A First Aid and CPR Training Program Designed for Peer Support and Overdose Responders – A Community Initiative Borne Out of Dire Need
By Nick Rondinelli – Owner and CEO of Heart to Heart CPR
This article offers background information on the origins of the Peer Support Responder training. Given that I have personally lost close friends to the opioid crisis, this work is close to my heart.
As the owner and CEO of Heart to Heart First Aid CPR Services Inc., I have had the privilege to train numerous members of the community to gain life-saving skills and become certified in various Canadian Red Cross courses, including First Aid, CPR, Basic Life Support (BLS), Professional Responder, Psychological First Aid, and Instructor Development courses. As a health professional and certified First Aid Instructor Trainer, I am passionate about first aid education, skills development, and adult learning.
I am a member of the 2SLGBTQ+ community and have lived in Downtown Toronto East for over two decades. As a resident, I have witnessed first-hand the harmful effects of systemic oppression and marginalization of vulnerable communities, where many of my friends within the community fell through the cracks and succumbed to their vulnerabilities. These losses have allowed me to gain deep insights on the harmful effects of stigma and discrimination towards visible minorities, people experiencing homelessness, people who use drugs (PWUD) and 2SLGBTQ+ people. Losing close friends has also enabled me to develop immense compassion as well as a sense of conviction to end the social injustices and inequities towards members of these communities. Where possible, I would like to support others to rise above their challenges and disparities, and to advocate for their health, well-being, and safety.
We began our advocacy work on the overdose crisis on October 15, 2020, when we first learned that Toronto shelters were experiencing a record high number of deaths from opioid poisoning. We discovered that many shelter operators and workers (who are required to be trained and certified in Standard First Aid and CPR) were following a similar protocol as outlined in a Toronto Public Health (TPH) “5-Step Overdose Response” graphic. This graphic recommends: “Do Chest Compressions ONLY during COVID-19, NO Rescue Breathing.” A version of the same “5-Step Overdose Response” is also on the City of Toronto’s website. It is also attached to all community emails from the Toronto Drug Strategy, which issues notices to many organizations and people within the sector of drug policy and harm reduction.
As a First Aid Instructor Trainer, I strongly felt that this “directive” to perform “compression-only CPR” was not appropriate for trained responders, who, with the right equipment and PPE, should be able to provide critical ventilations when managing an opioid overdose. It also may discourage a lay person who is able and willing to provide ventilations to a provide critical oxygen to a loved one or someone who in the same cohort and are already sharing germs with. The ambiguity arising from the 5-step graphic has created confusion among those who are trained, willing, and able to provide compressions with rescue breaths.
We also identified major gaps and breakdowns within the Toronto Shelter Standards regarding workers being under-trained as a result to taking basic training. I provided a list of critical skills in overdose response that are not covered in the current training. We notified them about the lack of proper equipment such as Bag- Valve Masks and Automatic External Defibrillator’s (AED’s). We also brought to their attention the minimum number of first aid certified staff per shift should be changed from 1 staff person to 2 staff persons. I also pointed out the lack of 4-piece PPE and PPE training among staff.
As a concerned citizen and a health and safety professional for 22 years, I contacted senior city officials as well as executive directors of two large city-run shelters about the risk of more shelter deaths amidst the pandemic. We communicated these concerns in late October and early November 2020, through a nationwide press release and subsequent direct emails.
The urgency of the situation motivated me to create The Johnston-Brais Initiative to honour my two dear friends who passed away from a lack of safe housing and opioid poisoning. The initiative offered us a way to advocate to the City of Toronto’s Shelter Support and Housing Administration (SSHA) in hopes that they would reform their shelter standards. It also served as a channel through which we could offer our professional expertise to help mitigate the gaps and breakdowns that we felt were contributing to the rising number of opioid-related deaths among shelter residents. We offered our services for free,1 with the aim of training all Toronto shelter workers in overdose response beyond the lay rescuer approach. Despite the pandemic, we understood that overdose response with ventilations could be done while complying with COVID-19 safety precautions by using 4-piece PPE, two-rescuer CPR, and protective breathing barrier equipment such as a Bag- Valve Mask with a HEPA filter to manage aerosol generating medical procedures. These precautions were laid out in the Toronto Public Health’s COVID-19 Guidelines for Harm Reduction Outreach & Community Response (pg.8,9)
Our multiple attempts at communicating with City officials and shelter executives as a health and safety professional were unanswered and there was no resolution to our inquiries or concerns. We understood early in our advocacy the urgency for specialized training not only for shelter workers but for any person who is most at risk of witnessing, encountering, and experiencing opioid poisoning. We wanted to provide our free services and specialized training in a meaningful way and in honour of my late dear friends. As a witness to their lives, I have seen first-hand how vulnerable communities are disproportionately impacted. We decided to focus directly on the populations most at risk. Our goal was to target people who use drugs (PWUD) and their friends, family, or peers who are close by and can intervene quickly to prevent accidental death.
We created a training program called Overdose Prevention & Resuscitation (CPR-OPR). It was conceptualized in October 2020 and designed on February 25, 2021. We had created this new classification of CPR training specifically for lay overdose responders who are most likely to perform overdose response.2 This training is unique as it covers critical opioid poisoning skills that are not covered in basic first aid/CPR courses.
CPR-OPR offers a 2-tiered response strategy that allows for an easier approach to care (naloxone administration and compression-only CPR) to a more advanced skill set that includes airway management, the provision of oxygen, two-rescuer approaches, protective equipment, and the donning, doffing and safe disposal of full PPE. On March 5th we piloted this training program and produced one promotional video and educational learning resources including 4 instructional videos (released on YouTube March 15th, 2021). Within two weeks of promoting our Peer Support Responder (CPR-OPR) training to the at-risk community we were fully booked with 100 registrations. We opened another 50 spaces and within one week those were fully booked too. Half attended and completed the training.
First Aid for Opioid Poisoning Emergencies
Between June 1, 2021, to July 17, 2021, Phase 1 of training was completed in Downtown Toronto East. Seventy-five (75) Peer Support Responders were trained under the Overdose Prevention & Resuscitation (CPR-OPR) program. Free supplies were provided to all participants, which included an emergency response backpack containing a one-way valve resuscitation mask, Bag-Valve Mask (BVM) with HEPA filter, mini- first aid kit, and 4-piece PPE. (See pictures of our Phase 1 responders in training ).
With the power of social media and the willingness of a Health Promotion Specialist from Toronto Public Health, Kris Guthrie along with her colleagues Nicole Greenspan, Michael Nurse and Amanda Leo, we presented our free training and supplies program to a network of 25 frontline organizations. We showed a powerful and impactful promotional video of the pilot program that captured the essence of our training.
The promotional video showed the skills development of two at-risk community members who completed the training. They both recently lost a loved one to an accidental overdose and they were both likely to witness more instances of opioid poisoning. The video shows the participants’ progression and skills development throughout the entire course. At the end of the two-hour training session, the participants were performing high quality CPR, assisted breathing, two-rescuer skills using a Bag-Valve Mask, while correctly wearing 4-piece PPE. We had evidence that our training program empowered two community members to develop the skills to avert preventable opioid related deaths while protecting themselves.
The Peer Support Responder (CPR-OPR) program was piloted to the members of affected communities through in-person testing and post-training evaluation. We received real-time feedback and made appropriate adjustments where needed. The program has evolved to become one that is co-created with people with lived experience, as well as frontline workers, first responders, and health care providers.
Shortly after the launch of our program, the American Heart Association’s journal “Circulation” released a medical statement with first-aid guidelines that coincide with those taken in the Peer Support Responder (CPR-OPR) program.3 This medical statement confirms that our training meets the current medical standards for opioid response.
This extraordinary alignment between our work and advocacy in overdose response, and the later published AHA medical statement solidifies that “evidence” must be rooted not only in science but also from lived experiences of people who use drugs (PWUD) along with the professional observations of frontline workers and service providers.
RECENT UPDATES TO REQUESTED INFORMATION ABOUT “NO BREATHS DURING COVID-19”:
- Seven months after our original request, we learned from Toronto Public Health (TPH) that the “5-Step Overdose Response” graphic is a population health tool / naloxone kit insert and it outlines the “minimum” care in overdose response. It can be used by untrained lay people or anyone who is unable or unwilling to provide rescue breaths. It does NOT exclude those with communities who are trained, able and willing to provide CPR with oxygen.
- Eight months after our original request we learned from TPH that the guidance on “no rescue breathing” as described on the “5-Step graphic” came from the Ministry of Health as a COVID-era amendment. Also, workers in high-risk settings need to have the necessary Infection Prevention and Control (IPAC) guidance in place with enhanced training to provide ventilations during COVID-19. This is what we offered the city to do for free.
- A few months ago after reviewing the City’s newly created Harm Reduction Tool Kit, we learned that all Toronto shelter and respite providers were given a directive (updated on February 22, 2021) (section “Q” pg. 2,3) by the General Manager of Shelter Support Housing Administration stating it is not advisable to perform full CPR during COVID-19, including rescue breaths as there is no evidence that “valve masks” protect against the virus.
- Two weeks ago, we learned that the directive (updated on January 17, 2022) (see section “S” pg.3) still advises compression-only CPR with no “rescue breaths” during COVID-19. It also states now, “When aerosol generating medical procedures (AGMPs) are planed or anticipated to be performed, airborne precautions must also be implemented including the use of fit-tested N95 mask. Staff who may be required to perform AGMPs should refer to their organizations relevant policies and /or procedure” (see IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID-19). Although these expectations are relevant during the pandemic, we expect to see less stringent IPAC expectations (i.e., “fit tested” N95 masks) post-pandemic. The data in this report clearly shows a willingness for frontline workers to provide oxygen safely. Employers are encouraged to support these workers and provide them with regular and frequent training in overdose response above the lay rescuer approach. We also want to acknowledge the City’s continued resources that are now available for shelter and respite operators, including the Harm Reduction Tool Kit, to protect frontline workers/patrons from opioid poisoning and COVID-19.
We hope that the data and recommendations we present in our full report, along with the medical statement from the American Heart Association, will encourage those who employ at-risk workers to provide them with the proper training and support they need and deserve. We also hope to protect the health and wellbeing of people who use drugs (PWUD) and train peers, allies, and bystanders to avert accidental deaths during this public health crisis.
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