Board 339 - Research Abstract Patient Simulation for Assessment and Reinforcement of Layperson Management of Opioid Overdose with Intranasal Naloxone in a Recently Released Prison Inmate Cohort (Submission #66)

Abstract

Introduction/Background Individuals who accidentally overdose (OD) with opioids, especially those recently released from prison, are at significant risk for death. Investigators initiated a program to assess, educate, equip and reassess at-risk, volunteering prison inmates in opiate OD prevention, recognition and naloxone administration for post-release exposure to OD situations. Methods Inmates expressing an interest in study participation after recruitment announcements, mailings and posters were approached for consent. Those agreeing to participate underwent a baseline assessment of OD-related knowledge, including recognition of opioid OD and awareness of naloxone. The study intervention was an educational DVD with standardized didactics; skills practice was not feasible during incarceration. Subjects were provided with an intra-nasal naloxone kit at time of release and scheduled for followup assessment. In order to evaluate subjects perception, acquisition, retention and delivery of layperson resuscitative skills for opioid OD at post-release followup, emergency medicine, simulation and substance abuse investigators developed an OD simulation script with accompanying 24 item assessment checklist for a low-fidelity full-body manikin. The scenario was designed to elicit, record and positively reinforce subjects performance of basic airway maneuvers, rescue breathing, naloxone administration, accessing of emergency services, avoidance of harmful actions and continued monitoring. Drug use props, distractor decoys (for common OD treatment errors) and ambient noise were provided. Investigators designed the simulation scenario for administration with video-recording as part of an assessment battery* that evaluated each subject soon after release. Pre-pilot sessions tested the scenario for feasibility and research utility. The study was IRB approved. *Assessments include the validated Brief Overdose Recognition and Response Assessment [BORR],1 questionnaires on OD risks, naloxone risks and perceptions of self-efficacy/confidence in pertinent knowledge and skills. Results One hundred sixty six inmates expressed an interest in study participation, of whom 99 (60%) consented to participate and completed the baseline assessment; 94 completed the study intervention training while incarcerated. Subject demographics were representative of the target population: average age 34.2 years; male 85%; race: white 81%, African American 7%, American Indian 5%, Hispanic/Latino 11%. 88 subjects received a naloxone kit. Six-month interim follow-up data were available for 40 subjects (43% of trained recruits) out of a projected cohort of 100 subjects. None of the follow-up subjects reported OD’s after release; 60% reported engaging in OD protective behaviors since release, including 3 naloxone administrations. At followup, subjects exhibited significant gains in OD recognition and response (naloxone administration) knowledge and self-efficacy scores as recorded by BORRA and questionnaires. Subjects scores on critical action checklists during simulation scenario at followup averaged 11.4±4.0 (range 3–22, out of 24 total correct actions). Average time to assemble the kit and administer intranasal naloxone was 55 seconds. Naloxone was administered IV, IM and without intra-nasal atomizer to the manikin by one participant each. Five participants incorrectly administered the naloxone (e.g., one nostril only or half the dose). Three participants stated they did not know how to put the naloxone together during the simulation; 5 individuals (12%) self-corrected themselves during the simulation. Additionally, potentially harmful interventions such as slapping, kicking or hitting the manikin were observed during 17 (46%) simulation sessions and unnecessary chest compressions were often performed. Conclusion Investigators developed and initiated an opioid OD prevention program for at-risk prison inmates, with a simulation component for hands-on demonstration of knowledge and assessment of skills at follow-up. The variation in in-simulation performance across subjects and relative to traditional assessment tools appears to support the utility of simulation as an evaluative methodology to assess layperson OD management skills. Reference 1. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction, 2008; 103(6): 979–89. Disclosures Part-time employee of Inflexxion Inc. University Emergency Medicine Foundation (research grant 2009) intellectual property (copyrights; patent pending) on GLIDEPATH system.