At Sunnybrook Health Sciences Centre, Registered Nurse Marley Gimblett was set to be in charge of the Emergency Department (ED) that weekend. Marley worked with colleagues on Sunnybrook’s Emergency Preparedness team to run through every potential scenario that could arise, part of the hospital’s ongoing imperative to be ready for any emergency event. However, as the weekend approached, there was a sense of unease among ED staff.

“In the ED, we’re ready for anything,” Marley says. “But for this, staff said they felt underprepared, especially to respond to large numbers of patients coming in who may be teargassed or pepper sprayed, and how they would protect staff and other patients from being exposed.”

Though a large-scale emergency in Toronto never materialized, Marley seized the opportunity to enhance emergency preparedness training in the Sunnybrook ED to help staff feel more confident and prepared in making critical decisions during a mass emergency – and to ensure proper procedures are in place to protect patients and staff from dangerous contaminants.

In September 2023, Marley enrolled in Sunnybrook’s Practice-Based Research and Innovation (PBRI) TAHSN fellowship, specifically to focus on improving preparedness among ED staff responding to chemical, biological, radiological, nuclear and explosive (CBRNE) events. The fellowship provides point-of-care health professionals such as Marley the opportunity to lead practice-based quality improvement projects that enhance patient care.

“My motivation for pursuing this came out of wanting to be a resource for staff, and wanting to have more knowledge about this topic,” Marley says. “When you’re getting involved in a fellowship project like this, you have to love your topic.”

Since completing the initial fellowship, Marley is now the inaugural PBRI advanced fellow at Sunnybrook, allowing her to continue her work. As an advanced fellow, Marley will support the implementation of a formal CBRNE response procedure, with a focus on training and education for clinical staff in the ED.

Among the initial training topics that Marley put together, and inspired by the convoy in Ottawa, was decontamination procedures for patients arriving in the ED with injuries or exposure to pepper spray and teargas.

“The focus was on Registered Nurses, as they’re typically the most hands-on in the ED,” Marley explains. “We trained staff on basic principles on CBRNE response and how to set up the decontamination room to prevent further staff and patient exposure to chemical substances like teargas and pepper spray,” adding that this protocol could be applied to other CBRNE exposures.

“For biological threats, that might be like having a patient with Ebola come in. For radiological or nuclear, it might be if someone has radiation poisoning or if there was an event at a nearby nuclear plant. Responding to explosives would be similar to a trauma, but on a different scale.”

Surveys following the training showed significant improvement in how confident and prepared ED staff felt about responding to CBRNE events.

Through the advanced fellowship, the project will continue and expand to support the implementation of dedicated CBRNE response training for Registered Nurses and Charge Nurses in the ED. Marley’s goal is to keep working with the Emergency Preparedness team to educate ED staff and have more ongoing training sessions. She says that would include further CBRNE preparedness education, proper personal protective equipment training, running a CBRNE simulation and further evaluating preparedness across the hospital as possible outcomes of her work.

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Within the arsenal of interventions is buprenorphine, a synthetic opioid that is among the recommended standards of care for people with untreated opioid disorder. However, despite evidence of its efficacy in both mitigating overdose and managing opioid use disorder and opioid addiction, uptake of buprenorphine in emergency departments (ED) widely across hospitals has been limited.

Dr. Kalocsai, alongside a team of scientists, clinicians – including Dr. Nikki Bozinoff, an associate scientist and physician at the Centre for Addiction and Mental Health (CAMH) and Dr. Dominick Shelton, an emergency physician at Sunnybrook – librarians and people with lived experience of opioid use, recently led a scoping review to find out why.

The findings, published this month in The Lancet Regional Health, point to a health system that is grappling with the intricacies of structural and social barriers that contribute to a worsening opioid crisis, but also an opportunity to enhance teaching and education for clinicians who work with people who use drugs through what Dr. Kalocsai calls structural competency training.

“We found that some of the barriers that limit uptake is the failure to recognize and address structural stigma, poorly equipped services to manage patients’ medical and psychosocial complexity, and difficulties adapting to the increasingly toxic drug supply,” Dr. Kalocsai says.

As an education scientist, she adds, “this research shows where there are opportunities to educate clinicians to better serve marginalized communities and think about the structures of power, health disparities and equity.”

Dr. Kalocsai explains the significance of the findings of this scoping review, and the ways that they can contribute to a body of knowledge around the opioid toxicity crisis.

What do people need to know about the social and structural barriers that exist in addressing opioid use and overdose?

We know that the overdose crisis has disproportionately affected racialized and marginalized people, but the research on buprenorphine initiation in the ED rarely reports on patient characteristics that can contribute to marginalization. In that sense, much of the existing research actually fails to consider how intersecting structural barriers influence the inequitable access to buprenorphine in the ED. Most of the articles, for example, refer to stigma as a barrier, but usually define stigma as a negative attitude rooted in the individual, without diving deeper into how it might be structurally embedded through laws, policies, norms and processes at the level of the organization and society.

What is structural competency training, and how could it help support health care providers’ decision-making in the ED?

Structural competency training is education that enables people to recognize and respond to various social and structural factors – such as racism, colonialism, sexism, heteronormativity, houselessness and poverty – that people who use opioids often navigate, and which produce persistent health disparities and marginalization.

When it comes to buprenorphine initiation, what we’ve seen in the literature is a lack of comfort with buprenorphine and substance use care generally in the ED, and consequently increasing biomedical buprenorphine training as a solution. But the research also suggests that biomedical training is insufficient in and of itself to bring about behaviour change among health care providers. We recommend including structural competency training – in addition to training on motivational interviewing, harm reduction approaches co-created with patients, as well as ongoing provider supports such as mentorship, communities of practice and just-in-time training – so health care providers can recognize the social and structural factors that impact the opioid crisis.

An as education scientist, what can you tell us about the role that this kind of research can play in fostering health care providers’ ability to recognize and respond to different systemic barriers?

I hope our findings will lead to changes in how health professions are trained to provide care for people with opioid use challenges and support the optimization of ED-based buprenorphine and opioid-agonist treatment initiation as both a treatment and harm reduction strategy. I also hope that the study will contribute to increased coordination of implementation efforts, and a shift to equitable and inclusive opioid agonist therapy initiation pathways across Canada and the United States.

What message do you have for front-line clinicians who are treating patients in the ED affected by substance use and overdose?

Our results point to innovations that deliver high-quality care: multi-disciplinary addiction consult teams, low-barrier harm reduction-informed services that support transition to outpatient care, and adaptations to introducing buprenorphine that address the toxicity of the drug supply. Taken together, these changes could lead to the normalization of opioid use disorder care in the ED and a shift in understanding opioid use disorder as a condition is amenable to treatment in the ED.

Education science is a niche area of health research, and this study is especially unique. Can you tell me about that, and what the added value is of this research?

This is the first comprehensive review of the complex web of factors that facilitate and challenge the implementation of buprenorphine initiation in the ED. We wedded two research frameworks — the Consolidated Framework for Implementation Research (CFIR), which is a popular implementation science framework, and critical theory to understand how relations and structures of power undergird buprenorphine implementation in the ED. Our analysis also sheds light to the limits of CFIR, which does not easily lend itself to the examination of power. It suggests that by adapting CFIR to incorporate a critical lens, for example, an intersectional approach could help us understand how structures of power and oppression influence the inequitable access to the implementation of buprenorphine in the ED.

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Conducting educational research in real clinical settings would be optimal, but often practically impossible. Exposing real patients to the risks posed by suboptimal clinical performance or gaps in trainees’ knowledge and skills for research purposes are not ethically acceptable. Simulation provides an environment where these studies can be safely conducted. Furthermore, the ability to control variables that may influence research outcomes and to record trainees’ behaviours and performance offers significant advantages for the researcher. However, simulation also presents some limitations as a research tool that must be considered early in the design of a study. 

Three types of challenges must be expected when designing a simulation-based study. First, organizing simulation sessions involves significant financial and human resources. Many educational projects are completed with minimal funding, and careful planning is needed to limit unnecessary expenses. Second, the choice of outcomes and variables used to measure these outcomes is important for producing informative results (e.g. Which scale should be used to measure communication skills?). Finally, researchers have to keep in mind that simulation is not exactly like the real clinical environment. Research findings resulting from simulation-based studies may need to be confirmed (when possible) in real clinical settings. However, simulation has a lot to offer as a research tool. With a bit of work, lots of help, and sparks of creativity, simulation-based research can be a rewarding and exciting adventure!

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