Calgary Emergency Department Research Articles

Understanding caregiver preferences and technology access to plan improvement of pediatric emergency department discharge instructions.

Approximately 95% of children treated in emergency departments (EDs) in Alberta, Canada, are discharged home. Discharge teaching is an opportunity to provide caregivers with the information that they need to manage their child's condition at home and ensure appropriate follow-up. Our ED lacked a standard discharge instruction process. In preparation for local quality improvement, we sought to understand caregiver preferences regarding discharge instructions by assessing the preferred format, need for translated resources, and ability to effectively access electronic information using a Quick Response (QR) code. This project was completed at a tertiary pediatric ED in Calgary, Alberta in July and August 2021. Caregivers of pediatric patients were invited to complete a survey. Families requiring an interpreter were not eligible; however, this was recorded to estimate translation needs. Survey questions addressed preference of discharge instruction modality (verbal, printed, electronic), primary language spoken at home, ability to use English resources, and ability to use QR codes. Descriptive analyses were performed, and preferences were compared. Of 117 caregivers approached, 104 completed the survey (89%). Caregivers had a strong preference for receiving written discharge instructions, with 98% desiring either electronic or printed resources in addition to verbal instructions. There was a similar likelihood of using printed (75%) versus electronic (79%) resources (p = 0.5). Three percent of families were unable to complete the survey due to a language barrier. Of the 104 participants, 19% noted that their primary language at home was not English but that they would still use English discharge instructions. Eighty percent of participants were able to successfully use the QR code. Caregivers had a strong preference for receiving written discharge instructions, with electronic or paper formats preferred equally. Translated resources will be important for some families. QR codes may be an effective tool for distributing electronic resources to most but not all families.

Electric scooter related injuries in Calgary emergency departments.

Electric scooters (e-scooters) have contributed to a rise in injury burden and emergency department (ED) utilization since their local introduction 3years ago. This study is a novel collaboration between the City of Calgary's Department of Transportation and emergency medicine researchers to better understand the nature and frequencies of e-scooter injuries. It quantifies the incidence and characteristics of e-scooter related injuries treated in Calgary EDs/urgent carecentres (UCCs). Administrative data from electronic medical records of all patients presenting to Adult Emergency Departments and one Urgent Care Centre in Calgary with an e-scooter related injury between July 8, 2019, and Oct 1, 2019, and May 22, 2020, and September 30, 2020 were collected. Additional data were obtained from paper EMS reports. Descriptive statistics were used to characterize injury-specific variables and comparisons were drawn between ED visits for other transportation modalities. 1272 ED/urgent care visits were attributed to an e-scooter related incident. The majority of incidents occurred between 20:00 and 24:00 (47%). Most injuries occurred to the lower limb (54.8%), followed by facial injuries (42.9%). The overwhelming majority of injuries happened to the e-scooter drivers (97.6%). E-scooter injuries made up approximately 15% of all trauma presentations to Calgary area adult EDsduring the e-scooter season and 1 in 1400 e-scooter rides resulted in a visit to an ED/UCC. Traumatic ED visits related to e-scooter use represent an increasing burden of preventable injuries. This study identified specific characteristics to focus future education and public policy efforts on.

Effectiveness of intravenous prostaglandin to reduce digital amputations from frostbite: an observational study

We assessed the effectiveness and safety of a 5-day intravenous prostaglandin (iloprost) protocol at reducing digital amputation for patients with severe frostbite injuries at urban emergency departments. This retrospective study examines consecutive patients who presented to Calgary emergency departments from April 2017 to April 2020 with Grade 2-4 frostbite injuries. Patients from February 2019 onward were managed using a 5-day iloprost infusion protocol, whereas patients prior to this time were managed with standard care (local best practice without iloprost as a therapeutic option). The primary effectiveness outcome was rate of affected digits amputated, stratified by frostbite severity. The secondary safety outcome was the incidence of serious adverse events associated with iloprost (allergic reactions or symptomatic hypotension requiring treatment or discontinuation of the infusion). 90 patients were included, 26 were treated with iloprost, compared to 64 patients who received usual care. Both the treatment and usual care groups experienced substantial rates of homelessness and substance use. No digital amputations were required for patients with Grade 2 injuries in either group, but significantly lower digital amputation rates were observed for patients with more severe frostbite injuries treated with iloprost versus usual care: Grade 3 (18% vs 44%, p < 0.001), Grade 4 (46% vs 95%, p < 0.001). No serious adverse events were associated with iloprost. In this unselected socially complex urban population, administration of iloprost for patients with frostbite was shown to be safe and was associated with lower digital amputation rates, particularly for those with more severe injuries.

Management of incomplete and missed spontaneous abortions: a cohort study of trends in Calgary emergency departments.

Incomplete and missed spontaneous abortion cases often first present to the emergency department (ED), where they can be managed operatively via dilation and curettage (D&C) or non-operatively through medical or expectant management. The primary objective of this study was to determine how rates of operative management have changed over time across Calgary EDs. The secondary objective was to assess correlates of effectiveness and potential drivers in management including gynecological consults, ED return visits requiring admission, and subsequent D&Cs. Sunrise Clinical Manager (electronic medical system) was accessed to collect data for patients who presented to a Calgary ED with an incomplete or missed spontaneous abortion from 2014 to 2019. Patients requiring resuscitation and those with complications were excluded. Return to care for D&C and ED revisits requiring admission were used as a proxy for failed non-operative management. Trends in management are reported using 95% confidence intervals. Of the 3845 patients included, 1110 (28.9%) received a D&C on initial ED visit. The remaining 2735 (71.1%) were initially managed non-operatively. Rates of D&Cs decreased 11.6% from 2014 to 2019, 95% CI (6.5%, 16.8%). There was minimal change in the rates of gynecological consults, ED returns requiring admission, and returns to care resulting in D&Cs over time. The management of incomplete and missed spontaneous abortions has shifted toward non-operative management over 6years in Calgary. As this is not associated with increased ED returns requiring admission or subsequent D&Cs, the shift appears to be appropriate. As gynecological consults were consistent over time, further knowledge translation around non-operative spontaneous abortion management may be useful for ED physicians.

Exploring the experience of boarded psychiatric patients in adult emergency departments

BackgroundThis study quantifies the frequency of adverse events (AEs) experienced by psychiatric patients while boarded in the emergency department (ED) and describes those events over a broad range of categories.MethodsA retrospective chart review (RCR) of adult psychiatric patients aged 18–55 presenting to one of four Calgary EDs (Foothills Medical Centre (FMC), the Peter Lougheed Centre (PLC), the Rockyview General Hospital (RGH), and South Health Campus (SHC)) who were subsequently admitted to an inpatient psychiatric unit between January 1, 2019 and May 15, 2019 were eligible for review. A test of association was used to determine the odds of an independent variable being associated with an adverse event.ResultsDuring the study time period, 1862 adult patients were admitted from EDs (city wide) to the psychiatry service. Of the 200 charts reviewed, the average boarding time was 23.5 h with an average total ED length of stay of 31 h for all presentations within the sample. Those who experienced an AE while boarded in the ED had a significantly prolonged average boarding time (35 h) compared to those who did not experience one (6.5 h) (p = 0.005).ConclusionsThe length of time a patient is in the emergency department and the length of time a patient is boarded after admission significantly increases the odds that the patient will experience an AE while in the ED. Other significant factors associated with AEs include the type of admission and the hospital the patient was admitted from.

Practice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project

Practice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project. Megg Wylie, Amelia Srajer, Kevin Lonergan, Philippa Brain, Eddy Lang Background: Practice variation in the management of spontaneous abortion exists in the Emergency Department (ED). We developed a multisite retrospective study to assess how the management of spontaneous abortion has changed over 2014-2019 across four Calgary EDs, with emphasis on assessing variation and trends between non-operative (medical/expectant) and operative (dilatation and curettage) management. Medical management has been increasingly indicated as effective, yet a knowledge gap exists regarding its use. Knowledge of that proportion and physician-level practice variation will facilitate educational and audit and feedback style initiatives. Results provide justification and supporting data for said initiatives, which may be extrapolated to elsewhere. Implementation: Two medical students are heading the day to day work of this project, with support from a principal investigator with the Department of Emergency Medicine in Calgary. We also have the support of a data manager and the head of pregnancy loss in the region. This study was implemented as a quality improvement project. Therefore, the Conjoint Health Research Ethics Board at the University of Calgary was consulted to ensure the project qualified as a quality improvement and that our privacy protections were appropriate. With approval from the ethics board, we needed the data to analyze and assess. To do so, we utilized Sunrise Clinical Manager (SCM) to retrospectively collect data. Sunrise Clinical Manager, a system utilized in Calgary EDs to track patient and department information, was accessed to collect administrative data. Sustaining this work will involve the continued efforts of the described team, largely in writing up the results and disseminating them via audit and feedback procedures. Evaluation Methods: Using SCM, data were retrospectively collected for patients coded with International Classification of Disease (ICD-10) codes O03.4 (incomplete spontaneous abortion without complication) or O02.1 (missed abortion) who presented to an ED in Calgary (Foothills Medical Centre, Peter Lougheed Centre, South Calgary Hospital, and Rockyview General Hospital) over 2014-2019. We collected patient and environmental factors to allow for the examination of unintended associations. Hemoglobin, HCG level, CTAS code, PIA (time to MD), and U/S result (to confirm diagnosis) were collected. Variables regarding length of stay, procedures received (D&amp;Cs, or other), and returns to care (within 72 hours, and 7 days) were collected. Return to care for future D&amp;C was considered a proxy for failed non-operative management. Demographic and practice data were collected on ED physicians who saw a minimum of 15 patients from our cohort, to gain understanding of trends in practice. Data were analyzed using Chi-square and Mann-Whitney U tests. Results: Within our cohort, 1110 (28.9%) patients received a D&amp;C. The remaining 2735 (71.1%) patients were managed non-operatively. Variation and trends were present between sites, with rates of D&amp;Cs ranging from 15.8% to 33.5% (p &lt;0.001). The rate of D&amp;Cs decreased from 34.2% in 2014 to 22.6% in 2019 across all sites (p &lt;0.001), and 11.6% absolute and 33.9% relative reduction; yet there was minimal variation over time in rates of ED returns and returns resulting in D&amp;Cs. 78.6% of physicians who saw ≥ 15 patients were female, with female physicians responding to 81.8% of our cohort Advice and Lessons Learned:1) Our first suggested lesson is to have a clear plan regarding deadlines and timelines, but toalso have room for flexibility. At some times the work on this project was slowed to alloweffective collaboration with the obstetrics and gyneocology department, or to allow for therefinement of data management. By setting realistic timelines, team members wereencouraged to progress the work in a timely fashion. However, by having flexibility the teamwas able to adapt to roadblocks along the way. 2) A second lesson would be the importance of meaningful collaboration between departments.Though the setting of the project was within Calgary EDs, the topic and content have clearrelevance to obstetics and gynaecology. By consulting with members of the obstetrics andgynaecology department we were able to clarify our objectives and have a betterunderstanding of local contextual factors that influenced our results.

Transfusions in patients with iron deficiency anemia following release of Choosing Wisely Guidelines.

In 2016, based on recommendations of the American Association of Blood Banks (AABB), Choosing Wisely Canada released transfusion guidelines for patients with Iron Deficiency Anemia. The goal of the present study was to examine the number of transfusions given in Calgary emergency departments (EDs) before and after the release of these guidelines. We analyzed 11,786 anemia encounters from January 2014 to December 2019. A transfusion was considered potentially avoidable if the patient's hemoglobin was > 70g/L and if the patient was hemodynamically stable. We used time-series analyses to examine change in rate of total and potentially avoidable transfusions quarterly over the total and pre and post intervention periods. In total, 1409/11,786 (12.0%) of the encounters received transfusions; 80.0% (1127/1409) were indicated while 19.9% (281/1409) were potentially avoidable. In the pre-intervention period, the rate of potentially avoidable transfusions was 21.5% (133/618) and in the post-intervention period, the rate of potentially avoidable transfusions was 18.7% (148/791). The rate of potentially avoidable transfusions decreased quarterly at a rate of 0.3% which did not reach statistical significance (p = 0.06). Our data suggest that the number of potentially avoidable transfusions has not decreased since the release of Choosing Wisely Canada guidelines and local educational initiatives. This may be due to the fact that there is a pre-existing down trend in the number of transfusions provided.

Rapid prediction of adverse outcomes for acute normotensive pulmonary embolism: derivation of the Calgary Acute Pulmonary Embolism score.

BackgroundAcute pulmonary embolism (PE) has a wide spectrum of outcomes, but the best method to risk-stratify normotensive patients for adverse outcomes remains unclear.MethodsA multicentre retrospective cohort study of acute PE patients admitted from emergency departments in Calgary, Canada, between 2012 and 2017 was used to develop a refined acute PE risk score. The composite primary outcome of in-hospital PE-related death or haemodynamic decompensation. The model was internally validated using bootstrapping and the prognostic value of the derived risk score was compared to the Bova score.ResultsOf 2067 patients with normotensive acute PE, the primary outcome (haemodynamic decompensation or PE-related death) occurred in 32 (1.5%) patients. In simplified Pulmonary Embolism Severity Index high-risk patients (n=1498, 78%), a multivariable model used to predict the primary outcome retained computed tomography (CT) right–left ventricular diameter ratio ≥1.5, systolic blood pressure 90–100 mmHg, central pulmonary artery clot and heart rate ≥100 beats·min−1 with a C-statistic of 0.89 (95% CI 0.82–0.93). Three risk groups were derived using a weighted score (score, prevalence, primary outcome event rate): group 1 (0–3, 73.8%, 0.34%), group 2 (4–6, 17.6%, 5.8%), group 3 (7–9, 8.7%, 12.8%) with a C-statistic 0.85 (95% CI 0.78–0.91). In comparison the prevalence (primary outcome) by Bova risk stages (n=1179) were stage I 49.8% (0.2%); stage II 31.9% (2.7%); and stage III 18.4% (7.8%) with a C-statistic 0.80 (95% CI 0.74–0.86).ConclusionsA simple four-variable risk score using clinical data immediately available after CT diagnosis of acute PE predicts in-hospital adverse outcomes. External validation of the Calgary Acute Pulmonary Embolism score is required.

Commitment to Comfort QI Collaborative: Improving the treatment of children’s pain in Alberta’s emergency departments

Background and Goal: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) led by our team was successful in improving treatment of children's pain across 4 EDs in Calgary, Alberta. We then formed a new QIC among general EDs across the province of Alberta to improve treatment of children's presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years …

Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department.

Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians. Our cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts. Seventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% CI: -19.8% to -11.2%) and 78.9% to 64.4% (absolute difference: -14.5%; 95% CI: -21.9% to -7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged. The combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

IOAT in the ED – Lessons Learned

Emergency Strategic Clinical NetworkTM &#x0D; Quality and Innovation Forum Presentation Proposal&#x0D; Name: xx&#x0D; Position (e.g. patient care manager, professor): Manager&#x0D; Primary Affiliation: (AHS) Other: AHS&#x0D; Project Title: iOAT in the ED – Lessons Learned&#x0D; Hospital: All adult sites in Calgary &#x0D; Location: Calgary&#x0D; Team Members: xx &amp; xx&#x0D; Background&#x0D; Deaths related to opioid poisoning have continued to climb over the last few years. The Injectable Opioid Agonist Treatment program (iOAT) provides injectable hydromorphone to those individuals with moderate to severe opioid use disorder and a history of injection drug use who have been unsuccessful with oral OAT and continue to be at high risk for opioid poisoning. Working with the emergency departments (ED) was identified as a critical step in the initial roll out of iOAT.&#x0D; Implementation &#x0D; The iOAT program began operating in October 2018. The clinic provides prescribed hydromorphone to clients within the program. Additionally, the team is comprised of physicians, nurse practitioners, nurses, social worker, peer support workers and administrative support to provide comprehensive wrap around care to every client that is registered to the program. It was recognized early on that the clients that were being served by iOAT were also high users of the ED and UCCs. Being part of iOAT became a factor that needed to be considered when these clients presented to the ED due to their prescription of hydromorphone. Working with management, medical leadership, and nurse educators, support and education were provided to ensure that iOAT clients were provided with optimal care when in the ED. Ongoing communication has been the primary strategy that has been used.&#x0D; Evaluation Methods &#x0D; The evaluation for this project has been informal and ongoing. The medical team at iOAT has worked with the medical team for the Calgary EDs to develop a detailed treatment plan that is visible on SCM. Telephone and emails have been the primary mode of feedback for both parties, and the plan is adjusted as necessary along the way.&#x0D; Results&#x0D; Improving the knowledge and understanding for all staff involved to understand iOAT and the role of the ED has been demonstrated to be effective when clients stay in the ED and don’t leave against medical advice, which likely occurred before. Additionally, the trust that is built within the iOAT clinic is maintained when the ED is a partner in care and as appropriate, provides them with the dosing that they would normally receive at iOAT.&#x0D; Advice and Lessons Learned &#x0D; 1) Involve the emergency department management in planning or initial implementation&#x0D; 2) Communicate, Communicate, Communicate&#x0D; 3) Use continuous feedback to adjust to find the best strategies to provide patient care

P081: The summer of the e-scooter: a multicenter evaluation of the emergency department impact of rentable motorized scooters in Calgary

Introduction: Calgary's introduction of rentable electronic scooters (e-scooters) in July of 2019 was met with wild popularity, representing the third most popular launch after Tel-Aviv and Paris. The present study aims to characterize the injury burden seen in all Calgary Emergency Departments (EDs) and Urgent Care Centres (UCCs) attributable to e-scooters since their 2019 introduction. Methods: We retrospectively reviewed all electronic medical records of patients presenting to Calgary EDs or UCCs with the term “scooter” in the triage note, where exclusion criteria are considered for non e-scooter injuries (e.g: non-motorized scooters). Trends in scooter injuries will be compared between April - October 2018 (control arm preceding e-scooter introduction) and April - October 2019. Injury incidence, types, patient demographics, and relative risk compared to bicycle-related injuries will be determined. Descriptive statistics will be calculated. Moreover, 33 ED visits were brought in by EMS and provide information about injury types and locations of injuries involving EMS transport. Results: Preliminary data reveals 540 scooter-related visits (3.10% admitted/transferred) between July 8th and September 30th 2019 (mean age of 28, 56.30% male). Conversely, the number of bicycle-related visits and motor vehicle related injuries were 1482 and 586 (9.90% and 9.70% admitted/transferred) respectively over the same time period suggesting a greater burden but likely a lower per-ride incidence of injury requiring ED or UCC care. Moreover, between July 8th to October 1st 2019, 33 e-scooter presentations involved EMS (21.21% admitted to hospital), where 12.12% involved upper extremity injury, 21.21% were lower extremity injuries, and 6.06% were head injuries (mean age of 34, 48.48% male). Conversely, estimated EMS transfers to EDs or UCCs for bicycle injuries and motor vehicle injuries were 197 and 463 respectively over the same time period. ICU admissions or fatality were not recorded. Conclusion: Representing the most comprehensive study of e-scooter injury patterns in Canada to date, we here demonstrate a significant injury burden attributable to e-scooters following their introduction in Calgary in 2019. Bicycle-related and motor vehicle injuries were both more prevalent in this time period, and required more EMS visits. Further characterization of injury types, injuries and comparison with injury patterns prior to e-scooter introduction is yet to be determined.

MP59: Exploring adverse events in boarded psychiatric patients in Calgary zone adult emergency departments

Introduction: Adult Emergency Departments (EDs) in Calgary are facing a crisis of boarded patients admitted to psychiatric in-patient units. In psychiatric emergency care, “boarding” describes the holding of patients in the ED after the decision to admit has been made by a staff psychiatrist and a bed request has been submitted. Literature review suggests psychiatric patients face exorbitantly higher boarding times than any other service in the hospital however little is published on the nature of these adverse events. Examples of adverse patient events from a psychiatric perspective could include: the need to initiate mechanical and/or chemical restraints after admission and while still in the ED, attempts to self-harm, and verbal and physical assault on ED staff. Methods: This study quantifies the incidence of adverse events experienced by psychiatric patients while boarded in the ED. It uses a retrospective chart review of all adult psychiatric patients, age 18 - 55yo, who presented to one of four adult EDs and who were admitted to a psychiatric in-patient unit in the Calgary Zone between January 1, 2019 and May 15, 2019. A randomly generated convenience sample identified 200 patients, 50 from each site, for in-depth review. Results: During the study time period, 1862 adult patients were admitted from emergency departments to the psychiatry service across all four sites. Of the 200 charts reviewed, patients ranged in age from 26-41 (average 34). 52.5% were male with the majority being admitted to a non-high observation bed. The average boarding time was 23.5 hours with an average total ED length of stay of 31 hours for all comers. Those who experienced an adverse event while boarded in the ED experienced a significantly prolonged average boarding time (35 hours) compared to those who did not experience an adverse event (6.5 hours) (p = 0.005). Significant adverse events were associated with the specific hospital site and the type of admission bed needed (high observation versus normal versus short stay) (p &lt; 0.05). Conclusion: Psychiatric patients boarded in Calgary EDs experience a number of significant adverse events. The importance of understanding the reality of the conditions that psychiatric ED patients face while waiting for in-patient placement cannot be overstated. This study is important to emergency medicine as it will allow for deeper understanding of the patient experience while in the ED and identifies areas that may require further advocacy amongst ED staff and our psychiatry colleagues.

MP38: Are we missing pulmonary embolism in acute exacerbations of chronic obstructive pulmonary disease presenting to the emergency department? Multicenter insights into incidence of concomitant disease and yield of testing

Introduction: Patients with Chronic Obstructive Pulmonary Disease (COPD) often present to the ED with acute exacerbations (AE-COPD) of the disease. A potential occult yet fatal disease that might contribute or accompany an AE-COPD presentation is a pulmonary embolism (PE). Previous studies have investigated and report rates of PE in up to 29% of patients presenting with AE-COPD. Misdiagnoses of PE leads to poor outcomes, however, over-testing for PE also presents with substantial risks to the patient and strain on acute care resources. The goal of this study was to pragmatically identify the prevalence and 30-day incidence of PE in patients presenting with AE-COPD to EDs, as well as the burden and yield of PE investigations. Methods: We conducted a retrospective analysis of extracted data for patients □50 years old presenting to one of four emergency departments in Calgary with an AE-COPD since 2013. Patients with a history of outpatient anticoagulation therapy from a community pharmacy were excluded. Each patient chart was reviewed to identify a diagnosis of PE during the admission for an AE-COPD, or 30 days post discharge from an AE-COPD admission or ED presentation. An AE-COPD diagnosis was defined as a primary. Results: A total of 9554 AE-COPD ED patient visits were included in the study. 0.69% (95%CI 0.54 to 0.88) were identified to have a PE. 26 of the 66 (39.4%) were diagnosed during an AE-COPD inpatient admission, while 43 (65.2%) were diagnosed within 30 days post-discharge from an AE-COPD admission or ED presentation. Since 2016, 7.4% of AE-COPD patients underwent a CT-PE, while 16.7% underwent a d-dimer. The most common chief complaint in PE patients was dyspnea (75.8%). The mean age of the PE diagnosed was 73.4, with nearly equal representation of both sexes. Many patients had underlying comorbidities, such as hypertension, diabetes, and cancer of various sites, all of which are risk factors for developing a PE. Conclusion: The prevalence and 30-day incidence of PE in AE-COPD patients appears to be lower than what was previously reported in the literature. Despite this, a significant proportion of AE-COPD patients were exposed to the risks and burden of a PE work up, with low diagnostic yield. PE investigations in AE-COPD should be used selectively and could inform a quality improvement indicator. A future prospective study would drastically contribute to whether a PE clinical work up should be recommended and of value to patients.

LO29: Unexplained variation in ‘to-go’ opioid prescribing across emergency departments in a large Canadian cohort

Introduction: Emergency Department (ED) opioid prescribing has been linked to long-term use and dependence. Small packets of opioid medications are sometimes prescribed at discharge, i.e. ‘To-Go’, in an attempt to treat pain but avoid unintended consequences. The extent of this practice and its associated risks are not fully understood. This study's objective was to describe the use of ‘To-Go’ opioids in a large urban center. Methods: Multicenter linked administrative databases were used to recruit an observational cohort. The referral population was comprised of all patients discharged from a Calgary ED in 2016 (four hospitals) with an arrival pain score greater than 0. We first described this population and then performed a multivariable analysis to assess for predictors of ‘To-Go’ opioids. ‘To-Go’ opioids were either Tylenol-Codeine or Tylenol-Oxycodone. Results: A total of 88,855 patients were recruited. The majority were female (57%) and the average age was 44.5 yrs. Abdominal pain was the most frequent complaint (22.1%) followed by extremity (18.3%) and cardiac pain (8.0%). Overall, 2,736 patients (3.1%) received an opioid ‘To-Go’ with significant variation in prescribing rates across hospitals (1.8-5% Chi2 p &amp;lt; 0.05). Logistic regression (covariates: age, sex, CTAS, pain score, type of pain, hospital, ED opioid, length of stay) revealed that receiving an opioid (IV or PO) prior to discharge was the strongest predictor of ‘To-Go’ opioid (OR 6.4 [5.9-7.0]). Hospital (OR 1.4 [1.3-1.4]) and male sex (OR 1.2 [1.1-1.3]) also emerged as predictors, whereas age over 65 decreased the odds of ‘To-Go’ opioid (OR 0.8 [0.6-0.9]). Hospital-specific ORs ranged from 1.3-2.7. Conclusion: In comparable patient populations some hospitals are more likely than others to provide a short course of opioids at discharge. This difference is not explained by patient demographics, pain profiles, or medications prior to discharge. The reasons for this variation are unclear but it underscores the need to determine the risks of ED opioid exposures and develop clear evidence-based prescribing guidelines.

P068: Significance of asymptomatic oxygen desaturation in elderly ED patients: A pilot study

Introduction: Pulse oximetry is a standard component of Emergency Department (ED) patient monitoring. Pulse oximetry measures peripheral capillary oxygen saturation (SpO2) levels and can be used to monitor cardiorespiratory conditions. The normal SpO2 level for adults is approximately 96%. Oxygen saturations of &amp;lt;92% are considered problematic and levels &amp;lt;90% may indicate cardiorespiratory disease. However, low oxygen saturations are often seen in elderly patients with comorbidities. This research investigated the significance of hypoxia in asymptomatic older ED patients with no apparent acute illness. Methods: ED patients &amp;gt;75 years with a documented room air pulse oximetry reading &amp;lt;92% were eligible. Exclusion criteria included dyspnea, chest pain, SBP &amp;lt;100mmHg, HR &amp;gt;120 or &amp;lt;50; sustained tachypnea (RR &amp;gt; 20); acute cardiopulmonary conditions, delirium or acutely altered mentation. Eligible patients were separated into two groups: 1) Sustained hypoxia: two or more SpO2 readings &amp;lt;92% 2) Unsustained hypoxia: one SpO2 reading &amp;lt;92%. 30-day adverse events were tracked using a Sunrise Emergency Care record review. Adverse outcomes investigated included death, MI, CHF, PE, cardioversion, ICU admission, intubation, ED revisit or re-hospitalization. Patient characteristics studied were age, sex, arrival mode, triage complaint, CTAS level, pulse, BP, RR, weight, residence (independent, assisted living, facility), comorbidities, PHN, referral, disposition, and test results (CXR, troponin, ECG, CT). Follow-up phone calls were completed after 30 days to assess patient status and confirm ED revisit. Results: A total of 876 ED patients &amp;gt;75 years were screened and 30-day follow-up data was analyzed for 34 enrolled patients. The sustained hypoxia group (n = 23) showed higher rates of 30-day adverse outcomes of death, ED re-visitation, MI, CHF, a severe episode of COPD, PE and ICU stays compared to the unsustained hypoxia group (n = 11). Administrative data of 31,095 patients &amp;gt;75 years from four Calgary EDs in 2017 was also analyzed and 7,771 (20%) were hypoxic at triage (SpO2 &amp;lt;92%). Adverse outcomes and mortality were significant in discharged hypoxic patients (especially if SpO2 &amp;lt;90%). Conclusion: ED re-visits, cardiorespiratory complications, and mortality were significant in discharged sustained hypoxic patients, especially if O2 sat &amp;lt;90%. Pulse oximetry assessment of oxygen saturation in seniors’ care facilities and physicians’ offices may be important in screening for future adverse health outcomes in elderly patients.

LO16: Predictors of appropriate hospitalization in elderly patients

Introduction: Admission decisions in older patients are often difficult. Our objectives were to identify clinical predictors of appropriate admission for older patients who attend the emergency department (ED). Methods: Administrative data were gathered on all Calgary ED patients &amp;gt;75 years old who were treated during 2017. We considered the following events indicative of appropriate admission: an index hospitalization lasting &amp;gt;72 hours, the need for ICU or CCU care, and 30-day death or readmission. Multivariable logistic regression was used to determine the association of the following potential predictors with appropriate admission: age, sex, EMS arrival, ILI symptoms, living situation (independent, homecare dependency or facility), acuity level, chief complaint, vital signs, need for IV fluid bolus ( &amp;gt;1Li), serum sodium, potassium, creatinine, hemoglobin, and advanced directive care level (comfort, medical, resuscitation, unspecified). Results: We studied 38866 older patients who were 55.9% female with a mean age of 84. Most (69%) lived independently, with 17% in a facility and 14% homecare dependent. Overall, 16,992 (43.7%) were admitted at their index visit and 17,340 had an outcome event, including index hospitalization &amp;gt;72 hours (N = 13,623, 35%), ICU care (352, 0.9%), CCU care (447, 1.2%), or 30-day death (2,241, 5.8%) or readmission (3,964 10.2%). Patients with appropriate admission events were more likely to have an advanced directive (80.7% v. 7.8%), triage hypoxia (30.5% v. 9.2%), EMS arrival (73% v. 48%), facility or homecare dependency (50% v. 15%), or to have a complaint of dyspnea (20.4% v. 8.6%), weakness (9.1% v. 3.8%) or altered mentation (8.8% v. 2.8%). Multivariable modeling showed that the strongest predictors of appropriate admission (adjusted odds ratio) were any advanced directive (OR = 30), need for IV bolus (OR = 1.67), homecare dependency (OR = 1.65), triage hypoxia (OR = 1.63), and a chief complaint of altered mentation (OR = 1.72), weakness (OR = 1.52) or dyspnea (OR = 1.25). Conclusion: The presence of an advanced care directive is strongly associated with appropriate admission in older ED patients. Other significant determinants include homecare dependency, EMS arrival, hypoxia or dyspnea, IV bolus and weakness or altered mentation. Age, sex, acuity, vital signs and laboratory findings were weak predictors.

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients.

ObjectivesThe Choosing Wisely Canada (CWC) Emergency Medicine group recommends avoidance of lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. The objective of this study was to evaluate imaging practices of emergency physicians (EPs) in four Calgary emergency departments (EDs) and identify patient, physician, and environmental factors associated with over-ordering of radiographs for low-risk LBP patients.MethodsData was retrospectively collected from patients, ages 18–50 and Canadian Triage and Acuity Scale (CTAS) codes 2–5, who presented with non-traumatic LBP to Calgary EDs from April 1, 2014 to March 31, 2016. Patients considered high risk, specifically with partial thromboplastin time (PTT) > 40 seconds or international normalized ratio (INR) > 1.2 seconds, any consult, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish the overall usage of lumbosacral radiographs. The secondary outcome was to identify factors that influenced lumbosacral spine imaging.ResultsData from 2128 low-risk patients showed that 14.8% of the patients received lumbosacral radiographs. Variation among 132 physicians in X-ray ordering ranged from 0% to 90.9%. There were site-specific differences in ordering patterns [Rockyview General Hospital (RGH) = 21.6% > South Health Campus (SHC) = 15.6% > Peter Lougheed Centre (PLC) = 13.1% > Foothills Medical Centre (FMC) = 9.7%, p < 0.001]. Canadian College of Family Physicians-Emergency Medicine (CCFP-EM) licensed physicians ordered more X-rays compared to Fellow of the Royal College of Physicians of Canada (FRCPC) licensed physicians (16.6% vs. 11.1%, p < 0.001). Older physicians and physicians with more experience ordered more X-rays than their younger and less experienced colleagues.ConclusionConsiderable variation exists in the ordering practices of Calgary EPs. Overall, EPs seem to be choosing wisely in terms of ordering plain radiographs for non-traumatic LBP.

LO88: Bronchiolitis management in Calgary emergency departments

Introduction: Bronchiolitis is a viral respiratory infection and the most common reason for hospitalization of infants. Despite evidence that few interventions are beneficial in patients with bronchiolitis, other studies would have shown that a significant proportion of patients undergo various forms of low value care. This objective of this project was to 1. establish baseline management of bronchiolitis in the Calgary Zone, and 2. deliver audit and feedback (A&amp;F) reports to pediatric emergency physicians (PEP) to identify opportunities and strategies for practice improvement. Methods: This retrospective cohort study included all patients 12 months old that presented to a Calgary emergency department or urgent care center with a diagnosis of bronchiolitis from April 1, 2013 to March 31, 2017. Using data from various electronic health data sources, we captured age, vital signs, CTAS, common therapeutic interventions (bronchodilators, steroids, antibiotics) and investigations (chest x-ray (CXR), viral studies, antibiotics). Results were stratified by site and by admission status. Descriptive statistics were used to report baseline characteristics and interventions. Interhospital ranges (IHR) were provided to compare different hospitals in the zone. For the A&amp;F component of the project, consenting PEP received a report of both their individual and peer comparator data and an in-person multi-disciplinary facilitated feedback session. Results: We included 4023 patients from all 6 sites (range from 28 to 3316 patients). Admission rates were 21.7% (IHR 0-29%). Mean age was 5.4 months old. Bronchodilator use was 27.0% (IHR 21-41%). 22.0% of patients received a CXR (IHR 0-57%) and 30.3% had viral studies done (IHR range 0.8-33%). PEP had higher usage of viral studies (30% vs 5.7%), whereas non-PEP had higher CXR usage (46.2% vs 23.4%). 41 of 66 PEP consented to receive their individual A&amp;F reports (62%). In the facilitated feedback session PEP 1. identified two areas (bronchodilators and viral studies) where improvements could be made and 2. discussed specific strategies to decrease practice variation and minimize low value care including development of a multi-disciplinary care pathway, alignment with in-patient management, education and repeated A&amp;F reports. Conclusion: Significant variability exists in management of patients with bronchiolitis across different hospitals in our zone. A facilitated feedback session identified areas for improvement and multi-disciplinary strategies to reduced low value care for patients with bronchiolitis. Future phases of this project include repeated data in 6 months and implementation of a provincial care pathway for the management of bronchiolitis.

P065: Development and implementation of a postpartum hypertension recognition and management protocol for use in the emergency department

Introduction: Hypertensive disorders of pregnancy (HDP), including preeclampsia, can develop or worsen in the early postpartum period, often following discharge from hospital, resulting in severe preventable maternal morbidity and mortality. Due to a lack of routine early out-patient follow-up, many women with postpartum HDP present to the emergency department (ED) with severe hypertension or symptoms of preeclampsia (e.g., headache). In the ED, postpartum HDP can be difficult for clinicians to recognize (due to vague presenting symptom) and manage (due to lower blood pressure targets and concern of medication safety). ED clinicians recognized a need for timely recognition and effective treatments for postpartum HDP in the ED to improve maternal outcomes. As such, as part of a multi-step quality improvement initiative, an interdisciplinary team developed and implemented a postpartum HDP management protocol (consisting of nursing and physician protocols and an electronic order set embedded in the electronic medical record). The aims of this specific project were to assess: 1) the use of this clinical management protocol in the ED; and 2) its impacts on clinical care. Methods: This quality improvement project used electronic medical records to identify: 1) ED visits for postpartum HDP for postpartum women ages 20-50; 2) utilization of the postpartum HDP order set; and 3) clinical care outcomes (consultation and admission). Patient population characteristics and clinical care measures were summarized with descriptive statistics and compared using a before and after design. Changes in the utilization of the protocol were assessed using run charts. Results: 540 women with postpartum HDP were seen in the four Calgary EDs in the 16-month period following protocol implementation compared with 335 women in the preceding 12 months. The protocol was used in 46% of these 540 women, and increased over the 16 month follow-up period. We found an increase in the frequency of consultation of specialists (47% to 52%) and admissions (26% to 29%) amongst these women after protocol implementation. Conclusion: This initial assessment demonstrated good uptake of a postpartum HDP management protocol including referral for consultation and admission to hospital for blood pressure management. Future steps include evaluation of the impacts of this management protocol on important patient outcomes.