Quality improvement in action: Cutting opioid overdose deaths in half
A cross-agency collaboration in Lowell, Mass., uses an overdose data-driven approach to improve performance and save lives
By Mike Taigman and Jon Kelley, FireRescue1 Contributors
When was the last time you saw a cop hug a homeless addict and tell him, “I love you and hope that you get into rehab soon?” If you live in Lowell, Massachusetts, it’s a pretty common sight. In Lowell, opiate-related overdose deaths have been cut in half through a compassionate collaboration between the Lowell Fire Department; Lowell Police Department; Trinity EMS; Lowell House; the District Attorney of Middlesex County, Mass. and others.
Unless you are totally unplugged from the news, you know that America is in the midst of an opioid overdose epidemic. According to the CDC, during 2015, 91 Americans died each day from opioid overdose. This year, it’s on pace to be 161 deaths per day. Lowell is not on the list of the top 20 worst cities in America for opiate problems, but it’s second in the state of Massachusetts.
Decide that you have an opioid problem
In January of 2015, the city manager asked the folks at Trinity EMS what data they had on overdoses related to heroin, fentanyl and oxycodone. An EMT volunteered to help with the project by reading all the patient care records since the beginning of 2014. That EMT found that overdoses doubled in May of 2014 and had been increasing nearly every month since then.
To help them really understand the evolving crisis, they worked with FirstWatch to create a system that alerts them every time a crew runs on an overdose-related incident. The system also aggregates and tracks these calls, monitors and alerts for surges in overdoses, and geographically highlights overdose locations.
Organize a team and a strategy to address the problem
Led by the Lowell police chief and fire chief, the Community Opioid Outreach Program (COOP) was created. Each chief assigned employees to this project full time along with Trinity EMS and Lowell House, an opioid addiction treatment facility. The objective of the COOP is to decrease overdose-related deaths and the suffering related to addiction.
One member of the team lost a relative to an opiate overdose. He asked his chief how he could help prevent this from happening to other families in their community. He, along with his colleagues from EMS, law enforcement and the treatment community, are kind, compassionate and experienced. They have a laser focus on preventing the next overdose.
Every time an EMS crew, fire crew or police officer is dispatched to an overdose-related call, members of the COOP receive an alert via e-mail and on their smartphone app. The day after a patient has been resuscitated from their overdose, the COOP team tracks them down wherever they are for a visit.
One of the most effective strategies to preventing overdose death is to help people who use opiates get into rehabilitation. The COOP has a direct line to in-patient beds and out-patient appointments. They are able to cut through the normal red tape and get people admitted quickly.
Often, one of the challenges involved with getting people to accept rehabilitation is that they often don’t remember how bad things were during their overdose. The team was visiting with a 28-year-old man in his home with his 3-year-old daughter sitting next to him. They were talking about getting him into rehabilitation. The man was brushing the incident off as no big deal and he was refusing rehab.
The Trinity EMT on the team pulled up the patient care report from the day before using the app on his smartphone. He read the narrative to the man, explaining what the medical jargon meant along the way, “Patient found unconscious, unresponsive and apneic – that means you were totally out and not breathing. With vomit on his shirt and feces in his pants. Skin was cool and cyanotic – that means you were cold and blue. You were close to death and you looked like it. Ventilations were supported with a bag-valve-mask – meaning that we had to breathe for you since you’d stopped breathing for yourself. Two mg of Narcan administered IV, continued ventilating for five minutes – that means that we gave you a high dose of the medication to counteract whatever it was that you shot-up and it still was not working. Two more mg of Narcan – that means whatever you shot was probably not heroin. Patient respirations restored – meaning that you were finally able to breathe on your own.”
After hearing what actually happened and realizing that his 3-year-old daughter had witnessed the whole thing, he allowed the team to admit him to a rehabilitation bed on the spot.
Policies and procedures to curb overdoses
The real-time monitoring and analysis of overdoses allows the COOP to spot when a new batch of opiates comes into their service area and geographically fence the area that’s hardest hit. One day they had six respiratory arrest overdoses in 15 hours. The COOP launched a social media campaign on Facebook and Twitter about the dangerous new batch of drugs that had entered their community.
They reached 20,000 people in two hours and 150,000 in 72 hours. It was on TV news within five minutes of launching the campaign. Overdoses dropped off within a day or so of their social media campaign.
Additional steps include:
- All Lowell Fire Stations are safe havens for rehabilitation. That means that someone who is using illegal drugs can come to any fire station and be referred to rehabilitation without fear of getting arrested for possession.
- They have tested several theories about opiate use using data. For example, there is no correlation between day of the week or between when Social Security checks are administered and overdoses. But there is a relationship between overdoses that occur outdoors and the proximity of the drug purchase. This is helpful for law enforcement working to arrest dealers. All of the 200 communities included in the 13 towns served by Trinity, across all socioeconomic backgrounds, have had at least one overdose.
- The COOP has been effective at pushing insurance companies to cover drug treatment even when reluctant.
- The Coop has developed a short presentation on overdoses for businesses and the general public. This presentation includes what a narcotic overdose looks like, when to call 911 and what to do with a needle when you find one.
- Because Trinity has such a deep dataset and the tools to analyze it, they have become the go-to agency for questions about the crisis. Recently, someone was asking about the number of overdoses that happen in public bathrooms. Trinity had the answer.
- The District Attorney became concerned about the impact this crisis was having on children. It’s estimated that 34,000 children are being raised by grandparents or others because their parents are dead, in jail or otherwise unavailable due to addiction. She launched Project CARE (Child Assessment and Response Evaluation) to help provide immediate services to children who experience opioid-related trauma. The COOP team activates this resource anytime they see toys, car seats or other evidence of children.
The opioid crisis shows no signs of slowing down across the country. Using a data-driven approach to performance improvement, it’s possible to save lives and decrease suffering for people who suffer from addiction and the people who love them.
About the authors
Mike Taigman uses more than four decades of experience to help EMS leaders and field personnel improve the care/service they provide to patients and their communities. Mike is the Improvement Guide for FirstWatch, a company which provides near-real time monitoring and analysis of data along with performance improvement coaching for EMS agencies.
He holds a Master’s Degree in Organizational Systems and is an Associate Professor in the Emergency Health Services Management graduate program at the University of Maryland Baltimore County. He’s also the facilitator for the EMS Agenda 2050 project. Email Mike Taigman at email@example.com.
Jon Kelley is the director of communications and information technology for Trinity EMS. An award-winning expert in the field of opioid related data analysis, program development and community engagement, he regularly presents at conferences and workshops.