SUMO – Substance Use Monitoring and Observation: Tackling a big problem in the ED

Background: The toxic drug crisis is an ongoing national public health crisis. In the province of British Columbia, overdose deaths are the leading cause of mortality in people ages 10–51. Patients presenting post opioid overdose are at higher risk for adverse outcomes when leaving before medically advised. Objectives: This quality improvement project aimed to reduce the rate of patients leaving before medically advised (BMA). This includes discharge dispositions of Against Medical Advice (AMA) and Left Without Being Seen (LWBS). Additionally, the project aimed to increase the level of observation and monitoring of patients by ED nursing staff compared to prior usual care. Methods: This project involved development of care guidelines for post-overdose patients and the implementation of a specialized care unit with an assigned nurse in the ED – SUMO: Substance Use Monitoring & Observation. The care focused on safe monitoring levels, overdose management, and offering substance use supports. Two PDSA cycles were utilized to validate the care model, along with ongoing informal staff feedback. ED Licensed Practical Nurses were trained to provide care under these guidelines and a scope optimization process was conducted. This strategy was used to address staffing challenges. BMA rates were observed and tracked using a real-time dashboard (Microsoft Power BI). Patient data was obtained from the electronic medical record. Patient location and chief complaint (substance overdose, intoxication, withdrawal CEDIS complaints & physician diagnoses) data were used to cohort patients being treated within the new care model vs prior usual care. Nursing documentation rates of vital signs and GCS were also used as proxy measures of monitoring levels during hospital stay. These findings were compared to the prior usual care, where patients with similar presenting complaint and acuity level (CTAS 2–4) were placed in a hallway care setting with a triage nurse providing monitoring. Results: Evaluation after 3 months of implementation showed a decrease of BMA rates for this patient cohort from 9% to 3%. Subsequent evaluation at 1-year post-implementation showed a consistent median decreased BMA rate of 4.5%. These findings show a relative reduction in BMA rate of 50-60%. Nursing monitoring rates (i.e. Vital Signs measurement frequency) in SUMO adhered to site specific monitoring and documentation guidelines. Implications and lessons learned: Utilizing a care model that included specific training for post-overdose care allowed for ED LPNs and non-ED qualified RNs to provide safe and patient-centred care for a high-risk population in the ED. Collaborative development of the care model with operational leadership and bedside staff allowed for SUMO to be sustainable and adaptable to the constantly changing ED care environment. Decreased BMA rates may be associated with care provided by a designated nurse, access to substance use and social supports, and a care space that provides more privacy, dignity, and comfort.