By Justin Eberly, Education Specialist, VFIS Education, Training & Consultant
The extent of our nation’s opioid epidemic is reaching crisis levels. The United States Health and Human Services has seen a rise in the rate of overdose deaths to four times as many as were reported in 1999, with an average of 78 Americans dying every day from an opioid-related overdose.1
As opioid-related dispatches become a common occurrence in EMS systems across the nation, many agencies have evolved airway management and Naloxone administration practices in response to the crisis. Naloxone (also referred to by a trademark name NARCAN), stops or reverses the respiratory depressing effects of an opioid overdose. It has recently been approved by the FDA for expanded use.2 Many regions have leveraged “user-friendly” routes of Naloxone, placing doses in the hands of more responders, including law enforcement, fire department personnel and, in some areas, even bystanders.2
Opioid Overdose: The True Cause of Death
While greater access to Naloxone is expected to reduce the rate of opioid-related overdose deaths, the need to emphasize proper airway management remains a priority for both bystanders and professionals. Victims of an opioid overdose are typically found with ineffective respirations at a rate of less than 10 breaths per minute.3 The mechanism of death for an opioid overdose is most often associated with respiratory depressing effects.3
The American Heart Association recommends standard ACLS for cardiac arrest presumed to be secondary to an opioid overdose.4 No recommendation regarding the administration of Naloxone has been made.4 The Emergency Medical Dispatch system has addressed public-access of Naloxone, instructing callers to administer Naloxone then monitor breathing.5 It was found that Naloxone deployment protocols vary around the country.
Airway Management in Conjunction with Naloxone
Providers must adhere to their local protocols and medical direction. For example, those with training or resources limited to basic first aid, a simple head-tilt chin-lift and rescue breaths are proactive steps to airway management. As basic life support arrives, nasopharyngeal and oropharyngeal airway adjuncts with bag-valve-mask ventilation are a crucial next step to maintaining the airway. Airway suctioning is another capability of basic life support. Advanced life support provides a wider variety of airway options, from endotracheal intubation to other airway rescues where deemed necessary. Regardless of the jurisdiction, the treatment of a patient is a collaborative effort between many individuals, from the bystander to the attending physician.
Following a review of opioid overdose protocols nationwide, actions to establish a patient airway were generally addressed either before or immediately following Naloxone administration. In jurisdictions where Naloxone was not immediately available, effective airway management was a priority aimed at maximizing the potential for a favorable patient outcome until Naloxone administration. Even after the administration of Naloxone, continual monitoring of the patient’s airway remains essential. Patients, especially those opioid dependent, may experience vomiting among many other Naloxone side-effects.2 Attentiveness to airway secretions and respiratory quality will prompt action in avoidance of aspiration, airway compromise or in some cases, additional doses of Naloxone. Frequent assessment and reassessment will prove to be invaluable in treating an opioid overdose and subsequently its respiratory depressing effects.
The respiratory depressing effects of opioid overdose can still result in respiratory and/or cardiac arrest even after the administration of Naloxone. Airway management remains one of the fundamental skillsets of the EMS provider, yet often can become the most unwieldy. The plethora of environmental factors, copious secretions, and the urgency of airway management seem to always create a less than ideal set of challenges for all EMS providers, especially paramedics, when opioids are involved.
Aid Rendered Prior to EMS Arrival
As firefighters, police officers, and bystanders become Naloxone-equipped, additional tiers to the traditional “transfer of care” are introduced. The actions and accounts of these individuals are pertinent to the care provided by EMS and healthcare providers down the road. Consequently, these actions and accounts must be uncovered by EMS providers and documented in the EMS PCR. Proper documentation is an effective way to minimize the risk associated with transfer of care, even if “care” is being transferred from a non-EMS responder or bystander. Documentation should detail the entirety of the patient care timeline, ensuring the times of interventions, assessments, and transfers, be documented precisely.
Communication is Key
In the hospital setting, communication was identified to contribute to 65%–70% of clinical mistakes.6 In respect to medication error, an average of 39% errors was deemed vulnerable to ineffective communication during the end-of-shift transfer of care.6 Using a standardized process, 55.1% of nurses surveyed had personally discovered errors during the end-of-shift transfer of care, subsequently taking action in the best interest of patient safety.6 Every “near miss” provides ample opportunity to take corrective actions in prevention of an event.
In 2013, the American College of Emergency Physicians (ACEP), Emergency Nurses Association (ENA), National Association of EMS Physicians (NAEMSP), National Association of Emergency Medical Technicians (NAEMT), and National Association of State EMS Officials (NASEMSO), collaboratively identified the importance of effective transfer of care procedures between EMS and the receiving facility.7 The cohort asserted “all members of the healthcare team, including EMS providers, nurses, and physicians, must communicate with mutual respect for each other and respect the verbal and written communication from EMS as an important part of the patient’s history.”7 Further, the group acknowledged a deficiency in the transfer of care between EMS and the receiving facility. From a risk control and patient safety standpoint, an emphasis was placed on a combination of verbal and written communication in the transfer of care process, citing both methods independently have their fallacies.7
Systems can facilitate verbal communication through the adoption of a standard “hand off” report such as I-PASS8. Integrating a transfer of care report form can serve as a facilitator for verbal communication and contribute to written documentation, including a signature by the receiving provider. Particular criteria, such as advanced airway placement, may require additional communication and documentation. VFIS, a division of Glatfelter Insurance Group, provides the Advanced Airway Verification Form for completion by the receiving provider not only supports the transfer of care, but also verifies the advanced airway placement was viable9. This verification should be obtained before transferring the patient from the EMS stretcher to the hospital bed.
Communication is an integral part of continuity of care. The observations and actions prior to EMS arrival, including airway management and Naloxone administration, should be ascertained by EMS personnel upon arrival. This information should be communicated verbally and documented in writing where possible, reducing the risks faced by those involved in providing care. Effective communication between anyone rendering initial aid on-scene and transporting EMS personnel is a key factor in providing quality patient care.
1. The Opioid Epidemic: By the Numbers. (2016, June). Retrieved November 11, 2016, from United States Department of Health & Human Services: http://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf
2. FDA. (2015). FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose.
3. White, J. M., & Irvine, R. J. (1999). Mechanisms of Fatal Opioid Overdose. Addiction, 961-972.
4. American Heart Association. (2015). Guidelines for CPR & ECC.
5. Priority Dispatch Corporation. (2015). Advanced Medical Priority Dispatch System.
6. Triplett, P., & Schuveiller, C. (2011). Nurses' End-of-Shift Reort Process and Implementation of a Standardized Report Format Tool and Bedside Handoff. Critical Care Nurse, 43-44.
7. ACEP. (2013, October). Transfer of Patient Care Between EMS Providers and Receiving Facilities. Retrieved November 14, 2016, from American College of Emergency Physicians: http://www.acep.org
8. Starmer AJ, S. N. (2014). IPASS Study Group. New England Journal of Medicine.
9. VFIS. (2016). Airway Verification Form.
Justin M. Eberly is an Education and Training Specialist for VFIS, responsible for the national delivery of educational and training programs, curriculum development, and information analysis. He is an active Emergency Medical Technician (EMT) in Cumberland County, Pennsylvania and currently serves in a variety of local emergency management roles, including training officer.