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Dispensing naloxone in the emergency department

At the triage desk, Jayne listens to the soft-spoken man in front of her. He’s asking for a naloxone kit for himself. She recognizes Mick—he’s been treated several times in the emergency department for conditions related to opioid use.

Dispensing naloxone 

As she explains that he must register and see a physician before he can receive a kit, Mick’s frustration is evident. He quietly repeats, “I’m feeling good today and don’t need to see a doctor. And I don’t want to go through all the time and effort to get registered and wait to be seen. I just need a naloxone kit.” 

Jayne notes that this is not the first time this situation has occurred: a number of people have been coming into the emergency department (ED) requesting a kit for themselves but they don’t want to register, see a physician, or share their personal information. It’s a busy ED, and this situation is frustrating for everyone.

Is there a better way?

Jayne and her colleagues pride themselves on providing competent and compassionate care to all the clients they see in the ED. They recognize the importance of following organizational policies for registration, triage and assessment, and of meeting regulatory standards, to ensure safe care for all those presenting to the ED. 

However, Jayne and her colleagues are worried that requiring individuals in this situation to follow these processes may result in them leaving without a kit, putting them at risk of dying from an overdose. She wonders if they can do anything differently.

What can Jayne do?

​Jayne decides to raise the issue at today’s team meeting. When she broaches the subject, heads nod around the room.

Everyone agrees they know what to do when a client already receiving care asks for a kit, or someone wants one for a family member or friend. 

"But what about individuals who just want a naloxone kit for themselves but don't want or need any other care?" Jayne asks. "Because the naloxone is for their own use, they're clients. But if they don't register or share information, how can we meet the Dispensing Medication standard?"

Another nurse chimes in: “We need a consistent process for how these situations are handled. And everyone in the department needs to knows what this process is.” An ED physician agrees, adding, “I just keep thinking about all those patients in the waiting room. How can we make sure we’re making the best use of our time and resources?”

What happens next?

​Jayne and her manager schedule a meeting with key clinical experts and operational decision-makers to bring forward the team’s suggestions. This group agrees that any new approach must respect each individual’s autonomy, including confidentiality, and ensure informed consent. At the same time, resources must be fairly allocated to ensure the well-being of all clients.

Together, they outline a process to address the issue.

Back in the emergency department, the team is relieved to have a way to manage the situation. They put the process in place, and agree to evaluate how the change is working at their next team meeting.

How is Jayne meeting standards?

​Jayne knows that she can autonomously dispense naloxone to treat an opiate overdose. There are no CRNBC limits and conditions for dispensing naloxone.

She’ll follow the Dispensing Medications practice standard, principles 1-5. The change in process will assist Jayne and her colleagues in providing safe, ethical care to clients in this situation.

By acting to promote the provision of safe, appropriate and ethical care to clients, and helping to develop policies and practices consistent with the standards of the profession, Jayne and her colleagues are demonstrating professional responsibility and accountability.

An exception for naloxone: dispensing when someone is not your client

In response to the opioid overdose public health emergency, there is an exception for dispensing naloxone. Jayne and her colleagues are now also able to dispense naloxone to a person who is not their client or their client’s delegate but who may encounter another person outside of a hospital setting who is experiencing a suspected opioid overdose.

In this instance, they would not be expected to fully meet principles 1-5 of the Dispensing Medications practice standard, as these required activities are primarily intended for the recipient for the naloxone. These include:

  • dispensing medications only for clients under their care.
  • taking steps to ensure the pharmaceutical and therapeutic suitability of the medication for the client
  • labeling the medication with the client's name
  • handing the medication directly to the client or the client's delegate
  • providing education based on an assessment of the client’s abilities and level of understanding regarding the medication.
  • recording dispensing information on an individual medication profile and/client record.

Instead, they’re expected to teach that person how to appropriately respond to an opiate overdose, following all organizational policies and procedures for dispensing naloxone.

B.C.'s opioid crisis

British Columbia is currently experiencing a public health crisis unlike any we have seen before. This is an unprecedented time whereby health authorities and nurses are working in non-traditional ways with other health care providers, first responders, service groups, non-profit organizations, volunteers and others to provide overdose prevention services.

Recent changes to the Dispensing Medications practice standard

Nurses follow the Dispensing Medications practice standard when dispensing medications to their client or the delegate of their client, and can only dispense medications for clients under their care.

The dispensing of naloxone is an exception in response to a public health issue. In this instance, the nurse may be dispensing to a person who is not their client or their client’s delegate but who may encounter another person outside of a hospital setting who is experiencing a suspected opioid overdose.

Nurses dispensing naloxone to persons who are not their client must teach that person how to respond appropriately to an opioid overdose and follow applicable organizational policies and processes.

Questions?

Please note that this case study was updated Feb. 9, 2017, to reflect the change in naloxone scheduling.

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