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Objectives Opioid use disorder is a major public health concern that accounts for a high number of potential years of life lost. Buprenorphine/naloxone is a recommended treatment for opioid use disorder that can be started in the emergency department (ED). We developed an ED-based program to initiate buprenorphine/naloxone for eligible patients who live with opioid use disorder, and to provide unscheduled, next-day follow-up referrals to an opioid use disorder treatment clinic (in person or virtual) for continuing patient care throughout Alberta. Methods In this quality improvement initiative, we supported local ED teams to offer buprenorphine/naloxone to eligible patients presenting to the ED with suspected opioid use disorder and refer these patients for follow-up care. Process, outcome, and balancing measures were evaluated over the first 2 years of the initiative (May 15, 2018–May 15, 2020). Results The program was implemented at 107 sites across Alberta during our evaluation period. Buprenorphine/naloxone initiations in the ED increased post-intervention at most sites with baseline data available (11 of 13), and most patients (67%) continued to fill an opioid agonist prescription at 180 days post-ED visit. Of the 572 referrals recorded at clinics, 271 (47%) attended their first follow-up visit. Safety events were reported in ten initiations and were all categorized as no harm to minimal harm. Conclusions A standardized provincial approach to initiating buprenorphine/naloxone in the ED for patients living with opioid use disorder was spread to 107 sites with dedicated program support staff and adjustment to local contexts. Similar quality improvement approaches may benefit other jurisdictions.

Objectives Repeated presentations to emergency departments (EDs) may indicate a lack of access to other health care resources. Age is an important predictor of frequent ED use; however, age-varying effects are not generally investigated. This study examines the age-specific effects of predictors on ED presentation frequency for children in Alberta and Ontario, Canada. Methods This retrospective study used population-based data during April 2010 to March 2017. Data were extracted from the National Ambulatory Care Reporting System for children aged Results There were 2,481,172 patients who made 9,229,156 ED presentations. The effects of sex, lowest income quintile, rural residence, access to primary health care provider and province on the frequency of presentations varied by age. Notably, boys go from having more frequent presentations than girls when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95% confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents aged ≥15 without access to a primary care provider had more frequent presentations compared to those with a primary care provider. Conclusions When examining the frequency of ED presentations in children, age-varying effects of predictors should be considered. Our more nuanced examination of age provides insights into how health services might better target programmes for different ages to potentially reduce unnecessary ED use by providing other health care alternatives.

Background: Prior to the pandemic, every day approximately 28 long term care (LTC) residents were transferred to an emergency department (ED) in Alberta. This was placing increasing strain on healthcare resources and potentially negatively impacting the health and wellness of residents (e.g., exposure to iatrogenic harms). Many residents’ conditions could be managed within LTC if appropriate supports were provided. Poor communication between LTC and EDs can also lead to long ED lengths of stay, unnecessary resource utilization, sub-optimal health outcomes, and exposure to iatrogenic harms for LTC residents. Two INTERACT® tools (tools for early identification of acute medical issues) and a new care and referral pathway were implemented to help identify and address changes in health status among LTC residents sooner, improve communication between LTC and ED providers, and reduce unnecessary ED transfers. Methods: Between October 2019 and April 2022, 40 LTC homes and 4 EDs within the Calgary zone implemented the standardized LTC-to-ED care and referral pathway supported by a centralized telephone advice and transfer system for healthcare providers, community paramedics, and two INTERACT® tools (Stop and Watch for healthcare aides; Change in Condition Cards for nursing). Using a randomized stepped-wedge design, the pathway was implemented within 9 cohorts of (4-5) LTC facilities every 3 months, supported by an implementation coach. Three-hour train the trainer implementation sessions were conducted in-person or online with over 325 health practitioners in the enrolled LTC homes using strategies adapted to consider local context and barriers, as well as considering pandemic-related challenges. Evaluation Methods: Evaluation of the intervention involved both qualitative and quantitative methods. The primary study outcome is change in transfers from LTC to ED; secondary (quantitative) outcomes include hospital admissions, utilization of the centralized telephone advice and transfer system, and community paramedic visits. Analysis of these quantitative outcomes utilized negative binomial regression to estimate the incident rate with 95% confidence intervals (per 1000 residents), while adjusting for the different cohorts. The quantitative evaluation also included an economic analysis to determine potential cost savings. Interviews with healthcare providers were conducted to provide context to their experience with the intervention and ways it can be improved. These interviews will be interpreted with the involvement of members of our project resident and family advisory council. Results: Quantitative results demonstrate a reduction in the LTC-to-ED transfer rate [1.70 (95%CI 1.61-1.79) post-intervention) vs 1.91 (95%CI 1.84-2.00) pre-intervention], along with reduction in hospital admission rates [0.94 (95%CI 0.88-1.00) vs 1.08 (95%CI 1.03-1.14)]. There was an increase in utilization of the centralized telephone advice and transfer system [0.18 (95%CI 0.16-0.22) vs. 0.13 (95%CI 0.11-0.16)], but no increase in the number of community paramedic visits [2.05 (95%CI 1.94-2.16) vs 2.50 (95%CI 2.39-2.61)]. Cost and qualitative outcome data is pending. Advice and Lessons Learned: LTC staff education and use of early warning tools for identifying a change in resident health status (INTERACT® tools) and/or utilization of a centralized telephone advice and transfer system may have played a role in reducing ED transfers. We did not observe the expected relationship between community paramedic visits and reduced LTC-to-ED transfers, possibly as a result of the pandemic-related facility outbreak restrictions. Teams should tailor implementation sessions and materials to site specific needs and contexts to help address their unique barriers and facilitators. Partnerships with key stakeholders across the care continuum are essential to ensure adequate support and effective uptake and sustainability of the mutli-faceted change intervention.

Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores.We conducted a population-based retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non-First Nations patients.First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92-0.94) compared with non-First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.76-0.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84-0.98) and anxiety disorder (OR 0.67, 95% CI 0.60-0.74).First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.

Frequent users to emergency departments (EDs) are a diverse group of patients accounting for a disproportionate number of ED presentations. This study examined sociodemographic and ED visit characteristics of adult high-system users in two Canadian provinces. Cohorts of high-system users were created for Alberta and Ontario including patients with the top 10% of presentations in the National Ambulatory Care Reporting System (April 2015–March 2016). Controls were random samples of non-high-system user patients. Sociodemographic and ED visits data were used to predict high-system user group membership in a multivariable logistic regression model. There were 579,674 high-system users and 2,115,960 controls. High-system users were more likely to be female [odds ratio (OR) = 1.1, 95% confidence interval (CI) 1.1,1.1], older (OR 1.02 per 5 years, 95% CI 1.02,1.02), from the lowest-income quintile (OR 1.8, 95% CI 1.7,1.8), and more rural (OR 1.6, 95% CI 1.6,1.6) than controls. High-system users had a higher proportion of presentations by ambulance (OR 1.1 per 0.25 increase, 95% CI 1.1,1.1) and disposition was admission/transfer (OR 1.1 per 0.25 increase, 95% CI 1.1,1.1), left without being seen (OR 1.1, 95% CI 1.1,1.1), or left against medical advice (OR 1.1, 95% CI 1.1,1.1) more often than controls. High-system users were more likely to be female, older, live in rural areas and within the lowest-income quintile compared to controls. Their heterogeneity in acuity, comorbid chronic diseases, and limited access to primary care suggests that interventions referring high-system users to primary care may be fruitful in reducing ED utilization by high-system users.

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ2 = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

ObjectivesHealth disparities between racial and ethnic groups have been documented in Canada, the United States, and Australia. Despite evidence that differences in emergency department (ED) care based on patient race and ethnicity exist, there are no comprehensive literature reviews in this area. The objective of this review is to provide an overview of the literature on the impact of patient ethnicity and race on the processes of ED care.MethodsA scoping review was conducted to capture the broad nature of the literature. A database search was conducted in MEDLINE/PubMed, EMBASE, CINAHL Plus, Social Sciences Citation Index, SCOPUS, and JSTOR. Five journals and reference lists of included articles were hand searched. Inclusion and exclusion criteria were defined iteratively to ensure literature captured was relevant to our research question. Data were extracted using predetermined variables, and additional extraction variables were added as familiarity with the literature developed.ResultsSearching yielded 1,157 citations, reduced to 153 following removal of duplicates, and title and abstract screening. After full-text screening, 83 articles were included. Included articles report that, in EDs, patient race and ethnicity impact analgesia, triage scores, wait times, treatments, diagnostic procedure utilization, rates of patients leaving without being seen, and patient subjective experiences. Authors of included studies propose a variety of possible causes for these disparities.ConclusionsFurther research on the existence of disparities in care within EDs is warranted to explore the causes behind observed disparities for particular health conditions and population groups in specific contexts.

OBJECTIVES: Long term care (LTC) facilities are essential in the provision of daily care needs for older adults experiencing frailty. In times of acute medical distress, LTC residents may require transfer to emergency departments (ED). However, many transfers from the LTC to ED may not be required and residents could instead be treated within LTC utilizing community paramedics (CP). We conducted a systematic review to assess the impact of community paramedicine on the frequency of resident transfer from LTC to ED. METHODS: We searched five electronic databases (Medline, CINAHL, PubMed, Embase, and Cochrane). The search was limited to primary peer-reviewed publications and excluded conference proceedings, review articles, and non-peer review articles. We restricted the search to papers published in English and articles published within the last 30 years. RESULTS: A total of 19,308 titles and abstracts were screened with a total of 181 full text reviews. One study that comprised of 4 articles was included in the review that evaluated the impact of community paramedic interventions in LTC. The study noted a reduction in transfers to the ED attributed to the presence of CP, reducing transports to ED by nearly 30%. CONCLUSIONS: There is a scarcity of research examining the role of CP in LTC. While the current research points towards CP interventions in LTC reducing the number of transfers to ED, further research needs to be conducted on the effectiveness of community paramedicine interventions in improving health outcomes for residence and improving cost efficiency within the health system.

Background Physical distancing, wearing face masks and hand hygiene are evidence-based methods to protect the public from coronavirus disease 2019 (COVID-19) infection. There has been a proliferation of research examining characteristics that can be targeted by public health interventions. This rapid review sought to identify predictors of attitudes toward and adherence to COVID-19 public health guidelines, and identify interventions aiming to improve adherence. Methods Articles were retrieved from multiple databases (e.g. MEDLINE, CINAHL and medRxiv) on 6 August 2020. Studies were limited to samples collected from Western countries. Studies were classified according to the types of factor (s) examined as independent variables. The consistency of evidence for each factor was scored by two reviewers. Results In total, 1323 unique articles were identified in the initial search, resulting in 29 studies in the final synthesis. The available evidence suggests individuals who are older, identify as women, trust governments, perceive COVID-19 as threatening and access information through traditional news media are more likely to adhere with COVID-19 public health guidelines. Interventions for improving adherence have not yet been investigated thoroughly, and this review identified only three experimental studies. Conclusions This review has identified several characteristics that impact attitudes and adherence to COVID-19 public health guidelines.

Background: During public health emergencies, disruptions to social landscapes and amplification of inequities for people with opioid use disorder raise important questions about reducing harms and providing treatment accountability to support this population during disasters including COVID-19. This research aims to a) identify how disasters impact persons with opioid use disorder (OUD) and their access to healthcare, with specific attention to COVID-19, and b) inform ongoing responses to the pandemic and future disaster-mitigation plans related to healthcare disruptions affecting persons with opioid use disorder (PWOUD). Methods: We conducted knowledge synthesis based on a 6-stage scoping review framework methodology. Stakeholder consultation was completed using a Nominal Group Technique with two groups, each composed of including providers in primary, emergency and community-based care. One group (n=7) represented voices from urban services, and the other (n=4) Indigenous contexts allowing for attention to healing the whole person, beyond OAT. Results: 61 scientific journal articles and 72 grey literature resources were included after full-text screening. Stakeholder NGT process revealed three contextual factors affecting system and service accountability for responsive OUD care during disaster-driven disruptions: (1) disasters focus attention on single risks and generalized solutions; (2) data-poor decision-making perpetuates stigma and produces policy inattentive to social determinants of health; and (3) harm reduction and contextually-tailored care prepare a system for future disasters. Conclusion: COVID-19 public health efforts require a coordinated systemic approach to serving PWOUD, based on accountability to patients and support for providers.

Evidence-based research and quality improvement work are pivotal to health systems meeting their goals. Translating findings and disseminating innovative practices to new settings occurs in part through knowledge translation events, such as conferences and workshops. The Emergency Strategic Clinical Network™ (ESCN) Quality Improvement and Innovation Forum fills a gap between local and national events. It is devoted to sharing methods and results of emergency department projects in Alberta among those working in emergency care. Despite the challenges presented by the COVID-19 pandemic, 2022 was the fourth consecutive year the ESCN has held this event. The event provides an opportunity for those working on quality improvement in emergency medicine to network with one another, share innovative projects, share know how and translate promising works to new settings. In addition, the event provides an opportunity to identify projects for potential development through local, provincial, or national funding opportunities. This year’s forum was, again, held virtually due to the ongoing pandemic. 18 teams provided oral presentations including the ESCN patient advisors who shared details of how to engage patients in quality improvement work.. Not all abstracts are published in this collection, as some abstracts will have been previously published elsewhere. Strong attendance shows the value practitioners see in the forum. In 2022, approximately 121 educators, managers, nurses, physicians and researchers from across Alberta and British Columbia, attended the forum. Post-event evaluation survey feedback suggests that the online format was greatly appreciated and many of the initiatives presented would be pursued further by participants. The findings presented in the abstracts are solely the work of the submitting authors. The ESCN does not guarantee the accuracy of any reported information. The views expressed in the abstracts are solely the views of the authors and do not represent the ESCN or Alberta Health Services.

Background During public health emergencies, people with opioid use disorder (PWOUD) may be particularly impacted. Emergent disasters such as the COVID-19 pandemic disrupt already-strained harm reduction efforts and treatment availability. This study aims to answer three research questions. How do public health emergencies impact PWOUD? How can health systems respond to novel public health emergencies to serve PWOUD? How can the results of this scoping review be contextualized to the province of Alberta to inform local stakeholder responses to the pandemic? Methods We conducted a scoping review using the 6-stage Arksey and O’Malley framework to analyse early-pandemic and pre-pandemic disaster literature. The results of the scoping review were contextualized to the local pandemic response, through a Nominal Group Technique (NGT) process with frontline providers and stakeholders in Alberta, Canada. Results Sixty one scientific journal articles and 72 grey literature resources were included after full-text screening. Forty sources pertained to early COVID-19 responses, and 21 focused on OUD treatment during other disasters. PWOUD may be more impacted than the general population by common COVID-19 stressors including loss of income, isolation, lack of rewarding activities, housing instability, as well as fear and anxiety. They may also face unique challenges including threats to drug supplies, stigma, difficulty accessing clean substance use supplies, and closure of substance use treatment centres. All of these impacts put PWOUD at risk of negative outcomes including fatal overdose. Two NGT groups were held. One group (n = 7) represented voices from urban services, and the other (n = 4) Indigenous contexts. Stakeholders suggested that simultaneous attention to multiple crises, with adequate resources to allow attention to both social and health systems issues, can prepare a system to serve PWOUD during disasters. Conclusion This scoping review and NGT study uncovers how disasters impact PWOUD and offers suggestions for better serving PWOUD.

Background Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges. Methods We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed. Results From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges. Conclusions A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.

BackgroundOpioid use disorder is a major public health crisis, and evidence suggests ways of better serving patients who live with opioid use disorder in the emergency department (ED). A multi-disciplinary team developed a quality improvement project to implement this evidence.MethodsThe intervention was developed by an expert working group consisting of specialists and stakeholders. The group set goals of increasing prescribing of buprenorphine/naloxone and providing next day walk-in referrals to opioid use disorder treatment clinics. From May to September 2018, three Alberta ED sites and three opioid use disorder treatment clinics worked together to trial the intervention. We used administrative data to track the number of ED visits where patients were given buprenorphine/naloxone. Monthly ED prescribing rates before and after the intervention were considered and compared with eight nonintervention sites. We considered whether patients continued to fill opioid agonist treatment prescriptions at 30, 60, and 90 days after their index ED visit to measure continuity in treatment.ResultsThe intervention sites increased their prescribing of buprenorphine/naloxone during the intervention period and prescribed more buprenorphine/naloxone than the controls. Thirty-five of 47 patients (74.4%) discharged from the ED with buprenorphine/naloxone continued to fill opioid agonist treatment prescriptions 30 days and 60 days after their index ED visit. Thirty-four patients (72.3%) filled prescriptions at 90 days.ConclusionsEmergency clinicians can effectively initiate patients on buprenorphine/naloxone when supports for this standardized evidence-based care are in place within their practice setting and timely follow-up in community is available.

Frequent users to emergency departments (EDs) are a diverse group of patients accounting for a disproportionate number of ED presentations. This study examined sociodemographic and ED visit characteristics of adult high-system users in two Canadian provinces.Cohorts of high-system users were created for Alberta and Ontario including patients with the top 10% of presentations in the National Ambulatory Care Reporting System (April 2015-March 2016). Controls were random samples of non-high-system user patients. Sociodemographic and ED visits data were used to predict high-system user group membership in a multivariable logistic regression model.There were 579,674 high-system users and 2,115,960 controls. High-system users were more likely to be female [odds ratio (OR) = 1.1, 95% confidence interval (CI) 1.1,1.1], older (OR 1.02 per 5 years, 95% CI 1.02,1.02), from the lowest-income quintile (OR 1.8, 95% CI 1.7,1.8), and more rural (OR 1.6, 95% CI 1.6,1.6) than controls. High-system users had a higher proportion of presentations by ambulance (OR 1.1 per 0.25 increase, 95% CI 1.1,1.1) and disposition was admission/transfer (OR 1.1 per 0.25 increase, 95% CI 1.1,1.1), left without being seen (OR 1.1, 95% CI 1.1,1.1), or left against medical advice (OR 1.1, 95% CI 1.1,1.1) more often than controls.High-system users were more likely to be female, older, live in rural areas and within the lowest-income quintile compared to controls. Their heterogeneity in acuity, comorbid chronic diseases, and limited access to primary care suggests that interventions referring high-system users to primary care may be fruitful in reducing ED utilization by high-system users.RéSUMé: OBJECTIF: Les utilisateurs fréquents des services d'urgence sont un groupe diversifié de patients qui représentent un nombre disproportionné de présentations aux services d'urgence. Cette étude a examiné les caractéristiques sociodémographiques et les visites aux urgences de grands utilisateurs adultes du système de santé dans deux provinces canadiennes. MéTHODE: Des cohortes de grands utilisateurs du système de santé ont été créées pour l'Alberta et l'Ontario, y compris les patients ayant fait l'objet des 10 % de présentations les plus importantes dans le système national d'information sur les soins ambulatoires (avril 2015-mars 2016). Les contrôles étaient des échantillons aléatoires des patients ne faisant pas partie des grands utilisateurs. Les données sociodémographiques et les données sur les visites aux urgences ont été utilisées pour prédire l'appartenance à un groupe de grands utilisateurs du système dans un modèle de régression logistique multivariable. RéSULTATS: Il y avait 579 674 de grands utilisateurs et 2 115 960 témoins. Les grands utilisateurs de système étaient plus susceptibles d'être des femmes (rapport des cotes [RC] = 1,1, intervalle de confiance à 95 % (IC) 1,1, 1,1), plus âgés (RC = 1,02 tous les 5 ans, IC à 95 % 1,02, 1,02), d'après quintile de revenu le plus bas (RC = 1,8, IC à 95 % 1,7,1,8), et plus rural (RC = 1,6, IC à 95 % 1,6,1,6) que les témoins. Les grands utilisateurs du système avaient une proportion plus élevée de présentations par ambulance (RC = 1,1 pour une augmentation de 0,25, IC à 95 % 1,1, 1,1) et la disposition était l'admission / transfert (RC = 1,1 pour une augmentation de 0,25, IC à 95 % 1,1, 1,1), parti sans être vu (OR = 1,1, IC à 95% 1,1, 1,1), ou parti contre l'avis médical (OR = 1,1, IC à 95 % 1,1, 1,1) plus souvent que les témoins. CONCLUSIONS: Les grands utilisateurs du système étaient plus susceptibles d'être des femmes, des personnes âgées, vivant dans des zones rurales et se situant dans le quintile de revenu le plus bas, par rapport aux témoins. Leur hétérogénéité en termes d'acuité, de comorbidité des maladies chroniques et d'accès limité aux soins primaires suggère que les interventions qui orientent les grands utilisateurs du haut système vers les soins primaires peuvent être fructueuses pour réduire l'utilisation des urgences par les grands utilisateurs du système.

In Alberta, First Nations members visit Emergency Departments (EDs) at almost double the rate of non-First Nations persons. Previous publications demonstrate differences in ED experience for First Nations members, compared to the general population. The Alberta First Nations Information Governance Centre (AFNIGC), First Nations organizations, Universities, and Alberta Health Services conducted this research to better understand First Nations members' ED experiences and expectations.This was a participatory research project. Elders selected topics of focus through discussion with the research team, and approved our method of data collection. Sharing circles were held in February 2018 with Elders, First Nations patients, healthcare providers and health administrators from across Alberta. We analyzed data using the Western approach of thematic analysis, with review by two Indigenous team members. AFNIGC is custodian of the research data on behalf of Alberta First Nations, and approves publication of this work.Forty-six persons participated in four sharing circles lasting between one and a half and three hours. Findings included First Nations patients' understandings of ED work, limited access to primary care services driving ED use, expectations of different treatment in ED based on race, experiences of racism, concerns about interactions with Children's Services, healthcare avoidance, and avoiding specific hospitals. Equity approaches were identified as key to improving First Nations patients' ED experiences.Bringing First Nations perspectives to Western understandings of ED care is an important step toward identifying required improvements in the health system for better patient experiences and outcomes.RéSUMé: OBJECTIFS: Les membres des Premières Nations en Alberta consultent un médecin au service des urgences (SU) presque deux fois plus souvent que les non-membres des Premières Nations. Par ailleurs, d’après des publications antérieures, l’expérience des membres des Premières Nations au SU est différente de celle de la population en général. L’Alberta First Nations Information Governance Centre (AFNIGC), des organisations des Premières Nations, des universités et les Alberta Health Services ont donc joint leurs efforts pour entreprendre une recherche afin de mieux comprendre l’expérience des membres des Premières Nations au SU ainsi que leurs appréhensions. MéTHODES: Il s’agit d’un projet de recherche participatif. Des aînés ont choisi les sujets de discussion après échange de points de vue avec l’équipe de recherche, et ont approuvé la méthode de collecte de données. Des cercles d’échange d’opinions ont été organisés en février 2018 avec des aînés, des patients des Premières Nations, des fournisseurs de soins et des gestionnaires de services de santé de partout en Alberta. Nous avons analysé les données en utilisant l'approche occidentale de l'analyse thématique, avec examen par deux membres de l'équipe autochtone. L’AFNIGC s’est fait le consignataire des données de recherche au nom des Premières Nations de l’Alberta et a approuvé la publication du travail de recherche. RéSULTATS: Quarante-six personnes ont participé à quatre cercles d’échange de points de vue, dont la durée a varié d’une heure et demie à trois heures. Les résultats incluent la compréhension du travail des urgences par les patients des Premières nations, l'accès limité aux services de soins primaires qui conduit à l'utilisation des urgences, les attentes d'un traitement différent aux urgences en fonction de la race, les expériences de racisme, les préoccupations concernant les interactions avec les Services pour Enfants, l'évitement des soins de santé et le fait d'éviter certains hôpitaux. Les approches axées sur l’équité ont été jugées essentielles à l’amélioration des expériences des patients des Premières Nations aux urgences. CONCLUSION: Intégrer les perspectives des Premières Nations à la compréhension occidentale des soins à l'urgence est une étape importante vers l'identification des améliorations requises dans le système de santé pour de meilleures expériences et de meilleurs résultats pour les patients.

BackgroundLong term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community.Methods/designWe will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care.DiscussionThis study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.

KEY POINTS Alberta’s population is aging,[1][1] and this increases the need for complex emergency care. Since 2005–2006, emergency department spending in Alberta has grown by an average of 7.5% per year, with a lower percentage change of 4% over the last 5 years.[2][2] Continued growth in

The Alberta Health Services Emergency Strategic Clinical Network Quality Improvement and Innovation forum 2021. Patrick McLane and Eddy Lang on behalf of the Emergency Strategic Clinical Network Evidence-based research and quality improvement work are pivotal to health systems meeting their goals. Translating findings and disseminating innovative practices to new settings occurs in part through knowledge translation events, such as conferences and workshops. The Emergency Strategic Clinical NetworkTM (ESCN) Quality Improvement and Innovation forum fills a gap between local and national events. It is devoted to sharing methods and results of emergency department projects in Alberta among those working in emergency care. 2021 was the third consecutive year the ESCN has held this event. The event provides an opportunity for those working on quality improvement in emergency medicine to network with one another, share innovative projects, share know how and translate promising works to new settings. In addition, the event provides an opportunity to identify projects for potential development through local, provincial, or national funding opportunities. In light of the ongoing pandemic, this year’s forum was held virtually with the support of the University of Calgary Continuing Medical Education group. Funding was kindly provided by the College of Physicians and Surgeons of Alberta. Nineteen teams presented their projects orally. Invited nurse and clinician scientists ranked all submissions to the forum, and the top ranked submissions were recognized in the following categories:Submissions by ESCN staff and the event sponsor were not eligible for recognition. A new feature this year was a presentation by ESCN patient advisors on their perspectives on quality improvement, which was well received by all. Strong attendance shows the value practitioners see in the forum. In 2021, the forum was attended by approximately 140 educators, managers, nurses, physicians and researchers from across Alberta. This is a marked increase over previous years. Post-event evaluation survey feedback suggests that the online format was greatly appreciated and made the event more accessible. Requests for more rural oriented content in event feedback may also indicate that the event drew more rural attendees this year. We are pleased to partner with the Canadian Journal of Emergency Nursing to make abstracts from the event widely available. Individual presenters have had the option of submitting their abstracts for publication in CJEN. In some instances, abstracts have already been published through other conferences and so could not be submitted to CJEN. The findings presented in the abstracts are solely the work of the submitting authors. The ESCN does not guarantee the accuracy of any reported information. The views expressed in the abstracts are solely the views of the authors and do not represent the ESCN or Alberta Health Services. Correspondence to: emergencyscn@ahs.ca

This is an introduction for a special issue publishing abstracts from the forum mentioned in the title, as requested by Christopher Picard.

Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures & Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.

Introduction: Emergency care serves as an important health resource for First Nations (FN) persons. Previous reporting shows that FN persons visit emergency departments at almost double the rate of non-FN persons. Working collaboratively with FN partners, academic researchers and health authority staff, the objective of this study is to investigate FN emergency care patient visit statistics in Alberta over a five year period. Methods: Through a population-based retrospective cohort study for the period from April 1, 2012 to March 31, 2017, patient demographics and emergency care visit characteristics for status FN patients in Alberta were analyzed and compared to non-FN statistics. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage Acuity Scale (CTAS)). Means and standard deviations (medians and interquartile ranges (IQR)) describe continuous variables (e.g., distances) as appropriate for the data distribution. These descriptions are repeated for the FN and non-FN populations, separately. Results: The data set contains 11,686,288 emergency facility visits by 3,024,491 unique persons. FN people make up 4.8% of unique patients and 9.4% of emergency care visits. FN persons live further from emergency facilities than their non-FN counterparts (FN median 6 km, IQR 1-24; vs. non-FN median 4 km, IQR 2-8). FN visits arrive more often by ground ambulance (15.3% vs. 10%). FN visits are more commonly triaged as less acute (59% CTAS levels 4 and 5, compared to non-FN 50.4%). More FN visits end in leaving without completing treatment (6.7% vs. 3.6%). FN visits are more often in the evening – 4:01pm to 12:00am (43.6% vs. 38.1%). Conclusion: In a collaborative validation session, FN Elders and health directors contextualized emergency care presentation in evenings and receiving less acute triage scores as related to difficulties accessing primary care. They explained presentation in evenings, arrival by ambulance, and leaving without completing treatment in terms of issues accessing transport to and from emergency facilities. Many factors interact to determine FN patients’ emergency care visit characteristics and outcomes. Further research needs to separate the impact of FN identity from factors such as reasons for visiting emergency facilities, distance traveled to care, and the size of facility where care is provided.

Studies examining risk of death during acute care transitions have highlighted potential predictors of death during transition. However, they have not closely examined the relationships and directional effects of organizational context, care processes, resident demographics and health conditions on death during transition. By employing structural equation modeling, we aimed to 1) identify predictive factors for residents who died during transitions from long term care (LTC) to emergency departments (EDs) and back; 2) examine relationships between identified organizational, process and resident factors with resident death during these transitions; and 3) identify areas for further investigation and improvement in practice. We tracked every resident transfer from 38 participating LTC facilities to two included EDs in two Western Canadian provinces from July 2011 to July 2012. Overall, 524 residents were involved in 637 transfers of whom 63 residents (12%) died during the transition. Sustained dyspnea (in both LTC and the ED), sustained change in level of consciousness (LOC) and severity measured by triage score were direct and significant predictors of resident death during transition. The model fit the data, (x2 = 83.77, df = 64, p = 0.049) and explained 15% variance in resident death. Dyspnea and change in LOC in both LTC and ED needs to be recognized regardless of primary reason for transfer. More research is needed to determine the specific influences of LTC ownership models, family involvement in decision-making, LTC staff decision-making on resident death during transition, and interventions to prevent pre-death transfers.

Introduction: Health disparities between racial and ethnic groups have been well documented in Canada, the United States, and Australia. Despite evidence that differences in emergency department (ED) care based on patient race and ethnicity exist, there is a lack of scientific reviews in this important area. The objective of this review is to provide an overview of the literature on the impact of patient race and ethnicity on ED care. Methods: A scoping review guided by the framework described by Arksey and O'Malley was undertaken. This approach was taken because it was best suited to the goal of providing an overview of all of the literature, given the broad nature of the topic. All studies with primary outcomes considering the impact of patient race and ethnicity on “throughput” factors in the ED as defined by Asplin et al., were considered. Outcomes considered included triage scores, wait times, analgesia, diagnostic testing, treatment, leaving without being seen, and patient experiences. Literature from Canada, the United States, Australia, and New Zealand was considered. A database search protocol was developed iteratively as familiarity with the literature developed. Inclusion and exclusion decisions were made using an established model. Results: The original search yielded 1157 citations, reduced to 453 after duplicate removal. 153 full texts were included for screening, of which 85 were included for final data extraction. Results indicate there is evidence that minority racial and ethnic groups experience disparities in triage scores, wait times, analgesia, treatment, diagnostic testing, leaving without being seen, and subjective experiences. Authors’ suggested explanations for these disparities can be placed in the following categories: (1) communication differences; (2) conscious or unconscious bias; (3) facility and resource factors in hospitals with higher minority presentation rates; and (4) differences in clinical presentations. Conclusion: This scoping review provides an overview of the literature on the impacts of race and ethnicity on ED care. As disparities have been shown to exist in numerous contexts, further research on the impact of race and ethnicity in ED care is warranted, especially in the Canadian literature. Such explorations could aid in the informing and creation of policy, and guide practice.

Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.

Introduction: Emergency Departments (EDs) are frequently the first point of entry to access health services for First Nation (FN) members. In Alberta, FN members visit EDs at almost double the rate of non-FN persons. Furthermore, preliminary evidence demonstrates differences in ED experience for FN members as compared to the general population. The Alberta First Nations Information Governance Centre, Maskwacis Health Services, Yellowhead Tribal Council, Treaty 8 First Nations of Alberta, and Alberta Health Services are working together to research FN members ED experiences and concerns. Methods: This is participatory research guided by a two-eyed seeing approach that acknowledges the equal value of both Western and Indigenous worldviews. FN and non-FN leaders researchers are full partners in the development of the research project. Six sharing circles will be held in February 2018 across Alberta, with Elders, FN patients, FN and non-FN clinicians and FN and non-FN administrators. Sharing circles are similar to focus groups, but emphasize everyone having a turn to speak and demonstrating respect among participants in accordance with FN protocols. Elders will select the questions for discussion based on topics that arose in initial team meetings. Sharing circle discussions will be audio recorded and transcribed. Analysts will include both Western and Indigenous worldview researchers, who will collaboratively interpret findings. Elders will review, discuss, contextualize and expand upon study findings. The research is also guided by FN principles of Ownership, Control, Access, and Possession of FN information. It is through these principles that First Nation research projects can truly be classified as FN lead and driven. Results: Based on initial team meeting discussions, results of sharing circles are expected to provide insights on issues such as: healing, patient-provider communication (verbal and non-verbal), shared decision making, respect for patient preferences, experiences leading to trust or distrust, understandings of wait times and triage, times when multiple (repeat) ED presentations occur, distances travelled for care, choosing specific EDs when seeking care, impacts of stereotypes about FN patients, and racism and reconciliation. Conclusion: Understanding FN ED experience and bringing FN perspectives to Western conceptions of the goals and provision of ED care are important steps toward reconciliation.

This paper presents a brief examination of the current trends and issues in the licensing of patented research tools, as well as perspectives on 'reach through' licensing of research tools.

A better way to care for Long Term Care residents (LTC) in times of medical urgency: improving acute care for LTC residents. Leanna Wyer, Shawna Reid, Abraham Munene, Eddy Lang, Vivian Ewa, Heather Hair, Greta Cummings, Patrick McLane, Eldon Spackman, Peter Faris, Dominic Alaazi, Marian George, Jayna Holroyd-Leduc Background: Many LTC residents are transferred to Emergency Departments (EDs) with conditions that could be cared for in LTC, perhaps with additional support (e.g. Community Paramedics). Communication between sites and EDs has also been lacking. These lead to long lengths of stay in EDs, unnecessary use of resources, and sub-optimal health outcomes. Two INTERACT tools will support initial management of the concern at the LTC site. Then a Care and Referral Pathway will help facilitate needed conversations and optimal transfers between LTC and ED. Implementation: Beginning in April 2019, standalone LTC sites in Calgary and Central zones have been invited to participate. Using a randomized stepped wedge design, we implement at 4-5 new sites every 3 months, with a total goal of implementing this change in 40 sites in Calgary and 9 sites in the Central zone. Early engagement with site medical directors, LTC and ED physicians, and managers at RAAPID (Referral, Access, Advice, Placement, Information and Destination) call centre and Community Paramedics was instrumental in getting the project initiated. Quarterly meetings with a project steering committee assists with ongoing project details and risk/issues. Operational leads and unit managers meet with our Senior Practice Consultant to be introduced to the project. This is followed by an implementation session at which site staff are given information about the specific tools and pathway, potential barriers are mitigated, and a site implementation plan is developed. Quarterly reports using data from a project Tableau dashboard are prepared by our Research Coordinator and distributed to LTC sites for them to monitor their performance compared to zone averages on a number of performance indicators. Evaluation Methods: The project will be evaluated using both qualitative and quantitative measures. Key Performance Indicators include a reduction in transfers to EDs, improved satisfaction, and increased use of available resources. Residents, families and healthcare providers will participate in interviews or focus groups to assess their experiences with the interventions. Quantitative evaluation includes an economic analysis to determine how the interventions have led to cost savings within the healthcare system, as well as examination of the number transfers to ED, hospital admissions, calls to RAAPID, and visits by Community Paramedics. This will help to determine if the intervention has led to better resource utilization, increased satisfaction among residents and families, and improved patient and health system outcomes. At this stage of the project, no unintended consequences have been identified. Results: Currently, we have implemented at 6 of 11 Cohorts (26 sites). Data from April 2019 (start of project) until December 2020 show a downward trend in number of ED visits and hospital admissions, as well as increased utilization of RAAPID. Formal evaluation will be completed when the project ends in June 2022. Given the COVID-19 pandemic, it is important to note that this may have an effect on our current trends and this will further be explored at the end of the project period. Anecdotal evidence is also beginning to indicate success of the right care being provided in the right place. Advice and Lessons Learned:1) Firstly, partnerships with key stakeholders are vital to ensure successful utilization of theLTC-ED Care and Referral pathway. Specifically, RAAPID is key to the facilitation ofcommunication between LTC sites and the EDs, and the services provided by CommunityParamedics allow many residents to remain at their LTC homes. 2) Secondly, good engagement with Site Medical Directors and Operational leads is needed toensure LTC staff and physicians are supported to use the interventions, and to care for theirresidents on site if appropriate. 3) Finally, tailored implementation strategies for each individual LTC site (and units in somecases) help mitigate site specific barriers, leverage strengths, and work within the site culture.