Safety of a Modified Community Trailer to Manage Patients with Presumed Fentanyl Overdose

Abstract

Opioid overdoses (OD) cause substantial morbidity and mortality globally, and current emergency management is typically limited to supportive care, with variable emphasis on harm reduction and addictions treatment. Our urban setting has a high concentration of patients with presumed fentanyl OD, which places a burden on both pre-hospital and emergency department (ED) resources. From December 13, 2016, to March 1, 2017, we placed a modified trailer away from an ED but near the center of the expected area of high OD and accepted low-risk patients with presumed fentanyl OD. We provided OD treatment as well as on-site harm reduction, addictions care, and community resources. The primary outcome was the proportion of patients requiring transfer to an ED for clinical deterioration, while secondary outcomes were the proportion of patients initiated on opioid agonists and provided take-home naloxone kits. We treated 269 patients with opioid OD, transferred three (1.1%) to a local ED, started 43 (16.0%) on opioid agonists, and provided 220 (81.7%) with THN. Our program appears to be safe and may serve as a model for other settings dealing with a large numbers of opioid OD.

Appendices

Appendix 1: Trailer Supplies (*Ultimately Used for Patients with Opioid Overdose)

Basic Equipment

• 4 Chairs

• 2 Stretchers with cardiopulmonary monitoring

• 1 Workbench for nurses and physicians

• 1 Refrigerator with at least 20 juices and 20 sandwiches per day

• 1 Warmer with warm blankets and spare clothing

• 1 Microwave

Standard Medications

• Intravenous lines and normal saline*

• Antiemetics including dimenhydrenate and ondansetron*

• Naloxone/take-home naloxone kits*

• Antiseizure medications including phenytoin

• Sedatives including benzodiazepenes and quetiapine (for induced withdrawal)

• Analgesics including acetaminophen, ibuprofen*

• Opioids: hydromorphone, long-acting morphine, and buprenorphine/naloxone*

Critical Care Equipment

• Oxygen*

• Bag-valve mask

• Difficult airway cart including endotracheal tubes, stylets, and intubating blades

• Vasoactive medications including epinephrine

Office Supplies

• Standardized paper forms including medical charts, applications for government assistance, and information regarding detoxification and housing, etc.

• Computers and printers

Appendix 2: British Columbia Ambulance Service Criteria for Transport of Patients with Opioid Overdose to the Trailer

• Patients had to be greater than 15 years of age, not pregnant, cooperative, and willing to be transferred.

• Patients could not have obvious acute medical, surgical, traumatic, obstetrical, or psychiatric illness, including severe agitation.

• Patients could not have additional ingestions of other prescription or illicit drugs.

• Patients had to regain normal vital signs prior in the field prior to transfer: Glasgow Coma Scale 15 and cooperative, respiratory rate > 12, oxygen saturations > 95% on room air, systolic blood pressure > 90 mmHg, and temperature from 35.0 to 37.5° C.