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P102
A quality improvement project: identifying and managing latent
safety threats though a zone wide emergency department in-situ
multidiscipline simulation program
L. Mews, MD, D. O’Dochartaigh, MSc, M. Chan, MD, T. Brown, MD,
A. Robb, MD, W. Ma, MD, MBA, University of Alberta, Edmonton, AB
Introduction: High fidelity in-situ simulation has been found to detect
system deficiencies, equipment failures, and conditions predisposing to
medical errors, also known as latent safety threats (LST). What is not
well reported is whether these LSTs are effectively managed. As a part
of an ongoing quality improvement project, multidisciplinary, in-situ
simulations were conducted across emergency departments (ED) in the
Edmonton zone with the aim to identify LST and subsequently manage
them to improve patient care. Methods: In 2017 simulations were
conducted at EDs in the Edmonton Zone (N =10). Following each
simulation, a cross sectional, survey based assessment tool, was com-
pleted by participants to identify LST. These LST were shared with the
site clinical nurse educator and/or site manager and a management plan
made. Two to six months follow-up was made to track progress. For
reporting, LST were grouped into themes, progress on LST were coded
as either resolved, ongoing, or not managed. Results: A total of 112
LST were identified through 18 separate simulations. The most com-
monly identified LTS were: resuscitation resource required (n 23), lack
of staff training (21), equipment not immediately available (20), IT
resource required (8), medication not immediately available (6), staff
requiring familiarization (5), medication resource required (5), IT issue
(4), large equipment needed (4), small equipment needed (4), lack of
staff resource (3), medication needed, (3), equipment malfunction (2),
Environment cluttered (2), non-appropriate resource removed (2). Site
follow-up identified a total of 52 LST that where resolved, and 60 LST
that had ongoing work to manage them. No occurrences of LST not
being managed were identified. Conclusion: Simulation was used to
effectively identify LST. Creating a structured plan and follow up
allowed many LST to be resolved and effectively managed. In 2018
simulation will reassess if LST remain.
Keywords: quality improvement and patient safety, simulation, latent
threats
P103
Performance characteristics of the modified Sgarbossa criteria for
diagnosis of acute coronary occlusion in emergency department
patients with ventricular paced rhythm and symptoms of acute
coronary syndrome
G. J. Mitchell, MB, BAO, K. Dodd, MD, D. L. Zvosec, PhD, E. Chen,
MD, M. A. Hart, MD, J. Marshall, MD, A. A. Smith, MD, J. Suna, L.
Cullen, MBBS (Hons) PhD, S. W. Smith, MD, University of Calgary,
Calgary, AB
Introduction: The ECG diagnosis of acute coronary occlusion (ACO)
in the setting of ventricular paced rhythm (VPR) is purported to be
impossible. However, VPR has a similar ECG morphology to LBBB.
The validated Smith-modified Sgarbossa criteria (MSC) have high
sensitivity (Sens) and specificity (Spec) for ACO in LBBB. MSC
consist of 1 of the following in 1 lead: concordant ST Elevation (STE) 1
mm, concordant ST depression 1 mm in V1-V3, or ST/S ratio <−0.25
(in leads with 1 mm STE). We hypothesized that the MSC will have
higher Sens for diagnosis of ACO in VPR when compared to the ori-
ginal Sgarbossa criteria. We report preliminary findings of the Paced
Electrocardiogram Requiring Fast Emergency Coronary Therapy
(PERFECT) study Methods: The PERFECT study is a retrospective,
multicenter, international investigation of ED patients from 1/2008 - 12/
2016 with VPR on the ECG and symptoms suggestive of acute coronary
syndrome (e.g. chest pain or shortness of breath). Data from four sites
are presented. Acute myocardial infarction (AMI) was defined by the
Third Universal Definition of AMI. A blinded cardiologist adjudicated
ACO, defined as thrombolysis in myocardial infarction score 0 or 1 on
coronary angiography; a pre-defined subgroup of ACO patients with
peak cardiac troponin (cTn) >100 times the 99% upper reference limit
(URL) of the cTn assay was also analyzed. Another blinded physician
measured all ECGs. Statistics were by Mann Whitney U, Chi-square,
and McNemars test. Results: The ACO and No-AMI groups consisted of
15 and 79 encounters, respectively. For the ACO and No-AMI groups,
median age was 78 [IQR 72-82] vs. 70 [61-75] and 13 (86%) vs. 48 (61%)
patients were male. The median peak cTn ratio (cTn/URL) was 260 [33-
663] and 0.5 [0-1.3] for ACO vs. no-AMI. The Sens and Spec for the
MSC and the original Sgarbossa criteria were 67% (95% CI 39-87) vs.
46% (22-72; p =0.25) and 99% (92-100) vs. 99% (92-100; p =0.5). In
pre-defined subgroup analysis of ACO patients with peak cTn >100 times
the URL (n =10), the Sens was 90% (54-100) for the MSC vs. 60%
(27- 86) for original Sgarbossa criteria (p=0.25). Conclusion: ACO in
VPR is an uncommon condition. The MSC showed good Sens for
diagnosis of ACO in the presence of VPR, especially among patients with
high peak cTn, and Spec was excellent. These methods and results are
consistent with studies that have used the MSC to diagnose ACO in LBBB.
Keywords: Sgarbossa’s criteria, acute coronary occlusion, ventricular
paced rhythm
P104
Evaluating the use of the pulmonary embolism rule-out criteria in
the emergency department
S. Sharif, MD, C. Kearon, MB PhD, M. Eventov, BSc, M. Li, MD,
P. Sneath, BSc, R. Jiang, R. Leung, K. de Wit, MBChB, MSc, MD,
Department of Medicine, Division of Emergency Medicine, McMaster
University, Hamilton, ON
Introduction: Diagnosing pulmonary embolism (PE) can be challen-
ging because the signs and symptoms are often non-specific. Studies
have shown that evidence-based algorithms are not always adhered to in
the Emergency Department (ED), which leads to unnecessary CT
scanning. The pulmonary embolism rule-out criteria (PERC) can iden-
tify patients who can be safely discharged from the ED without further
investigation for PE. The purpose of this study is to evaluate the use of
the PERC rule in the ED and to compare the rates of testing for PE if the
PERC rule was used. Methods: This was a health records review of ED
patients investigated for PE at two emergency departments over a two-
year period (April 2013-March 2015). Inclusion criteria were ED phy-
sician ordered CT pulmonary angiogram, ventilation-perfusion scan, or
D-dimer for investigation of PE. Patients under the age of 18 were
excluded. PE was considered to be present during the emergency
department visit if PE was diagnosed on CT or VQ (subsegmental level
or above), or if the patient was subsequently found to have PE or deep
vein thrombosis during the next 30 days. Trained researchers extracted
anonymized data. The rate of CT/VQ imaging and the negative pre-
dictive value was calculated. Results: There were 1,163 patients that
were tested for PE and 1,097 patients were eligible for our analysis. Of
the total, 330/1,097 (30.1%; 95% CI 27.4-32.3%) had CT/VQ imaging
for PE, and 48/1,097 (4.4%; 95% CI 3.3-5.8%) patients were diagnosed
with PE. 806/1,097 (73.5%; 95% CI 70.8-76.0%) were PERC positive,
and of these, 44 patients had a PE (5.5%; 95% CI 4.1-7.3%).
Conversely, 291/1,097 (26.5%; 95% CI 24.0-29.2%) patients
were PERC negative, and of these, 4 patients had a PE (1.4%; 95%
2018 Scientific Abstracts
CJEM JCMU 2018;20 Suppl 1 S93
https://doi.org/10.1017/cem.2018.301
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