SuboxED clinical experts were able to suggest a triage tool for nurses and pharmacists, by setting clinical criteria for ED patients at risk of opioid overdose (Figure 1). The group added an item to the existing ED triage questionnaire to identify patients exposed to opioids. The ED triage is a process through which patients are registered upon arrival and ranked in order of treatment priority following a nurse’s assessment. If a patient is flagged as at-risk, either by a computer-based triage system at CHUM or by manual triage at Hôtel-Dieu and Notre-Dame Hospital, the triage nurse stamped an “OPIOD” label on the patient’s chart. This stamp alerted the ED physician to assess the patient for take-home naloxone or B/n eligibility using a clinical decision algorithm.
The ED pharmacist could in parallel recommend take-home naloxone and OAT initiation assessment with an ED physician for all patients at risk of overdose, including patients who were unconscious due to overdose or those that had received intravenous naloxone in the ED.
Training of ED staff
The SuboxED ED staff training plan consisted of the 3 training formats: 1. online modules, 2. in person clinical course; and 3. Clinical question and answer sessions.
Two 20-minute online training modules explaining the use of the Clinical Opioid Withdrawal Scale (COWS) and the provision of THN were created by a group of key training leads including nurses and physician specialized in addiction medicine from the CHUM. These COWS modules were developed specifically for ED staff and provided general information about naloxone, overdose risk factors, signs and symptoms of an opioid withdrawal or overdose. The training modules are available the online provincial learning management platform (https://fcp.rtss.qc.ca/ena-login/index.html). Pre and post training competency verification tests are integrated into the training plan with systematic personalized feedback to those who failed the post-test. In addition to these online modules, a 60-minute in-person course was offered at ED team meetings. At Notre-Dame Hospital, training leads offered a 30-minute in-person session on a regular basis during the SuboxED project training window to answer questions and explain the new project to all ED staff.
ED head nurses prioritized completion of the two online modules in their annual curriculum training, within the SuboxED project training window of November 2018 to March 2019. Human resources departments’ facilitated training uptake by making training time paid time for ED staff. The results of the ED staff training are included in Table 1. When we excluded the attendees who did not complete the training, competency verification failures were mostly anecdotal post review.
Topics covered during the training included: epidemiology of opioid use disorders; DSM-V criteria for diagnosing opioid use disorders; indications for opioid agonist therapy, THN, and ED-initiated B/n; overdose recognition and prevention education; protocol for B/n initiation; and the adverse effects of B/n, including induced withdrawal (Figure 2). The treatment algorithm and the clinical tools were presented to ED staff at team meetings, to increase the ED- staff awareness, implement new evidence-based practices and to promote skill retention and increase rapid incorporation of this algorithm into their practice.
Availability and complete engagement of head nurses, ED physicians, and pharmacists to support their teams, identify and solve operational problems, and to ensure practice adoption and sustainability, were imperative to the implementation phase.
THN and B/n ED prescription templates, were reviewed and approved by each participating health centers’ medical board. For THN, after the patient was flagged for opioid exposure by the triage nurse or pharmacist, the emergency physician checked for eligibility of the screened patient (Figure 2). Patients who received take-home naloxone in the ED were provided information to ensure that they understood why they were at risk and knew how to use the naloxone if they witnessed an overdose. Family members and significant others were invited to the information session if available.
The information given included how to recognize the signs of an opioid overdose, how to contact local emergency services, and how to stay and assist the person until help arrives, as highlighted in the information card from Health Canada (https://www.canada.ca/content/dam/hc-sc/documents/services/publications/healthy-living/opioid-overdose-wallet-cards-public-events/full-wallet-card-eng.pdf).
Triage was carried out in the same way as for THN but with differing criteria. Inclusion criteria for the prescription of B/n by an emergency physician were: meeting the criteria for opioid use disorder using the DSM-V (13), having a COWS score ≥12 (i.e. moderate to severe withdrawal) or no opioid use for ≥5 days, and having no contraindication. Multiple substance use disorders, pregnancy, and acute pain were the main exclusion criteria for B/n initiation; these exclusion criteria did not apply to take-home naloxone. Patients who had exclusion criteria were referred to the drug addiction expert of each hospital for evaluation and follow-up.
When a patient was confirmed eligible (no exclusion criteria, all inclusion criteria) and consented, the ED physician initiated 4 mg of sublingual B/n under nurse supervision. Patients were re-assessed 1–2 hours after the first dose for B/n-induced opioid withdrawal. In the event of withdrawal, the ED physician prescribed an additional opioid or contacted a physician with expertise in addiction medicine.
Additional doses of 4mg B/n could be administered every 2 hours until the patient was free from withdrawal symptoms or until a dose of 12mg was reached. If considered appropriate, these additional doses could be prescribed and retrieved at a retail pharmacy, thus reducing the patient’s ED stay. If the patient had an opioid use disorder and a COWS score of <12, and no contraindication to be released from the ED, a prescription for B/n would be faxed to the patient’s preferred pharmacy among eight participating locations for an in-pharmacy outpatient induction.
Patients discharged from the ED received: an instruction card detailing the use of B/n; information on take-home naloxone, overdose, and opioid withdrawal management; the address of the selected pharmacy; and a follow-up appointment at an opioid agonist therapy clinic within 5-7 days.
The physician also indicated to the retail pharmacy the initial ED-administered dose and the final dose to be administered along with B/n dosage adjustments for withdrawal symptoms (to be further verified at the retail pharmacy). The maximum dose given during the first 24 hours was 12mg. The clinical tools and ready-to-use printed prescriptions facilitated this task for ED physicians to ensure dosage safety.
An addiction medicine expert was always available to answer clinical questions from ED physicians and pharmacists and was ready to take charge of more complicated cases directly on site. Participating retail pharmacists sent a memo to the opioid agonist therapy clinic regarding follow-up for patients, in accordance with their professional code of ethics.