departmental, hospital, and regional meetings, a physician leadership training seminar, a departmental presentation, and a leadership project. Curriculum, Tool, or Material: The curriculum involved 4 weeks combining 8 emergency department (ED) clinical shifts with a leadership and administration component. The latter involved clinical interdepartmental meetings, a hospital medical advisory council (MAC) meeting, a provincial medical directors meeting, a health authority MAC meeting, and taking part in planning for an ED quality improvement initiative focused on triage. Attendance at a 2-day physician administrator leadership training seminar was also included. The reading list included books on leadership and references to ED quality improvement. In addition, exposure to a B.C. Ministry of Health document entitled, “Setting Priorities for the Health Care System,” the KGH Medical Staff Rules, and the B.C. Health Quality Matrix occurred. A summary presentation to the full ED on change management and leadership in residency occurred at completion. Conclusion: This innovative leadership and administration elective was the culmination of a need to see more formal post graduate leadership training in residency. The rotation was based on the CanMEDS framework, particularly the “leader” competency, and was based on recent evidence regarding leadership and administration competencies in emergency medicine. We hope this serves as a potential model for other rotation based electives or core rotations that desire to blend leadership competencies with clinical emergency medicine.

Introduction: Our tertiary care institution embarked on the Choosing Wisely campaign to reduce unnecessary testing, and selected the reduction of ankle x-rays as part of its top five priority initiatives. The Low Risk Ankle Rule (LRAR), an evidence-based decision rule, has been derived and validated to clinically evaluate ankle injuries which do not require radiography. The LRAR, is cost-effective, has 100% sensitivity for clinically important ankle injuries and reduces ankle imaging rates by 30-60% in both academic and community setting. Our objective was to significantly reduce the proportion of ankle x-rays ordered for acute ankle injuries presenting to our pediatric Emergency Department (ED). Methods: Medical records were reviewed for all patients presenting to our tertiary care pediatric ED (ages 3- 18 years) with an isolated acute ankle injury from Jan 1, 2016-Sept 30, 2016. Children with outside imaging, an injury that occurred >72 hours prior, or those who had a repeat ED visit for same injury were excluded. Quality improvement (QI) initiatives included multidisciplinary staff education about the LRAR, posters placed within the ED highlighting the LRAR, development of a new diagnostic imaging requisition for ankle x-rays requiring use of the LRAR and collaboration with the Division of Radiology to ensure compliance with new requisition. The proportion of patients presenting to the ED with acute ankle injuries who received x-rays was measured. ED length of stay (LOS), return visits to the ED and orthopedic referrals were collected as balancing measures. Results: At baseline 88% of patients with acute ankle injuries received x-rays. Following our multiple interventions, the proportion of x-rays decreased significantly to 54%, (p<0.001). This decrease in x-ray rate was not associated with an increase in ED LOS, ED return visits or orthopedic referrals. There was an increase uptake of the dedicated x-ray requisition over time to 71%. Conclusion: This QI initiative to increase uptake of the LRAR, resulted in a significant reduction of ankle x-rays rates for children presenting with acute ankle injuries in our pediatric ED without increasing LOS, return visits or need for orthopedic referrals for missed injuries. Just as in the derivation and validation studies, the reductions have been sustained and reduced unnecessary testing and ionizing radiation.

Introduction: Poor physicians’ knowledge of health care costs has been identified as an important barrier to improving efficiency and reducing overuse in care delivery. Moreover, costs of tests and treatments estimated with traditional costing methods have been shown to be imprecise and unreliable. We estimated the cost of frequent care activities in the emergency department (ED) using the time-driven activity-based costing (TDABC) method. Methods: We conducted a TDABC study in the ED of the CHUL, Québec city (77000 visits/year). We estimated the cost of all potential care activities (e.g. triage) provided to adult patients with selected urgent (e.g. pulmonary sepsis) and non urgent (e.g. urinary tract infection) conditions frequently encountered in the ED. Following Lean management principles, process maps were developed by a group of ED care providers for each care activity to identify human resources, supplies and equipment involved, and to estimate the time required to complete each process. Resource unit cost (e.g. cost per minute of a nurse) and overhead rate were calculated using financial information from fiscal year 2015-16. Estimated cost of each care activity (e.g. chest X-ray) including physicians’ charges was calculated by summing overhead allocation and the cost of each process (e.g. disinfection of the X-ray machine) as obtained by multiplying the resource unit cost by the time for process completion. Results: Process maps were developed for 14 conditions and 68 ED care activities. We estimated the costs of activities (CAN$) related to nursing (e.g. urinalysis and culture triage ordering $14.70), clerk tasks (e.g. patient registration $3.40), physicians (e.g. FAST scan $20.90), laboratory testing (e.g. CBC $6.30), diagnostic imaging (e.g. abdominal CT scan $146.50), therapy (e.g. 5 mg of iv morphine $20.40), and resuscitation (rapid sequence intubation with ketamine and succinylcholine $146.40). Overall, emergency physicians’ charges, personnel salaries and overheads accounted for 38%, 22% and 16% of all ED care costs, respectively. Conclusion: Our results represent an important step toward increasing emergency physicians’ awareness on the real cost of their interventions and empowering them to adopt more cost-effective practice patterns.

Introduction: Prehospital transport of patients to an alternative destination (diversion) has been proposed as part of a solution to overcrowding in emergency departments (ED). We evaluated compliance and safety of an EMS protocol allowing paramedics to transport medically stable patients with psychiatric issues directly to an alternate facility [Crisis Intervention (CI)], bypassing the ED. Patients were eligible for diversion if they were ≥18 years old, classified as CTAS III-IV, scored <4 on the Prehospital Early Warning (PHEW) score, and did not have any vital sign parameters in a danger zone (as per PHEW score criteria). Methods: A retrospective analysis was conducted on patients presenting to Sudbury EMS with behavioural or psychiatric issues. Data was abstracted from EMS reports, hospital medical records, and discharge forms from CI. Protocol compliance was measured using missed protocol opportunities (patients eligible for diversion but taken directly to the ED) and protocol noncompliance rates; protocol safety was measured using protocol failure (presentation to ED within 48 hours of appropriate diversion) and patient morbidity rates (hospital admission within 48 hours of diversion). Data was analysed qualitatively and quantitatively using proportions. Results: EMS responded to 695 calls with psychiatric complaints. Of the 650 taken directly to the ED, 18 met diversion criteria; these were missed protocol opportunities (3%). 45 patients were diverted. There was protocol noncompliance in 36 cases (80%), but 34 were due to incomplete recording of vital signs. There were direct protocol violations in only 2 cases (4%). There was protocol failure in 3 cases (33%), and patient morbidity in 8 cases (18%). No patients died within 48 hours of diversion. Conclusion: EMS providers were highly compliant with the protocol when transporting patients directly to the ED. There were high levels of protocol non-compliance in diverting patients to CI, though this is largely attributed to incomplete recording of vital signs; direct protocol violations were low. The protocol provides moderate levels of safety in diverted patients. Broader implementation of a diversion protocol could reduce the volume of mental health patients seen in the ED, and improve quality of care received by this patient population.

Introduction: Prehospital transport of patients to an alternative destination (diversion) has been proposed as part of a solution to overcrowding in emergency departments (ED). We evaluated compliance and safety of an EMS bypass protocol allowing paramedics to transport intoxicated patients directly to an alternate facility [Withdrawal Management Services (WMS)], bypassing the ED. Patients were eligible for diversion if they were ≥18 years old, classified as CTAS level III-IV, scored <4 on the Prehospital Early Warning (PHEW) score, and did not have any vital sign parameters in a danger zone (as per PHEW score criteria). Methods: A retrospective analysis was conducted on intoxicated patients presenting to Sudbury EMS. Data was abstracted from EMS reports, hospital medical records, and discharge forms from WMS. Protocol compliance was measured using missed protocol opportunities (patients eligible for diversion but taken directly to the ED) and protocol noncompliance rates; protocol safety was measured using protocol failure (presentation to ED within 48 hours of appropriate diversion) and patient morbidity rates (hospital admission within 48 hours of diversion). Data was analysed qualitatively and quantitatively using proportions. Results: EMS responded to 681 calls for intoxication. Of the 568 taken directly to the ED, 65 met diversion criteria; these were missed protocol opportunities (11%). 113 patients were diverted. There was protocol noncompliance in 41 cases (36%), but 35 were due to incomplete recording of vital signs. There were direct protocol violations in only 6 cases (5%). There was protocol failure in 16 cases (22%), and patient morbidity in 1 case (1%). No patients died within 48 hours of diversion. Conclusion: EMS providers were fairly compliant with the protocol when transporting patients directly to the ED. There was some protocol non-compliance with patients diverted to WMS, though this is largely attributed to incomplete recording of vital signs; direct protocol violations were low. The protocol provides high levels of safety for patients diverted to WMS. Broader implementation of the protocol could reduce the volume of intoxicated patients seen in the ED, and improve quality of care received by this population.

Introduction: Intravenous (IV) cannulation is a common and important procedure in the emergency department (ED). Ultrasound-guided IV (UGIV) insertion has been shown to be more effective than the blind approach for patients with difficult IV access. The optimal technique for UGIV insertion has not been determined. The objective of this study is to compare the first-attempt canulation success rate between a single-operator technique (provider holds the ultrasound probe while simultaneously placing the IV), with dual-operator technique (whereby a second provider holds the probe) in ED patients with predicted difficult access. Methods: We conducted a randomized controlled trial using a convenience sample of adult ED patients. Participating ED nurses received a one-hour UGIV training session on including didactic and practical training on simulated arms. Patients were enrolled if they met any of three criteria for difficult access: (1) history of difficult access, (2) no visible or palpable veins, or (3) two failed blind attempts. High-acuity patients or those unable to consent or comply with the procedure were excluded. Eligible patients were randomized to single or dual-operator technique and a maximum of two UGIV attempts were allowed. The primary outcome was first-attempt success rate. Additional outcomes included overall success rate, number of attempts, time to successful cannulation (needle insertion to flashback), patient pain scores, operator ‘ease of use’ scores, and complications 30 minutes after insertion including IV failure. Other variables collected included patient demographics, presenting complaint, indication for ultrasound use, relevant medical history, and location/depth of the target vessel. Fisher’s exact test was used to compare success rates between groups. Results: Data collection was ongoing at the time of submission, but is expected to be completed by May 01, 2017. Conclusion: This is the first randomized-controlled trial comparing single and dual-operator ultrasound technique for difficult IV insertion in ED patients. The results from this study will provide evidence to guide education, and ensure best practice of UGIV insertion in the ED.

Introduction: Animal-assisted interventions (AAI) have been applied in numerous clinical settings to help reduce pain, stress, and anxiety. This qualitative study sets out to evaluate the St. John Ambulance Therapy Dog program in the emergency department of the Royal University Hospital. Methods: An observer identified patients interested in visiting with a Therapy Dog during their emergency department stay and obtained consent. Participants were asked to indicate on a pictographic scale their physical and mental states before and after the visit. The Therapy Dog team, consisting of a dog and handler, visited the patient for 5-10 minutes. During this time an observer took notes. Participants were asked at the conclusion of the visit to answer questions regarding their overall experience with the Therapy Dog team. Results: 117 patients participated in this study. Pre- and post AAI pictographic faces [c1] scale results showed an average improvement of 1.2. Before AAI, patients most commonly reported feeling pain, anxiety, tiredness, sadness, boredom, weakness, and a desire to go home. Immediately after the AAI, they most commonly reported feeling happiness, relaxation, better, calmness, and good. Observers noted positive participant and family changes during the AAI, including tone of voice, body language, facial expression (e.g., smiling), and openness. Patients often made efforts to make physical contact for the majority of the visit, often despite pain and immobility. There was also frequent sharing of stories about patients’ pets, which seemed to serve as a comfort within the emergency department environment. Conclusion: Animal-assisted interventions with a therapy dog team in an emergency department is a ‘pawsitive’ addition to the patient experience. An important next step is to measure whether the positive impact continued post visit.

Introduction: Most medically unfit drivers are not reported to licensing authorities. In BC, physicians are only obligated to report unfit drivers who continue to drive after being warned to stop. This study investigates barriers to and incentives for physician reporting of medically unfit drivers. Methods: We used an online survey to study physician-reported barriers to reporting medically unfit drivers and their idea of incentives that would improve reporting. Email invitations to participate in the survey were sent to all physicians in BC through DoctorsofBC and to all emergency physicians (EPs) in the UBC Department of Emergency Medicine. Results: We received responses from 242 physicians (47% EPs, 40% GPs, 13% others). The most common barrier to reporting was not knowing which unfit drivers continue to drive (79% of respondents). Other barriers included lack of time (51%), lack of knowledge of the process, guidelines, or legal requirement for reporting (51%, 50%, 45% respectively), fearing loss of rapport with patients (48%), pressure from patients not to report (34%), lack of remuneration (27%), and pressure from family members not to report (25%).EPs were significantly less likely than other physicians to cite loss of rapport, pressure from patients, or pressure from family as barriers, but more likely to cite not being aware of drivers who continue to drive after being warned, lack of knowledge (regarding legal requirements to report, guidelines for determining fitness, and the reporting process), and lack of time. Factors that would increase reporting unfit drivers included better understanding of criteria for fitness to drive (70%), more information regarding how to report (67%), more information on when to report (65%), and compensation (43%).Free text comments from respondents identified other barriers/incentives. Reporting might be simplified by telephone hotlines or allowing physician designates to report. Physicians feared legal liability and suggested the need for better medico-legal protection. Loss of patient rapport might be minimized by public education. Failure of response from licensing authorities to a report (long wait times, lack of feedback to physician) was seen as a barrier to reporting. Conclusion: We identified barriers to physician reporting of medically unfit drivers and incentives that might increase reporting. This information could inform programs aiming to improve reporting of unfit drivers.

Introduction: Walking as a form of active transportation is promoted by health professions and environmentalists alike. While the health benefits are indisputable, active transportation is not without risk. Pedestrians are vulnerable road users who often suffer serious injuries especially when involved with collisions with motor-vehicles. While pedestrian injuries involving motor-vehicles are captured in road trauma surveillance systems based on police crash reports, non-collision injuries in this population may be caused by poorly designed infrastructure but are seldom counted as road trauma. This gap hinders road improvement efforts aiming to increase safety for all road users. This study aims to address this knowledge gap. Our objective is to study the profile and circumstances of injuries in pedestrians presenting to ED. Methods: This was a cross-sectional historical chart review study. All injured patients attending our ED are electronically flagged according to mechanism of injury. We reviewed the medical charts of all ED visits flagged as “Pedestrian” or “Fall” to identify all injured pedestrians (defined in this study as anyone walking on a public roadway or getting on/off public transportation). All pedestrian injuries occurred in 2015 were included for chart review. Results: In 2015, a total of 6192 ED presentations were flagged as pedestrian (n=436) or fall (n=5756), and 1108 of these met our inclusion criteria. Of these, 181 (16%) were admitted to hospital. Older pedestrians (≥70 yrs) had a higher hospital admission rate (78/303; 27%) compared to younger ones (<70 yrs: 103/805; 13%). Collision with motor vehicles (MVCs) resulted in only 25% of pedestrian injuries while fall (or tripping) accounted for about 72%. MVC related injuries were more common in younger pedestrians (29% vs 13%) whereas fall related injuries occurred more in older pedestrians (85% vs 67%). The most commonly sustained injuries among the fallers were abrasions followed by fractures. Conclusion: Police crash reports (which capture only MVC related pedestrian injuries) or hospital admission data (which miss those who are treated and released from ED) do not capture all cases of pedestrian injury. ED visit data provides a more realistic count of pedestrian injuries. More pedestrian injuries are caused by falls than by MVCs and policymakers should pay more attention to fall prevention strategies for older pedestrians outside their home environment.

Introduction: Medical conditions that impair perception, cognition or motor skills may make people unfit to drive. Reporting unfit drivers to licensing authorities is seen by many as a public health obligation. This study investigates physician knowledge, attitudes and practice around the management of medically unfit drivers. Methods: We used an online survey to explore physician knowledge of fitness to drive issues and their attitudes and practice with regard to counselling and reporting unfit drivers. Email invitations to participate in the survey were sent to all physicians in BC through DoctorsofBC and to all emergency physicians (EPs) in the UBC Department of Emergency Medicine. Results: We received responses from 242 physicians (47% EPs, 40% GPs, 13% others). The majority (78%) reported little/no knowledge on determining driver fitness and 94% had little/no training around guidelines, reporting, and laws involving fitness to drive. Most (88%) agreed that physicians should be obligated to advise medically unfit patients not to drive, and 74% reported that they often warn patients not to drive. The majority of physicians also chart their opinion of patients’ fitness to drive (67% do so more than twice per year). Most respondents (70%) indicated that it is “always appropriate” to report definitely unfit drivers whereas only 25% indicated that it is “always appropriate” to report potentially unfit drivers. However, in practice physicians see far more unfit drivers than they report to licensing authority: 67% of physicians encounter definitely unfit drivers more than twice per year but only 19% report definitely unfit drivers more than twice per year and 34% never report definitely unfit drivers. Compared to other physicians, EPs reported less knowledge and training about criteria for determining fitness to drive, were more likely to feel that reporting unfit drivers was not their responsibility, and were less likely to report unfit drivers to licensing authorities. Conclusion: Our findings indicate a need for more education and information resources to help physicians, particularly EPs, identify and manage medically unfit drivers. Although most physicians warn unfit drivers not to drive and document this in medical records, many medically unfit drivers are not reported to licensing authorities, a potential public health problem that should be further investigated.

Introduction: It is difficult for learners to perform accurate self-assessments. This difficulty may be exaggerated in unskilled learners, a phenomenon termed the Dunning-Kruger Effect (Dunning & Kruger, 1999). Learners with the least amount of knowledge or skill may paradoxically be more likely to evaluate themselves favorably compared with their peers. This phenomenon is particularly relevant in medicine where we rely on self-directed learning not only in many of our undergraduate and postgraduate programs, but in guiding the pursuit of continuing medical education. The objectives of this study are to 1) determine whether the Dunning-Kruger Effect is present in medical education settings, 2) to determine the quality of studies in this area, and 3) to determine how this effect, if present, could influence approaches to the learner in difficulty. Methods: This is a review of the literature. PubMed databases were searched for all relevant articles. Included studies reported self-assessment of medical trainees or staff and comparison with an external rating. Studies were identified using select keywords and MeSH terms. Only studies published in English were included. No publication date limits were adopted. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality. Both authors independently abstracted data and rated study quality. Results: Eighty-six articles were identified in the PubMed search. On abstract review, 45 studies were found to meet criteria for further full article review. Studies were variable in setting and approach to self and external assessment. Criteria were not met for pooled analyses/meta-analysis. Results are presented as a summary of findings with special consideration of findings based on level of training (undergraduate, postgraduate, staff clinician). Conclusion: This review summarizes the current literature on the Dunning-Kruger Effect in medical education and provides an assessment of the quality of studies in this area to date. The potential relevance of the Dunning-Kruger Effect in medical education is discussed as are implications for interventions to support the learner in difficulty. Additional study in this area is indicated, in particular given the significant upcoming changes to postgraduate medical education in Canada in the era of Competence By Design (CBD).

Introduction: Emergency medicine physicians in our urban/suburban area have a range of training in medical education; some have no formal training in medical education, whereas others have completed Master’s level training in adult education. Not all staff have a university appointment; of those who are affiliated with our university, 87 have appointments through the Department of Medicine, 21 through the Department of Pediatrics, and 117 through the Department of Family Medicine. Emergency physicians in our area are a diverse group of physicians in terms of both formal training in adult education and in the variety of settings in which we work. The purpose of this study was to gauge interest in formal training in adult education among emergency medicine physicians. Methods: With research ethics board approval, we created and sent a 10-item electronic questionnaire to emergency medicine staff in our area. The questionnaire included items on demographics, experience in emergency medicine, additional post-graduate training, current teaching activities and interest in short (30-60 minute) adult education sessions. Results: Of a potential 360 active emergency physicians in our area, 120 responded to the questionnaire (33.3%), representing 12 area hospitals. Nearly half of respondents had been in practice over 10 years (48.44%). Respondents were mainly FRCP (50%) or CCFP-EM (47.50%) trained. 33.3% of respondents had masters degrees, of which 15% were MEd. Most physicians were involved in teaching medical students (98.33%), FRCP residents (80%) and family medicine residents (88.3%), though many were also teaching off-service residents, and allied health professionals. More than half of respondents (60%) were interested in attending short sessions to improve their skills as adult educators. The topics of most interest were feedback and evaluation, time-efficient teaching, the learner in difficulty, case-based teaching and bedside teaching. Conclusion: Emergency physicians in our area have a wide variety of experience and training in medical education. They are involved in teaching learners from a range of training levels and backgrounds. Physicians who responded to our survey expressed an interest in additional formal teaching on adult education topics geared toward emergency medicine.

Introduction: With ongoing medical advances and an increase in elderly and complex patients presenting to the Emergency Department (ED), there is a requirement for nurses to continue to gain new knowledge and skills to provide optimal patient care. Quality initiatives are frequently introduced with the goal of improving patient safety and the effectiveness of care delivery; some being provincial, while others are new requirements from Accreditation Canada. We sought the perspectives of emergency nurses regarding the importance of key ED processes and standards, and their impact on patient care and nurse efficiency. Methods: All Registered Nurses and Licensed Practical Nurses throughout the Edmonton Zone EDs were invited to complete an online survey consisting of 23 statements on nursing attitudes (10 on nursing duties) and beliefs (11 on the importance of Accreditation standards and their impacts; two that involved selecting the 5 most important nursing activities). The survey was constructed through an iterative approach. Response options included a 7-point Likert scale (‘very strongly disagree’ to ‘very strongly agree’). Median scores and interquartile ranges were determined for each survey statement. Results: A total of 433/1241 (34.9%) surveys were submitted. Respondents were predominantly Registered Nurses (91.4%), female (88.9%), and worked 0-5 years overall in the ED (43.7%). Overall, respondents were favourable (‘agree’ or ‘strongly agree’) towards the Accreditation Canada standards and other quality initiatives. They were, however, ‘neutral’ towards universal domestic violence screening, and whether there is a difference between Best Possible Medication History (BPMH) and med reconciliation. The top five nursing activities in terms of perceived importance were: vital sign documentation, recording of allergies, listening to patients’ concerns, hand hygiene, and obtaining a complete nursing history. Best Possible Medication History and the screening risk tools followed these. Conclusion: Despite their heavy workload, nurses strongly agreed on the importance of med reconciliation, falls risk, and skin care, but felt that improved documentation forms could support efficiency. Nursing perspective is valuable in informing future attempts to standardize, streamline, and simplify documentation, including the design and implementation of a provincial clinical information system.

Introduction: Abdominal pain is the most common complaint in the emergency department (ED), accounting for approximately 7% of all visits. Of the patients discharged from the ED with this complaint, 25% will carry a diagnosis of undifferentiated abdominal pain and many will subsequently have an outpatient ultrasound for further assessment. The objective of this study was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days. Methods: This was a retrospective chart review of non-pregnant patients aged 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound from November 2014 to November 2015. Data was abstracted by trained research personnel independently and in duplicate and inter-rater agreement was calculated for 25% of charts. Results: Of the 315 included patients, 261 (82.9%) were female and mean (SD) age was 28.5 (5.9) years. 28 (8.9%) patients had ultrasounds requiring intervention within 14 days. Of these, 8 (28.6%) had appendicitis, 6 (21.4%) had cholecystitis, 5 (17.9%) had gynecological, 5 (17.9%) had urological and 4 (14.3%) had gastrointestinal diagnoses. However, 15 (53.6%) patients requiring intervention within 14 days had symptoms which had improved or resolved at the time of the US. Of the 287 (91.1%) patients not requiring intervention, 92 (32.1%) had unchanged, 120 (41.8%) had improved, 52 (18.1%) had resolved and 5 (1.7%) had worsened symptoms at the time of follow-up. Of the non-intervention patients, 13 (4.5%) required alternative imaging (CT scan). Conclusion: The large majority of patients with abdominal pain discharged from the ED with planned next day US were found to have either no pathology or pathology that did not require further ED management. However, 8.9% of patients had pathological findings requiring intervention within 14 days and half of these had symptoms that had resolved or improved at the time of the US. Next day US imaging remains a viable option for identifying patients with serious pathology not appreciated at the time of their ED visit.

Introduction: Collaborative Emergency Centres (CECs) provide access to care in rural communities. After hours, registered nurses (RNs) and paramedics work together in the ED with telephone support by an emergency medical services (EMS) physician. The safety of such a model is unknown. Relapse visits are often used as a proxy measure for safety in emergency medicine. The primary outcome of this study is to measure unscheduled relapses to emergency care. Methods: The electronic patient care record (ePCR) database was queried for all patients who visited two CECs from April 1, 2012 to April 1, 2013. Abstracted data included demographics, time, acuity score, clinical impression, chief complaint, and disposition. Records were searched for each discharged CEC patient to identify unscheduled relapses to emergency care, defined as presenting back to EMS, CEC, or any other ED within the Health Authority within 48 hours of CEC discharge. Results: There were 894 CEC visits, of which 66 were excluded due to missing data. The dispositions from CEC were: 131/828 (15.8%) transferred to regional ED; 264/828 (31.9%) discharged home; 488/828 (58.9%) discharged with follow up visit booked; and 11/82 (1.2%) left the CEC without being seen. There was 37/828 (4.5%) visits which relapsed back to emergency care, all of whom were discharged from CEC or left without being seen: 3/828 (0.4%) relapsed back to EMS (two taken to regional ED and one to CEC); 16/828 (1.9%) relapsed to regional ED (by walking-in); and 18/828 (2.2%) had a relapse to the CEC (walk-in). 516/828 (62.3%) CEC visits were resolved in a single visit. Conclusion: This study was based on only two of the 7 operating CECs due to accessing paper-based charts for multiple health regions. We also acknowledge the limitations of using relapse as a proxy for safety, and that low volumes and acuity will make detection of adverse events challenging. Albeit a proxy measure, the rate of patients who relapse to emergency care was under 5% in this case series of two CECs. Most patients had their concern resolved in a single visit to a CEC. Further research is underway to determine the effectiveness, optimal utilization and safety of this collaborative model of rural emergency care.

Introduction/Innovation Concept: Feedback provided to residents by physicians emphasize the medical expertise competency and may limit the attention paid to other CanMEDS competencies. Recent years have seen the emergence of the concept of multisource feedback, a process through which different members of the care team assess and provide feedback to residents. This approach is considered one of the best for providing relevant feedback on competencies that are less often addressed by physicians. To date, very few studies have explored emergency residents’ perceptions following feedback from their physicians, nurses with whom they have worked, and patients they have treated. Methods: In the emergency department of a tertiary-care university hospital, 10 emergency medicine residents participated, on a voluntary basis, in individual and semi-structured group interviews, three months after having received multisource feedback. Two researchers then qualitatively analyzed the data collected in those interviews. Thematic content analysis using QDA Miner identified dominant themes in the residents’ perceptions. Curriculum, Tool, or Material: Multisource feedback tool: Three questionnaires were designed to gather assessment from different sources: physicians, nurses, and patients. The questionnaires were adapted from those created by Joshi and colleagues for use in a study of residents’ competency in interpersonal and communication skills. During a nine months period, the residents distributed questionnaires to physicians, nurses, and patients with whom they felt they had enough interactions during their clinical shifts. Data from the questionnaires were compiled by two educators that prepared individual feedback reports for each resident. An educator was asked to conduct individual meetings with each resident to present the feedback report and discuss its content. Conclusion: Each source provided relevant comments that differed significantly in their content. Physicians focused primarily on medical expertise, whereas nurses addressed competencies related to management, collaboration, and communication, and patients commented on the competencies of professionalism and communication. Residents concluded that obtaining feedback from nurses and patients was not only acceptable but useful in their training. Several reported modifying certain behaviours after receiving the multisource feedback. Multisource feedback appears to have obvious teaching potential to provide feedback on competencies other than medical expertise in emergency residents.

Introduction: Background: Medical education is transitioning from a time-based system to a competency-based framework. In the age of Competency-Based Medical Education, however, there is a drastically increased amount of data that needs to be interpreted. With this data, however, comes an opportunity to develop predictive analytics. Machine learning is a method of data analysis that automates analytical model building. Using algorithms that iteratively learn from data, machine learning allows computers to find hidden insights without being explicitly programmed where to look. Machine learning has been successfully used in other fields to create predictive models. Objective: This study evaluates the application of neural network as a machine learning algorithm in learning from historical data in emergency residency program and predicting future resident performance. Methods: We analyzed performance data for 16 residents (PGY1-5) who were assessed at end of each shift. Performance was graded in each of the CanMEDS Roles with scores from 1 to 7 by different attending physicians who observed residents during the shift. We transformed sequences of scores for each resident to a fixed set of features and combined all of them in one dataset. We considered scores under 6 as “At Risk Resident” and scores 6 or more as “Competent Resident”, and then we separated the dataset into training and testing sets using K-Fold cross validation and trained an artificial Neural Network in order to make decision about the future situation of residents in a specific CanMEDS Role and general performance. Results: We used 5-fold cross validation to evaluate the model, one round of cross-validation involves partitioning the whole data into complementary subsets, performing the training phase on the training set, and validating the analysis on the testing set. To reduce variability, multiple rounds of cross-validation are performed using different partitions, and the validation results are averaged over the rounds. Results of cross validation show that accuracy of model was 72%, sensitivity was 81% and specificity was 43%. Conclusion: Machine learning algorithms such (as Neural Network) have the ability to predict future resident performance on a global level and within specific domains (i.e. CanMEDS roles). Used appropriately, such information may be a valuable for monitoring resident progress.