Trends in emergency department visits during cold weather seasons among patients experiencing homelessness in Ontario, Canada: a retrospective population-based cohort study.

PURPOSE: Recent anecdotal reports suggest increasing numbers of people experiencing homelessness are visiting emergency departments (EDs) during cold weather seasons due to inadequate shelter availability. We examined monthly ED visits among patients experiencing homelessness to determine whether there has been a significant increase in such visits in 2022/2023 compared to prior years. METHODS: We used linked health administrative data to identify cohorts experiencing homelessness in Ontario between October and March of the 2018/2019 to 2022/2023 years. We analyzed the monthly rate of non-urgent ED visits as a proxy measure of visits plausibly attributable to avoidance of cold exposure, examining rates among patients experiencing homelessness compared to housed patients. We excluded visits for overdose or COVID-19. We assessed level and significance of change in the 2022/2023 year as compared to previous cold weather seasons using Poisson regression. RESULTS: We identified a total of 21,588 non-urgent ED visits across the observation period among patients experiencing homelessness in Ontario. Non-urgent ED visits increased 27% (RR 1.24 [95% CI 1.14-1.34]) in 2022/2023 compared to previous cold weather seasons. In Toronto, such visits increased by 70% (RR 1.68 [95% CI 1.57-1.80]). Among housed patients, non-urgent ED visits did not change significantly during this time period. CONCLUSION: Rates of ED visits plausibly attributable to avoidance of cold exposure by individuals experiencing homelessness increased significantly in Ontario in 2022/2023, most notably in Toronto. This increase in ED visits may be related to inadequate access to emergency shelter beds and warming services in the community.

RéSUMé: OBJECTIFS: Des rapports anecdotiques récents suggèrent qu'un nombre croissant de personnes en situation d'itinérance visitent les services d'urgence (SU) pendant les saisons froides en raison de la disponibilité insuffisante d'hébergement d'urgence. Nous avons examiné les visites mensuelles aux urgences chez les personnes en situation d'itinérance afin de déterminer s'il y a eu une augmentation significative de ces visites en 2022-2023 par rapport aux années précédentes. MéTHODES: Nous avons utilisé des données administratives de santé liées pour identifier les cohortes de personnes en situation d'itinérance en Ontario entre octobre et mars des années 2018/2019 à 2022/2023. Nous avons analysé le taux mensuel de visites aux urgences non urgentes comme mesure approximative des visites vraisemblablement attribuables à l'évitement de l'exposition au froid, en examinant les taux chez les personnes en situation d'itinérance par rapport aux patients logés. Nous avons exclu les visites pour surdose ou COVID-19. Nous avons évalué le niveau et l'importance du changement dans l'année 2022/2023 par rapport aux saisons froides précédentes en utilisant la régression de Poisson. RéSULTATS: Nous avons recensé un total de 21 588 visites non urgentes aux urgences au cours de la période d'observation chez des personnes en situation d'itinérance en Ontario. Les visites aux urgences non urgentes ont augmenté de 27 % (RR 1,24 [IC à 95 % 1,14-1,34]) en 2022­2023 par rapport aux saisons froides précédentes. À Toronto, ces visites ont augmenté de 70 % (RR 1,68 [IC à 95 % 1,57-1,80]). Parmi les patients logés, les visites aux urgences non urgentes n'ont pas changé de façon significative pendant cette période. CONCLUSIONS: Les taux de visites aux urgences attribuables vraisemblablement à l'évitement de l'exposition au froid par les personnes en situation d'itinérance ont augmenté considérablement en Ontario en 2022­2023, surtout à Toronto. Cette augmentation du nombre de visites aux urgences peut être liée à un accès inadéquat aux lits des refuges d'urgence et aux services de réchauffement dans la collectivité.

Cold-related injuries among patients experiencing homelessness in Toronto: a descriptive analysis of emergency department visits.

PURPOSE: Homelessness increases the risk of cold-related injuries. We examined emergency department visits for cold-related injuries in Toronto over a 4-year period, comparing visits for patients identified as homeless to visits for patients not identified as homeless. METHODS: This descriptive analysis of visits to emergency departments in Toronto between July 2018 and June 2022 used linked health administrative data. We measured emergency department visits with cold-related injury diagnoses among patients experiencing homelessness and those not identified as homeless. Rates were expressed as a number of visits for cold-related injury per 100,000 visits overall. Rate ratios were used to compare rates between homeless vs. not homeless groups. RESULTS: We identified 333 visits for cold-related injuries among patients experiencing homelessness and 1126 visits among non-homeless patients. In each of the 4 years of observation, rate ratios ranged between 13.6 and 17.6 for cold-related injuries overall, 13.7 and 17.8 for hypothermia, and 10.3 and 18.3 for frostbite. Rates per 100,000 visits in the fourth year (July 2021 to June 2022) were significantly higher than in the pre-pandemic period. Male patients had higher rates, regardless of homelessness status; female patients experiencing homelessness had higher rate ratios than male patients experiencing homelessness. CONCLUSION: Patients experiencing homelessness visiting the emergency department are much more likely to be seen for cold-related injuries than non-homeless patients. Additional efforts are needed to prevent cold-related exposure and consequent injury among people experiencing homelessness.

RéSUMé: OBJECTIF: L'itinérance augmente le risque de blessures liées au froid. Nous avons examiné les visites aux urgences pour des blessures liées au froid à Toronto sur une période de quatre ans, en comparant les visites de patients en situation d'itinérance aux visites de patients pas en situation d'itinérance. MéTHODES: Cette analyse descriptive des visites aux services d'urgence à Toronto entre juillet 2018 et juin 2022 a utilisé des données administratives de santé liées. Nous avons mesuré les visites aux services d'urgence avec un diagnostic de blessure liée au froid parmi les patients en situation d'itinérance et ceux pas en situation d'itinérance. Les taux ont été exprimés en nombre de visites pour les blessures liées au froid par 100 000 visites au total. Le rapport de taux ont été utilisés pour comparer les taux entre les groupes en situation d'itinérance et ceux pas en situation d'itinérance. RéSULTATS: Nous avons identifié 333 visites pour des blessures liées au froid chez les patients en situation d'itinérance et 1126 chez les patients pas en situation d'itinérance. Au cours de chacune des quatre années d'observation, les rapports de taux variaient entre 13,6 et 17,6 pour l'ensemble des blessures liées au froid, 13,7 et 17,8 pour l'hypothermie et 10,3 et 18,3 pour les engelures. Les taux par 100 000 visites au cours de la quatrième année (de juillet 2021 à juin 2022) étaient considérablement plus élevés que pendant la période précédant la pandémie. Les patients de sexe masculin affichaient des taux plus élevés, peu importe leur statut d'itinérance; les patients de sexe féminin en situation d'itinérance affichaient des rapports de taux plus élevés que les patients de sexe masculin en situation d'itinérance. CONCLUSION: Les patients en situation d'itinérance qui se rendent à l'urgence sont beaucoup plus susceptibles d'être vus pour des blessures liées au froid que les autres. Des efforts supplémentaires sont nécessaires pour prévenir l'exposition au froid et les blessures qui en découlent chez les personnes en situation d'itinérance.

Trends in the role of security services in the delivery of emergency department care.

BACKGROUND: Security services in most settings are an essential part of emergency department (ED) care, but their role remains poorly understood. We sought to:(1) identify the frequency of security services involvement in ED care;(2) characterise the events security services are called for; and (3) identify temporal trends in use. METHODS: We used a hospital-wide security database at a tertiary care ED in downtown Toronto, Ontario. Data from January 2017 to June 2021 related to the ED, patient or visitor related safety calls were included. We categorised calls by type of event (e.g.: Code White or Restraints). Call numbers were calculated as rates to adjust for visit volumes for each period. Univariate analyses were used to assess association between security services' calls and shift time, day of week, and month of the year. RESULTS: Over the 4.5-year study period, 20,033 ED-related calls were recorded. On average, we identified 61 calls per 1000 patient visits. On univariate analysis, no increase in security calls were found based on day of week or month, but a disproportionate number of security calls were recorded overnight. CONCLUSION: This study reveals high security services involvement in the delivery of care in one urban ED. Security databases can inform improvement work and could be augmented by better coding of violent events and linkage with electronic health records when involving patients.

RéSUMé : CONTEXTE: Dans la plupart des contextes, les services de sécurité constituent un élément essentiel des soins dispensés dans les services d'urgence, mais leur rôle reste mal compris. Nous avons cherché à: (1) identifier la fréquence de l'intervention des services de sécurité dans les soins aux urgences; (2) caractériser les événements pour lesquels les services de sécurité sont requis; et (3) identifier les tendances temporelles de l'utilisation. MéTHODES: Nous avons utilisé une base de données de sécurité à l'échelle de l'hôpital dans un service d'urgence de soins tertiaires du centre-ville de Toronto, en Ontario. Les données de janvier 2017 à juin 2021 relatives aux appels de sécurité liés aux urgences, aux patients ou aux visiteurs ont été incluses. Nous avons catégorisé les appels par type d'événement (par exemple : Code blanc ou Contraintes). Les nombres d'appels ont été calculés sous forme de taux afin d'ajuster les volumes de visites pour chaque période. Des analyses univariées ont été utilisées pour évaluer l'association entre les appels des services de sécurité et l'heure du quart de travail, le jour de la semaine et le mois de l'année. RéSULTATS: Au cours des 4,5 années de l'étude, 20 033 appels liés aux urgences ont été enregistrés. En moyenne, nous avons recensé 61 appels pour 1 000 visites de patients. L'analyse univariée n'a révélé aucune augmentation des appels de sécurité en fonction du jour de la semaine ou du mois, mais un nombre disproportionné d'appels de sécurité a été enregistré pendant la nuit. CONCLUSION: Cette étude révèle une forte implication des services de sécurité dans la prestation des soins dans un service d'urgence urbain. Les bases de données sur la sécurité peuvent servir de base aux travaux d'amélioration et pourraient être complétées par un meilleur codage des événements violents et une liaison avec les dossiers médicaux électroniques lorsqu'ils concernent des patients.

Repeat assault injuries: A scoping review of the incidence and associated risk factors.

OBJECTIVE: Individuals who experience assault are at high risk of being re-assaulted. Our objective was to identify reported incidences of re-assault and associated risk factors to better inform prevention strategies. METHODS: We conducted a scoping review and searched databases (MEDLINE, PsychINFO, CINAHL, Cochrane Reviews, and Scopus) and grey literature. We performed abstract and full-text screening, and abstracted incidence of re-assault and information related to age, sex, socioeconomic status, mental illness, and incarceration. RESULTS: We included 32 articles. Studies varied based on setting where index assaults were captured (n=18 inpatient only, n=13 emergency department or inpatient, n=1 other). Reported incidences ranged from 0.8% over one month to 62% through the lifetime. Important risk factors identified include young age, low socioeconomic status, racialized groups, history of mental illness or substance use disorder, and history of incarceration. CONCLUSIONS: Rates of re-assault are high and early intervention is necessary for prevention. We identified notable risk factors that require further in-depth analysis, including sex, gender and age-stratified analyses. POLICY IMPLICATIONS: Key risk factors identified should inform timely and targeted intervention strategies for prevention.

Factors associated with experiencing reassault in Ontario, Canada: a population-based analysis.

BACKGROUND: Individuals who experience a violence-related injury are at high risk for subsequent assault. The extent to which characteristics of initial assault are associated with the risk and intensity of reassaults is not well described yet essential for planning preventive interventions. We sought to describe the incidence of reassault and associated risk factors in Ontario, Canada. METHODS: In this population-based retrospective cohort study using linked health and demographic administrative databases, we included all individuals discharged from an emergency department or hospitalised with a physical assault between 1 April 2005 and 30 November 2016 and followed them until 31 December 2016 for reassault. A sex-stratified Andersen-Gill recurrent events analysis modelled associations between sociodemographic and clinical risk factors and reassault. RESULTS: 271 522 individuals experienced assault (mean follow-up=6.4 years), 24 568 (9.0%) of whom were reassaulted within 1 year, 45 834 (16.9%) within 5 years and 52 623 (19.4%) within 10 years. 40 322 (21%) males and 12 662 (17%) females experienced reassault over the study period. Groups with increased rates of reassault included: those aged 13-17 years versus older adults (age 65+) (males: relative rate (RR) 2.16; 95% CI 1.96 to 2.38; females: RR 2.79; 95% CI 2.39 to 3.26)), those living in rural areas versus urban (males: RR 1.22; 95% CI 1.19 to 1.24; females: RR 1.32; 95% CI 1.27 to 1.37) and individuals with a history of incarceration versus without (males: RR 2.38; 95% CI 2.33 to 2.42; females: RR 2.57; 95% CI 2.48 to 2.67). CONCLUSION: One in five who are assaulted experience reassault. Those at greatest risk include youth, those living in rural areas, and those who have been incarcerated, with strongest associations among females. Timely interventions to reduce the risk of experiencing reassault must consider both sexes in these groups.

Towards gender equity in emergency medicine: a position statement from the CAEP Women in Emergency Medicine committee.

As of January 2019, over half of all doctors working in Canada under the age of 40 were women. Despite equal representation in the profession of medicine, women still experience harassment, discrimination, and pay inequity when compared to their male colleagues. Gender discrimination is present at all levels of medical training and negatively impacts women who want to become emergency physicians. The right to gender equity is part of the Canadian Charter of Rights and Freedoms. The World Health Organization states that "gender inequities are socially generated and, therefore, can be changed." CAEP recognizes that gender equity is important to its members and that it intersects with inequities experienced by other minority groups. This position statement from the committee for Women in Emergency Medicine (EM) is intended to support women and those who identify as women who have chosen EM as their career. Furthermore, it is meant to inform and support policy makers as they consider the unique challenges that women face in their pursuit of excellence in EM.

Factors associated with SARS-CoV-2 positivity in 20 homeless shelters in Toronto, Canada, from April to July 2020: a repeated cross-sectional study.

BACKGROUND: It is unclear what the best strategy is for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among residents of homeless shelters and what individual factors are associated with testing positive for the virus. We sought to evaluate factors associated with testing positive for SARS-CoV-2 among residents of homeless shelters and to evaluate positivity rates in shelters where testing was conducted in response to coronavirus disease 2019 (COVID-19) outbreaks or for surveillance. METHODS: We conducted a retrospective chart audit to obtain repeated cross-sectional data from outreach testing done at homeless shelters between Apr. 1 and July 31, 2020, in Toronto, Ontario, Canada. We compared the SARS-CoV-2 positivity rate for shelters where testing was conducted because of an outbreak (at least 1 known case) with those tested for surveillance (no known cases). A patient-level analysis evaluated differences in demographic, health and behavioural characteristics of residents who did and did not test positive for SARS-CoV-2 at shelters with at least 2 positive cases. RESULTS: One thousand nasopharyngeal swabs were done on 872 unique residents at 20 shelter locations. Among the 504 tests done in outbreak settings, 69 (14%) were positive for SARS-CoV-2 and 1 (0.2%) was indeterminate. Among the 496 tests done for surveillance, 11 (2%) were positive and none were indeterminate. Shelter residents who tested positive for SARS-CoV-2 were significantly less likely to have a health insurance card (54% v. 72%, p = 0.03) or to have visited another shelter in the last 14 days (0% v. 18%, p < 0.01). There was no association between SARS-CoV-2 positivity and medical history or symptoms. INTERPRETATION: Our findings support testing of asymptomatic shelter residents for SARS-CoV-2 when a positive case is identified at the same shelter. Surveillance testing when there are no known positive cases may detect outbreaks, but further research should identify efficient strategies given scarce testing resources.

Protecting Frontline Health Care Workers from COVID-19 with Hydroxychloroquine Pre-exposure Prophylaxis: A structured summary of a study protocol for a randomised placebo-controlled multisite trial in Toronto, Canada.

OBJECTIVES: Primary Objective: To determine if pre-exposure prophylaxis (PrEP) with 400mg hydroxychloroquine (HCQ), taken orally once daily reduces microbiologically confirmed COVID-19 among front line health care workers at high risk for SARS-CoV-2 exposure. Secondary Objectives: To compare the following between study arms: adverse events; symptomatic COVID-19; duration of symptomatic COVID-19; days hospitalized attributed to COVID-19; respiratory failure attributable to COVID-19 requiring i) non-invasive ventilation or ii) intubation/mechanical ventilation; mortality attributed to COVID-19, number of days unable to work attributed to COVID-19, seroconversion (COVID-19 negative to COVID-19 positive over the study period); ability of participant plasma to neutralize SARS-CoV-2 virus in vitro; To describe short-term psychological distress associated with risk of COVID-19 exposure at 1, 60, 120 days of the study. To explore laboratory markers within participants with confirmed COVID-19: including circulating markers of host immune and endothelial activation in participant plasma and their correlation with disease severity and outcome TRIAL DESIGN: The HEROS study is a two-arm, parallel-group, individually randomized (1:1 allocation ratio), placebo controlled, participant and investigator-blinded, multi-site superiority trial of oral HCQ 400 mg taken once daily for 90 days as PrEP to prevent COVID-19 in health care workers at high risk of SARS-CoV-2 exposure. At 90 days, there is an open label extension wherein all participants are offered a one-month course of HCQ 400mg once daily for PrEP of COVID-19. PARTICIPANTS: Frontline HCWs aged 18 years of age or older, at high risk of SARS-CoV-2 exposure (including staff of emergency departments, intensive care units, intubation teams, COVID-wards, and staff deployed to Long Term Care facilities) of five academic hospitals in downtown Toronto, Canada. Exclusion criteria include: currently pregnant, planning to become pregnant during the study period, and/or breast feeding; known hypersensitivity/allergy to hydroxychloroquine or to 4-aminoquinoline compounds; current use of hydroxychloroquine; known prolonged QT syndrome and/or baseline resting ECG with QTc>450 ms and/or concomitant medications which simultaneously may prolong the QTc that cannot be temporarily suspended/replaced; known pre-existing retinopathy, G6PD deficiency, porphyria, liver disease including cirrhosis, encephalopathy, hepatitis or alcoholism, diabetes on oral hypoglycemics or insulin, or renal insufficiency/failure; disclosure of self-administered use of hydroxychloroquine or chloroquine within 12 weeks prior to study; confirmed symptomatic COVID-19 at time of enrollment. INTERVENTION AND COMPARATOR: Intervention: hydroxychloroquine, 400mg (2 tablets) orally per day. Comparator: placebo, two tablets visually identical to the intervention, orally per day MAIN OUTCOMES: The primary outcome is microbiologically confirmed COVID-19 (i.e. SARS-CoV-2 infection). This is a composite endpoint which includes positive results from any validated SARS-CoV-2 diagnostic assay including detection of viral RNA, and/or seroconversion. Participants will be assessed at baseline, and then undergo monthly follow-up at day 30, 60, and 90, 120. At each visit, participants will provide an oropharyngeal sample, blood sample, and will undergo electrocardiogram monitoring of the QTc interval. Secondary outcome measures include: adverse events; symptom duration of COVID-19; days of hospitalization attributed to COVID-19; respiratory failure requiring ventilator support attributed to COVID-19; mortality attributed to COVID-19; total days off work attributed to COVID-19; seropositivity (reactive serology by day 120); and short term psychological impact of exposure to SARS-CoV-2 at day 1, 60, 120 days using the K10, a validated measure of non-specific psychological distress. RANDOMISATION: Within each site, participants will be individually randomized to either the intervention arm with HCQ or the placebo arm using a fixed 1:1 allocation ratio using an interactive web-based response system to ensure concealment of allocation. Randomization schedules will be computer-generated and blocked using variable block sizes. BLINDING (MASKING): All participants, research coordinators, technicians, clinicians and investigators will be blinded to the participant allocation group. Numbers to be randomised (sample size) N=988, randomised into two groups of 494 patients. TRIAL STATUS: This summary describes protocol version No. 1.6, May 15, 2020. Recruitment is ongoing - started April 20, 2020 and anticipated end date is July 30, 2021 TRIAL REGISTRATION: ISRCTN.com Identifier: ISRCTN14326006, registered April 14, 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Child injuries in land vehicles that do not require restraints.

The goal of this study was to determine the injury profiles of Canadian children who presented to the Emergency Department from 1990 to 2016 due to an injury caused while traveling in a form of land transportation that did not require child restraint. A case series was conducted using data from the electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP). Children who were injured while travelling on land transportation for which child restraint is not required, who presented to a Canadian Emergency Department that participates in eCHIRPP between April 1, 1990 to August 29, 2016, were included. Overall, 1856 children sustained 2139 injuries (mean age: 9.8 years (SD 4.5), 45.5% male). The majority of children were injured on a school bus (49.3%). The most commonly injured body part was the head or neck (52.6%). The most common type of injury was a superficial or open wound (33.1%), followed by traumatic brain injury (19.3%). Overall, 39.4% of injuries required no treatment in hospital. Overall, approximately 70 children presented to eCHIRPP EDs per year on a land transportation vehicle that does not require restraints. Biomechanical studies are needed to improve safety on land transportation vehicles that do not require seatbelts.

The Cost of Use of the Emergency Department by Persons With Inflammatory Bowel Disease Living in a Canadian Health Region: A Retrospective Population-Based Study.

BACKGROUND: We aimed to determine the costs of emergency department (ED) attendance by persons with inflammatory bowel disease (IBD) not admitted to hospital from the ED. METHODS: This was a population-based administrative database study linking the University of Manitoba IBD Epidemiology Database with the Winnipeg Regional Health Authority (WRHA) ED Information Service database. We identified persons with IBD who presented to the ED and were not admitted between January 1, 2009 and March 31, 2012. We then applied costs in Canadian dollars for these visits including an average ED visit cost plus 26% for overhead (total = $508), an average estimated cost of laboratory investigations ($50), and costs for each of radiographic imaging, lower endoscopy and consultation with an internist/gastroenterologist or a surgeon. We tallied the costs of each unique ED presentation. We determined average costs for visits associated with specific consultations or investigations. RESULTS: One thousand six hundred and eighty-two persons with IBD (4,853 individual visits) attended the ED and did not get hospitalized. The average cost per ED visit by a person with IBD who did not get hospitalized was $650. This resulted in a total expenditure of $3,152,227 on these persons for their ED attendance or $969,916 per year. The visits with the highest mean costs were those associated with an abdominal computerized tomography scan ($979), those associated with surgical consultation ($1019), and those associated with an internist/gastroenterologist consultation ($942). CONCLUSION: Better strategies for management of acute issues for persons with IBD that can reduce the use of an ED are needed and can be considerably cost saving.

An environmental scan of emergency medicine research support, training, and infrastructure across Canada.

OBJECTIVE: Our study objective was to describe the Canadian emergency medicine (EM) research community landscape prior to the initiation of a nationwide network. METHODS: A two-phase electronic survey was sent to 17 Canadian medical schools. The Phase 1 Environmental Scan was administered to department chairs/hospital EM chiefs, to identify EM physicians conducting clinical or educational research. The Phase 2 Survey was sent to the identified EM researchers to assess four themes: 1) geographic distribution, 2) training/career satisfaction, 3) time/financial compensation, and 4) research facilitators/barriers. Descriptive analyses were conducted, and results were stratified by Canadian regions. RESULTS: A total of 92 EM researchers were identified in Phase 1; 67 (73%) responded to the Phase 2 Survey. Of those, 42 (63%) reported being clinical researchers, and 19 (45%) had a graduate degree. Three provinces encompassed most of the researchers (n = 35). Of the respondents, 61% had a research degree, 66% felt adequately trained for their research career, 73% had financial support, 83% had access to office spaces, 52% had no mentor during their first years of their career, 69% felt satisfied with their research career, and 82% suggested that they will still be conducting research in 5 years. CONCLUSION: EM researchers reported being adequately trained, even though only a little over half had a graduate degree. Only two-thirds had financial support, and mentorship was lacking in one-third of the participants. Not all respondents had a form of infrastructure, but most felt optimistic about their careers. The Canadian EM research environment could be improved to ensure better research capacity.

The competency-based medical education evolution of Canadian emergency medicine specialist training.

Canadian specialist emergency medicine (EM) residency training is undergoing the most significant transformation in its history. This article describes the rationale, process, and redesign of EM competency-based medical education. The rationale for this evolution in residency education includes 1) improved public trust by increasing transparency of the quality and rigour of residency education, 2) improved fiscal accountability to government and institutions regarding specialist EM training, 3) improved assessment systems to replace poor functioning end-of-rotation assessment reports and overemphasis on high-stakes, end-of-training examinations, and 4) and tailored learning for residents to address individualized needs. A working group with geographic and stakeholder representation convened over a 2-year period. A consensus process for decision-making was used. Four key design features of the new residency education design include 1) specialty EM-specific outcomes to be achieved in residency; 2) designation of four progressive stages of training, linked to required learning experiences and entrustable professional activities to be achieved at each stage; 3) tailored learning that provides residency programs and learner flexibility to adapt to local resources and learner needs; and 4) programmatic assessment that emphasizes systematic, longitudinal assessments from multiple sources, and sampling sentinel abilities. Required future study includes a program evaluation of this complex education intervention to ensure that intended outcomes are achieved and unintended outcomes are identified.

Health human resources for emergency medicine: a framework for the future.

In June of 2016, the Collaborative Working Group (CWG) on the Future of Emergency Medicine presented its final report at the Canadian Association of Emergency Physicians (CAEP) annual meeting in Quebec City. The CWG report made a number of recommendations concerning physician Human Health Resource (HHR) shortfalls in emergency medicine, specific changes for both the Royal College of Physicians and Surgeons of Canada (FRCPC) and the College of Family Physicians of Canada (CCFP-EM) training programs, HHR needs in rural and remote hospitals, future collaboration of the CCFP-EM and FRCPC programs, and directions for future research. All recommendations were endorsed by CAEP, the Royal College of Physicians and Surgeons of Canada (RCPSC), and the College of Family Physicians of Canada (CFPC). The CWG report was published in CJEM and has served as a basis for ongoing discussion in the emergency medicine community in Canada. The CWG identified an estimated shortfall of 478 emergency physicians in Canada in 2016, rising to 1071 by 2020 and 1518 by 2025 assuming no expansion of EM residency training capacity. In 2017, the CAEP board struck a new committee, The Future of Emergency Medicine in Canada (FEMC), to advocate with appropriate stakeholders to implement the CWG recommendations and to continue with this important work. FEMC led a workshop at CAEP 2018 in Calgary to develop a regional approach to HHR advocacy, recognizing different realities in each province and region. There was wide representation at this workshop and a rich and passionate discussion among those present. This paper represents the output of the workshop and will guide subsequent deliberations by FEMC. FEMC has set the following three goals as we work toward the overarching purpose to improve timely access to high quality emergency care: (1) to define and describe categories of emergency departments (EDs) in Canada, (2) define the full time equivalents required by category of ED in Canada, and (3) recommend the ideal combination of training and certification for emergency physicians in Canada. A fourth goal supports the other three goals: (4) urge further consideration and implementation of the CWG-EM recommendations related to coordination and optimization of the current two training programs. We believe that goals 1 and 2 can largely be accomplished by the CAEP annual meeting in 2020, and goal 3 by the CAEP annual meeting in 2021. Goal 4 is ongoing with both the RCPSC and the CFPC. We urge the EM community across Canada to engage with our committee to support improved access and EM care for all Canadians.

Feasibility and efficacy of a hospital-based violence intervention program on reducing repeat violent injury in youth: a randomized control trial.

OBJECTIVES: To determine feasibility and efficacy of an Emergency Department Violence Intervention Program (EDVIP) to reduce violence related injuries in youth. METHODS: One hundred and thirty youth aged 14-24 presenting to an emergency with violence related injury were randomized in parallel to receive EDVIP for 1 year (n = 65) or a waitlist control (n = 65). The primary outcome was to determine feasibility. Secondary outcomes are incidence, number/severity of repeat violence related injury, justice and education systems interactions, substance misuse and mental health presentations, and ED length of stay (LOS). RESULTS: This study established feasibility in recruitment, outcomes collection and safety. Fidelity and adherence measures required optimization during the study. Efficacy analysis of EDVIP vs. the control group demonstrates an absolute decrease of 10.4% in repeat violence related injury (13.7% vs. 24.1%) (p = 0.15), reduction in new interactions in the justice system (OR = 0.36 (0.07-1.77)), improved engagement in education (11.8% EDVIP vs. 7.6% control, p = 0.42) and no change in repeat visits for substance or mental health. LOS decreased by 59.5 min (p = 0.21). CONCLUSIONS: This program is feasible for ED implementation and for completion of a future RCT to measure effectiveness.

A multilevel analysis of risk and protective factors for Canadian youth injured or killed by interpersonal violence.

PURPOSE: The study's purpose was to determine individual-level and neighbourhood-level risk and protective factors for severe intentional injury among youth. METHODS: We conducted a multilevel case-control study using registry data to determine individual-level and neighbourhood-level social determinants associated with severe violent injury/homicide among youth from Winnipeg, Manitoba. RESULTS: The study includes 13 206 youth, aged 12-24 years (1222 cases, 11 984 controls). Individual-level risk predictors of being a victim of violence were male sex (OR 5.72 (95% CI 4.77 to 6.86)) and First Nations (OR 2.76 (95% CI 2.32 to 3.29)). Education was inversely associated with victimisation for individuals under (OR 0.36 (95% CI 0.26 to 0.51)) and over (OR 0.58 (95% CI 0.49 to 0.69)) 18 years. Ever having been in protective care (OR 1.66 (95% CI 1.39 to 1.99)), receiving income assistance from the government (OR 1.26 (95% CI 1.05 to 1.51)) or ever having criminal charges (OR 4.76 (95% CI 4.08 to 5.56)) were also significant predictors of being a victim of violence. Neighbourhood-level risk factors for victimisation included low socioeconomic status (OR 1.14 (95% CI 1.04 to 1.25)) and high levels of assault (OR 1.07 (95% CI 1.04 to 1.10)). CONCLUSIONS: This study demonstrates a complex web of risk and protective factors among youth injured by violence. It underscores the ongoing, injurious effects of historical trauma experienced by many Canadian First Nations people. Strong victim-perpetrator overlap suggests that intersectoral policies are needed to address these issues. Our findings highlight the need to improve education and family supports.

Validity of the days supply field in pharmacy administrative claims data for the identification of blister packaging of medications.

PURPOSE: Pharmacy claims data is often used in pharmacoepidemiology studies, but no studies to date have examined whether it was possible to identify the use of blister packs in these databases. We aimed to determine whether medications dispensed in days divisible by 7 are more likely to be blister packed than medications dispensed in other quantities. METHODS: Community pharmacies in Manitoba were invited to participate in a mail-out survey to identify the use of blister packaging for up to 25 patients who had a solid oral medication dispensed from April 1, 2012 to March 31, 2014. Eligible medications were identified using the population-based province-wide retail pharmacy network. Algorithms for identifying the use of blister packaging were determined by comparing the proportion of fills that confirmed blister pack use between different days supply quantities. RESULTS: Twenty-seven out of 32 pharmacies that agreed to participate completed the survey. The total number of prescriptions in the analysis was 2045 of which 131 (6.4%) were dispensed in blister packaging. Overall, prescriptions dispensed in days divisible by 7 yielded a 72.5% sensitivity, 86.6% specificity, 30.3% PPV, and 97.9% NPV compared with prescriptions dispensed in other quantities. A 28-day to 30-day comparison yielded an 87.9% sensitivity, 96.1% specificity, 64.6% PPV, and 99.0% NPV. CONCLUSION: While the NPV was high, the PPV for identifying blister packaging using the days supply field in pharmacy claims data was modest given the low prevalence in blister pack use. The best predictor occurred when 28 days was compared with 30 days. KEY POINTS Blister packs are arranged in 4 × 7 compartments and are often used to improve adherence, but no studies have examined whether it was possible to identify the use of blister packs using the days supply field in pharmacy claims data. Findings show that a 28-day supply yielded a high sensitivity and specificity for identifying the use of blister packaging compared with a 30-day supply, but there is potential for misclassification. Future studies directed at examining subgroups that are more likely to use blister packs and replication of findings using other data sources in other jurisdictions are encouraged.

Validation and adaptation of the danger assessment-5: A brief intimate partner violence risk assessment.

AIMS: The aim of this study was to assess the predictive validity of the DA-5 with the addition of a strangulation item in evaluating the risk of an intimate partner violence (IPV) victim being nearly killed by an intimate partner. BACKGROUND: The DA-5 was developed as a short form of the Danger Assessment for use in healthcare settings, including emergency and urgent care settings. Analyzing data from a sample of IPV survivors who had called the police for domestic violence, the DA-5 was tested with and without an item on strangulation, a potentially fatal and medically damaging IPV tactic used commonly by dangerous abusers. DESIGN: Researchers interviewed a heterogeneous sample of 1,081 women recruited by police between 2009-2013 at the scene of a domestic violence call; 619 (57.3%) were contacted and re-interviewed after an average of 7 months. METHODS: The predictive validity of the DA-5 was assessed for the outcome of severe or near lethal IPV re-assault using sensitivity, specificity and ROC curve analysis techniques. RESULTS: The original DA-5 was found to be accurate (AUC = .68), equally accurate with the strangulation item from the original DA substituted (AUC = .68) and slightly more accurate (but not a statistically significant difference) if multiple strangulation is assessed. CONCLUSION: We recommend that the DA-5 with the strangulation item be used for a quick assessment of homicide or near homicide risk among IPV survivors. A protocol for immediate referral and examination for further injury from strangulation should be adopted for IPV survivors at high risk.