Objective: We assessed the impact of the transition from a primarily paper-based electronic health record (EHR) to a comprehensive EHR on emergency physician work tasks and efficiency in an academic emergency department (ED). Methods: We conducted a time motion study of emergency physicians on shift in our ED. Fifteen emergency physicians were directly observed for two 4-hour sessions prior to EHR implementation, during go live, and then during post-implementation. Observers performed continuous observation and measured times for the following tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other. We compared time spent on tasks during the 3 phases of transition and analyzed mean times for the tasks per patient and per shift using 2-tailed t test for comparison. Results: Physicians saw fewer patients per shift during go-live (0.51 patient/hour, P < 0.01), patient efficiency increased in post-implementation but did not recover to baseline (−0.31 patient/hour, P = 0.03). From pre-implementation to post-implementation, we observed a trend towards increased physician time spent charting (+54 seconds/patient, P = 0.05) and documenting (+36 seconds/patient, P = 0.36); time spent doing direct patient care trended towards decreasing (−0.43 seconds/patient, P = 0.23). A small percentage of shifts were spent receiving technical support and time spent on teaching activities remained relatively stable during EHR transition. Conclusion: A new EHR impacts emergency physician task allocation and several changes are sustained post-implementation. Physician efficiency decreased and did not recover to baseline. Understanding workflow changes during transition to EHR in the ED is necessary to develop strategies to maintain quality of care.

Introduction: Public health response to the coronavirus 2019 (COVID-19) pandemic has emphasized social distancing and stay-at-home policies. Reports of decreased emergency department (ED) visits in non-epicenters of the outbreak have raised concerns that patients with non-COVID-19 emergencies are delaying or avoiding seeking care. We evaluated the impact of the pandemic on ED visits at an academic tertiary care center. Methods: We conducted an observational health records review between January 1–April 22, 2020, comparing characteristics of all ED visits between pre- and post-pandemic declaration by the World Health Organization. Measures included triage acuity, presenting complaints, final diagnoses, disposition, and mortality. We further examined three time-sensitive final diagnoses: stroke; sepsis; and acute coronary syndrome (ACS). Results: In this analysis, we included 44,497 ED visits. Average daily ED visits declined from 458.1 to 289.0 patients/day (-36.9%). For the highest acuity triaged patients there was a drop of 1.1 patients/day (-24.9%). Daily ED visits related to respiratory complaints increased post-pandemic (+14.1%) while ED visits for many other complaints decreased, with the greatest decline in musculoskeletal (-52.5%) and trauma (-53.6%). On average there was a drop of 1.0 patient/day diagnosed with stroke (-17.6%); a drop of 1.6 patients/day diagnosed with ACS (-49.9%); and no change in patients diagnosed with sepsis (pre = 2.8 patients/day; post = 2.9 patients/day). Conclusion: Significant decline in ED visits was observed immediately following formal declaration of the COVID-19 pandemic, with potential for delayed/missed presentations of time-sensitive emergencies. Future research is needed to better examine long-term clinical outcomes of the decline in ED visits during pandemics.

BackgroundStructured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians.AimOur goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%–75% in 4 months.MethodsWe used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling.MeasuresOur outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics.ResultsWe observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education.ConclusionsWe achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.

Introduction: Over 1 million patients with head injuries (HIs) are seen every year at emergency departments (EDs) in North America, with over 90% being minor HIs. Over-utilization of computed tomography (CT) scans in these patients results in unnecessary exposure to radiation and increases health-care resource utilization. Using recommendations from the Choosing Wisely Campaign (CWC) and quality improvement (QI) methodology, we developed a local initiative targeting this issue. Our aim was to reduce the CT scan rate for patients presenting with HIs by 10% over a 6-month period at two academic EDs. This was considered both achievable and meaningful by our stakeholders. Methods: Baseline CT scan rates for patients with HIs were determined through a 10-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and PDSA cycles, which included: 1) Assessing and improving provider knowledge about the CWC recommendations; 2) Testing, refining and implementing a modified Canadian CT Head Rule checklist in the ED; 3) Developing and giving patients CWC-themed handouts pertaining to HI best practice; 4) Bimonthly reporting of CT scan rates to providers. Our primary outcome measure was the number of CT scans performed for patients with HIs. Process measures included the number of checklists completed and ED length of stay (LOS). Our balance measure was return ED visits within 72 hours. Results: Baseline rate of CT scans prior to our interventions was 47.9%. Our QI initiative resulted in a significant shift in the run chart of the weekly CT scan rates, associated with the second PDSA cycle cluster. We observed a 16% relative decrease in CT scans at 3 months (47.9% to 40.5%, P = 0.005) and 10.4% at 8 months (47.9% to 43.1%, P = 0.02). Non-sustained trends and shifts were seen in the run chart of median ED LOS for HI patients, but overall beforeand-after median times were not significantly different (237min to 225min, P = 0.18). 33% of total checklists were completed. 72-hr return visits did not change during the 8-month study period (4.0% to 4.16%, P = 0.85). Conclusion: Our local QI initiative was successful in decreasing CT rates for patients presenting with a HI. The decrease in effect at 8 months suggests the need for continued feedback and reminders to ensure long-term sustainability. Other centres could use similar QI methods, as well as the materials we developed, to achieve similar results of improved evidence-based utilization of diagnostic tests. Keywords: quality improvement and patient safety, Choosing Wisely campaign, emergency department LO25The development and implementation of a standardized emergency department handover tool E. S. H. Kwok, MD, MHA, MSc, G. Clapham, BA, S. White, BA, M. Austin, MD, L. Calder, MD, MSc, University of Ottawa, Department of Emergency Medicine, Ottawa, ON Introduction: There is a high risk for communication breakdown, discontinuity of clinical care, and medical errors during ED physician handover. Locally, there is no standa...

Objectives In June 2019, The Ottawa Hospital launched the Epic electronic health record system, which transitioned all departments from a primarily paper-based system to an electronic system using a 1-day "big bang" approach. We sought to evaluate emergency physicians' satisfaction with system implementation and perception of its impact on clinical practice in an academic emergency department (ED) setting. Methods Four electronic surveys were distributed to staff during pre-implementation (1-month prior [May 2019]) and postimplementation (1-month [July 2019], 9-month [March 2020], and 20-month [February 2021]) time periods. 5-point Likert scales were used to rate agreement with statements. Responses were compared using the Cochran-Mantel-Haenszel trend test to assess for significant differences. Results Response rates were consistent, ranging between 41 and 51%, with the exception of +9 months which was 27%. The majority of respondents were staff, working 8-15 shifts/month, with ≤ 10 years in practice. General satisfaction and confidence improved substantially from pre-implementation to 20 months post-implementation. Personalization sessions were perceived as not effective and lacking in quality, particularly immediately after Epic launch. Although clinical workflow tasks got easier, there were sustained challenges in efficiency and patient flow, including number of patients seen/hour, time spent after shift-end, and time spent on post-shift documentation. Conclusions Although satisfaction and system confidence improved over time, there were sustained difficulties in overall efficiency long after implementation, with opportunities for future optimization. Training was lacking in terms of relevance to emergency physician workflow. These factors should be considered in future electronic health record implementations in ED settings. Keywords EHR • Informatics • Implementation • Digital health RésuméObjectifs En juin 2019, l'Hôpital d'Ottawa a lancé le système de dossiers de santé électroniques Epic, ce qui a permis de faire passer tous les services d'un système principalement basé sur le papier à un système électronique en utilisant une approche * Samantha Calder-Sprackman