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Overcoming barriers to micro-dose Suboxone initiation from ER
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In Victoria we have started micro-dose inductions of patients with opioid use disorder to build on the success of standard opioid inductions started in 2017 ( over 200 to date! ).We want to make this a minimal barrier process, ideally with patient leaving with a blister pack of Suboxone micro dose with instructions and daily partitioned doses and linkage to outpatient OAT providers. It may take several days to get to outpatient provider so dispensing multiple days of the induction regime makes sense.
We have come up against a hard barrier of inability to dispense more than 24 hours of medication from the ED according to our pharmacy colleagues.
Is this a legislative barrier, an edict from college of pharmacies or a local health authority ( Island Health) issue?
Has anyone been able to set up a program that allows them to dispense blister packs from the ED for this vulnerable population?
It seems with the opioid death rate and the extra financial and political resources cast into this arena that this sort of barrier should be easily surmountable?
Jason Wale, Victoria BC
Jason Wale
December 10, 2020
New Comment • January 20Flag a comment
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Hey Jason, in Terrace (Northern Health) we have to-go packs of suboxone we can dispense from the ED. I think it's 3 or 4 days of medication which covers them for enough time to see the OAT clinic regardless of what day the induction was started. We don't have anything for microdosing but I think the principle of hospital pharmacy dispensing should be the same? SIM Cases
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Minimal small ER standard supports
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HiJust wondering if there is any work/research/thoughts anywhere about what are the minimum standards to work in an ER. I see some ERs have no lab or XRAY. Some have limited POC. Some have one nurse and others have none. In some ERs , the docs are first call.
Is there a link between the population, which in turn dictates the acuity and frequency of the cases and the minimum standards ER docs need to have to support quality care?
Just curious if anyone has ever thought about this?
nancy humber
November 17, 2020
New Comment • January 19Flag a comment
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Do we even have an inventory of what services BC EDs provide, or the hours? Or in Australian terms, what level the EDs qualify as? Interestingly, the Australian document says nothing about data. (For example, whether the notes are electronic or paper, or where data [ie discharge diagnoses] are sent...) -
New CCS atrial fibrillation guidelines
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Hello all, please be advised that there are changes in the management of atrial fibrillation: the 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for theManagement of Atrial Fibrillation have just been released.Hopefully the attachment works for everyone--while the document is 102 pages, the relevant points for emergency physicians have been highlighted to avoid eyestrain and guideline rage, and most of the germane information starts on page 38 (anticoagulation) and on page 51. (ED management)
Good news: The main points of ED management are now aligned with the CAEP guidelines.
1. Ensure patient is stable, otherwise immediate cardioversion (this is rare).
2. Ensure no acute underlying cause; if there is an underlying cause, please identify and treat
3. a. For patients with acute onset atrial fibrillation or flutter, (generally less than 48 hours, but less than 12 hours if CHADS2 > 1) please use a rhythm control method.
3.b. For patients who cannot be undergo rhythm control, attempt rate control.
4. Unless a patient is still symptomatic after treatment, or if the heart rate cannot be decreased to less than 110 beats per minute, patients can be safely discharged.
5. Pay attention to anticoagulation! At least discuss with patients and document appropriately.
Bad news: CCS has again emphasized 4 weeks of anticoagulation in every patient who undergoes rhythm conversion. CAEP has published 2 editorials arguing for a more nuanced approach (ie does every 35 year old mountain biker need a month of anticoagulation) but CCS is holding firm despite admittedly weak evidence.
A group of motivated CAEP members will be updating the CAEP 2018 guidelines to ensure congruence with the CCS approach, while hopefully maintaining some flexibility.
Keep ya posted!
Frank Scheuermeyer
January 19, 2021
New Comment • January 19Flag a comment
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Find the 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation file here. -
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Jason Wale
Royal Jubilee Hospital
December 10, 2020