Elizabeth (Liz) Dogherty is the Clinical Nurse Specialist for Substance Use in the Urban Health Program at Providence Health Care, in Vancouver, B.C.. St. Paul’s Hospital opened an overdose prevention site (OPS) in 2021 in response to the public health emergency. Liz discusses her experience and reflections on the implementation process, to help mobilize knowledge through the Hospital-Based Supervised Consumption Services Community of Practice. Responses have been edited for clarity and length.
How did your organization identify the need for a hospital-based supervised consumption service?
In May 2018, St. Paul’s Hospital (SPH) became the first hospital in Canada to open an Overdose Prevention Site (OPS) in partnership with Vancouver Coastal Health and RainCity Housing. The Thomus Donaghy OPS was an outdoor supervised consumption service. It was the first OPS in the City of Vancouver that was located outside of the Downtown Eastside. It was on hospital property but was staffed by people with lived/living experience from RainCity.
The OPS started out as a tent in the hospital’s parking lot, then eventually moved into a trailer there. At the end of 2020, the OPS moved a couple blocks away, off hospital property. Since we knew that about 20 per cent of the site’s clients were St. Paul’s patients, we realized we needed to continue to provide this type of service.
Photo of Liz Dogherty (left), Clinical Nurse Specialist at St. Paul’s Hospital, with colleague Carlin Patterson, Nurse Educator. Together, they opened the hospital’s overdose prevention site in February 2021.Can you give a brief description of your site/program, including what services you provide and how patients access the site?
The new indoor site is on the fourth floor of the hospital. There are no other acute care units on that floor, it’s right across from the cafeteria. Also, on the fourth floor, we have an outdoor patio/garden, which is where people often go to smoke cigarettes.
When the site was in the hospital’s parking lot, it was staffed by peers with lived/living experience. Given that people who are in our hospital clearly have acute medical needs, we decided to staff our hospital’s site with two licensed practical nurses. We have since added peers to create a peer-nurse model, which is ideal.
Our site is open from 10 AM to 8 PM. We offer supervised injection, drug testing strips, safer use/harm reduction supply kits (smoking and injection supplies), take-home naloxone kits, and harm reduction education. A common topic of harm reduction education that patients ask for is how to access their IV line to use non-prescribed substances, so we provide education and support around that.
We decided to limit the use of our site to hospital’s inpatients as well as outpatients who are accessing our outpatient clinics and patients in our emergency department. Of course, we do not turn people away. If someone who we know is not a patient seeks our services, we let them access the site but then direct them to community sites nearby.
Does the site link patients to other services?
If they're inpatients, most people will have a bed on a unit and they'll be followed by our Addiction Medicine Consult Team (AMCT), so that's where medication and treatment options would be made available to them through this service. The OPS is really focused on overdose prevention and response, and providing harm reduction education and services.
Our site is classified as an OPS, which is different from a supervised consumption site. Supervised consumption sites require an exemption to Health Canada’s Controlled Drugs and Substances Act, which can take a lot of time to obtain. See the resources section below for more information about the difference between OPS and SCS.
In 2016, at the beginning of the toxic drug crisis, the Minister of Health gave British Columbia’s health authorities the approval to open OPSs in areas where the need is identified under the Emergency Health Services Act. The goal of was to prevent deaths. I am not sure if we will apply for an supervised consumption site exemption. Right now, there is no time restriction on the OPS due to Ministry order M488, which supports this work.
We were the second hospital in Canada to offer supervised consumption services. The site in the Royal Alexandra Hospital in Edmonton, Alberta, was the first – their site has a Health Canada exemption. We relied heavily on and learned a lot from our colleagues in Edmonton, and from the other community-based OPS teams in Vancouver. We visited different sites in the community and learned so much from peers about how they respond to overdoses and how to make our site more accessible and welcoming.
A hospital does offer a different environment and there are certain things to consider. For example, people in hospital are often dealing with acute pain, they’re dealing with a lot of stress, they may be more likely to use substances, at least until they are titrated onto a medication like opioid agonist therapy.
What resources were required to get things up and running?
We needed several resources. For example:
- Supplies (e.g., safer injection and safer smoking supplies)
- Physical space. We had to set up the physical space, that included setting up booths, sharps containers, we needed a computer, a phone, a cell phone, etc.
- Housekeeping support to cleaning the site.
- Standard operating procedures for overdose response.
- Nursing Guidelines and supporting the nursing staff in their practice.
We required some financial resources, but also we needed time to figure out the logistics of setting up an OPS. Some examples of logistical items include how to move a client who is overdosing onto the floor and how to transfer them to the emergency department or the intensive care unit (ICU). This item required us to consult with our Occupational Health and Safety colleagues. They suggested several safety measures and equipment, such as transfer belts and a stretcher. Since we’re in a high-traffic area near the cafeteria, we also realized we would need a curtain in front of the OPS door so that we could maintain client privacy as people were coming in and out of the space.
Our Program Director’s fierce advocacy and strong voice was critical in communicating the need for an OPS to senior leadership and across the organization. Once that happened, he gave us the reins and we went with it.
While we’ve been open for two years, it’s still a work in progress. We will continue to change how we do things based the feedback we get.
Who were the key stakeholders that you and/or your team consulted?
We consulted our Occupational Health and Safety colleagues regarding transferring people safely from chair to floor during overdoses, and also air safety. For example, if someone is cooking a substance, will others in the space be exposed to that substance in the air, and should people be wearing masks to prevent exposure.
We opened during the COVID pandemic, so our colleagues in Infection Prevention and Control helped us manage air flow and protocols for managing COVID positive patients.
We consulted with the housekeeping team because they would be responsible for cleaning the OPS area.
We consulted with the neighbors around the site/areas adjacent to the site (e.g., the cafeteria, dietician office, etc.) to make sure they were aware of our site, what they might expect, and who to reach out to if there were any questions or concerns.
We liaised with our ICU colleagues and the ICU nurse educator, to walk through various aspects of our collaboration, such as what it would it look like for their team to come into the OPS site and respond to a code blue, what kind of supplies they would need, and how we might we support them.
We consulted with hospital security to discuss violence prevention and how to access their support in case of an incident. As a result, we installed some Code White buttons and a second doorway on the site.
We also engaged with patients to better understand their needs and preferences. We have peer support workers (people with lived and living experience of substance use) who work in a number of our hospital’s addiction services programs, so they’re always a good resource to engage with informally and ask questions about how we can best support patients who use non-prescribed substances.
How are you evaluating any outcomes/objectives/goals related to the service?
Vancouver Coastal Health keeps collects data from all OPSs and supervised consumption sites in the region, so every week we submit our data. They ask for basic information, such as the time the client came in and left, their "handle" (we don't require clients to provide their name), what substance they think they’re using, and whether they overdose. They also track all supplies and take-home naloxone kits we distribute.
We have an average of about eight to 10 supervised injection visits per day. However, that number doesn’t capture all our other harm reduction services, (e.g. sterile supplies, take-home naloxone kits, drug testing). Those were key pieces that we also want to capture, so we also have our own data collection form where we track important information and can change it when new things come up.
For example, we used to have a column for supplies to go, but then we realized we needed to differentiate between injecting and smoking supplies. That was really telling because we found that most people were picking up supplies for smoking, and we don’t do supervised inhalation in our space. People will often use the garden that is adjacent to our space to smoke, both cigarettes and substances, and unfortunately we have been seeing a lot of overdoses out there.
And so now we’re looking at how we can provide supervised inhalation. So that’s just an example of how we can use the data that we collect to notice trends and advocate for improvements to our service.
We wish we could’ve planned for evaluation sooner, but it’s a work in progress and we continue to improve. Right now, we are collecting the data manually. So we are now working with our data analytics team to develop an electronic database, which will make data collection a lot more efficient and easy to retrieve.
So, I think there are different ways you can think about what data you want to look at and how you want to measure success. Overdoses reversed and lives being saved are important, of course, but you can’t underestimate the value and impact of all the other impacts of the harm reduction interventions that are being offered.
What are some of the barriers that you and/or your team encountered? How did you address them?
It’s interesting. I expected some more resistance to our OPS because of stigma, so I thought we would get some complaints or concerns. There were a few but not as much resistance as I expected.
One challenge that we encountered was the code response. In the beginning we called quite a few Code Blues, so a whole team of people would show up to resuscitate a patient, and the responding ICU physician would want a physician to hand off to. Now, we have a new process for Code Blues. The OPS nurse will call the patient’s doctor or nurse on the unit and have them come to the OPS to give support and receive the handoff from the ICU team.
We also worked with our ICU colleagues to develop a process that allows our OPS nurses to give a couple doses of naloxone and wait for a response before calling a code blue. This has resulted in far fewer codes as our nurses got more experienced at responding to overdoses. As a result, we were able to adapt our Standard Operating Procedures for overdose response, which was really helpful in reducing our use of ICU resources.
Lack of supervised inhalation space. Many people smoke their substances, but we are not allowed to have an enclosed space for supervision of these clients as a result of the smoking bylaw. So we’re now working on a proposal to set up some sort of tent in the garden so that we can provide this service.
Privacy and confidentiality. We wanted to make the space as welcoming as possible and protect people’s anonymity and make it a non-judgmental space. Being part of a hospital, we are required to include all hospital services on a patient’s chart, which makes it difficult to maintain the level of privacy and confidentiality around their drug use that the patient may want. We now have a “Program Expectations” form that explains our processes to everyone who comes to the OPS. The form states that patients will remain anonymous unless they require a medical intervention, in which case we will inform their doctor or nurse on the unit, and add it to their chart if they are an inpatient.
What factors influenced implementation success?
Definitely dedicated and passionate people. At our hospital, we have a policy document, it’s a philosophy of care for patients and residents who use substances. It has harm reduction language and sets the expectation for harm reduction approaches to be offered. If someone discloses that they're using substances, it doesn't result in a discharge from hospital or punitive response, which may have happened elsewhere. In our organization we have a policy around that, which provides a foundation for what we do, that is communicated to throughout the organization.
We are also a smaller organization. We know our colleagues in different areas of the hospital pretty well, which is a big factor in our success because you already know the people you're working with, so we have a shared understanding that we're in a drug poisoning crisis and staff need to support patients at risk.
What do you wish you had known before embarking on this journey? (What surprised you the most?)
After a patient is brought back from an overdose, they need to be transferred back to their unit for ongoing monitoring, because we can't provide ongoing care in the OPS. The nurse in the OPS calls the nurse on the unit, gives them a report, then takes the patient back up to their bed or care area. But what we didn't realize was that nurses on the units needed some guidance and direction on how to care for someone post-overdose. We realized that training for overdose prevention and response isn’t necessarily mandatory for nurses so they had many questions, such as monitoring needs or naloxone dosing frequency. They didn't feel comfortable providing care without more direction, so we developed a one-page “practice pointer” on how to continue monitoring patients post-overdose.
Another thing is recognizing that the drug supply is constantly changing, so it requires quite a lot of adaptability. I wish I had known how quickly things can change. Especially around how we can support people who inhale their substances. It's unfortunate that we're still seeing overdoses in the hospital from people smoking, and that's something we didn't really consider. Things change so quickly in the community and with the drug supply so we need the ability to be nimble and change what we’re doing to meet peoples’ needs.
We have recently incorporated some peer support workers in our program. The peers have such a different perspective and on-the-ground knowledge. I wish we had incorporated them from the beginning, but it wasn’t an option at the time. The more we work with peers, the more we realize they're teaching us so much about the nuances of overdose response.
Another thing that surprised me was how quick people are to give extra naloxone doses during Code Blues. Healthcare providers needed education around overdose response, to understand that naloxone is going to reverse the respiratory depression, so we don’t need to keep giving more naloxone until the patient wakes up.
Another thing I wish we had known was how to support patients who want to use their IV lines to inject. We conducted an extensive ethics consultation regarding this issue. Although there is not a lot of evidence on this practice, we can still use what we know about maintaining the sterility of IV lines and to do some education about the risks of using their IV lines. If the patient still chooses to do this, we can support them by teaching them good technique. We developed an internal guideline, which we’re testing right now. This is the most common topic that patients ask for related to harm reduction education. They are usually experienced substance users.
What drug testing approach are you using?
We have test strips for benzodiazepines and fentanyl. I don't know if most people use the fentanyl strips because fentanyl is known or expected to be in most substances. More patients are looking for benzodiazepine test strips, but we need to be very clear with patients that the test strips won’t detect many of the benzo analogues in the street supply.
Could you provide any final few words of advice to other hospitals looking to implement supervised consumption services?
It's possible. You can do it.
One of the hospital’s policies that we had to change when we opened our OPS was the prohibition against patients bringing in non-prescribed substances. Before we set up our site, our staff had to send their patients outside to use their substances, which caused staff moral distress because it put patients at high risk of overdose. What we’ve heard from informal staff feedback is that they appreciate being able to send patients to a safe place because they don’t need to worry whether the patient will be safe or are going to overdose. Now, we have a post card that nurses can give patients with the information they need to find our site. This reduces that moral distress and gives patients another option other than using on the unit or in unsafe, unsupervised spaces such as public washrooms and stairwells.
Resources
- Canada’s Supervised Consumption and Overdose Prevention Sites – Pivot
- What’s the difference between a supervised consumption site and an overdose prevention site? – CBC
- Liz and colleagues published an article in the Harm Reduction Journal that describes the implementation of their OPS: Implementation of a nurse-led overdose prevention site in a hospital setting: lessons learned from St. Paul’s Hospital, Vancouver, Canada.