Establishing Consensus‐based Objectives for the Creation of an Opioid Overdose Curriculum for Emergency Medical Services Clinicians

Abstract

Objectives

Emergency medical services (EMS) clinicians are on the front lines of the opioid epidemic and are often the first health care personnel system to contact patients experiencing opioid toxicity. Although national educational guidelines include opioid toxicity, no specific standardized prehospital educational objectives or competencies exist. The goal of this project was to identify objectives for an EMS opioid toxicity curriculum that could be used for EMS training.

Methods

A list of preliminary educational objectives from U.S. EMS training programs was compiled and reviewed by a group of experts. The Delphi method was used to attain consensus on a final list of objectives for an EMS opioid curriculum.

Results

A total of 107 opioid‐related preliminary objectives were identified and then narrowed down to 81 preliminary objectives after accounting for redundancy. After four successive rounds of evaluating/accepting/rejecting objectives, 18 final objectives were identified and unanimously approved by the expert panel.

Conclusion

We identified 18 objectives to serve as a framework for an opioid toxicity curriculum for EMS clinicians. These objectives can serve as a basis for creating a standardized didactic training program for EMS training programs nationwide. Further evaluation will be needed to explore the best means for educational program delivery.

More than 47,000 individuals in the United States died as a result of opioid overdose in 2017. ¹ Emergency medical services (EMS) clinicians are often the first members of the health care system to contact patients after an opioid overdose. The rate of naloxone administration by EMS increased roughly 75%, from 573.6 to 1004.4 per 100,000 EMS events between 2012 and 2016. ² EMS clinicians must have the knowledge and skills to recognize opioid‐related emergencies, administer medications, and perform procedures. These medical professionals must also be facile in their ability to communicate with patients to describe risks, benefits, and alternatives to medical treatment and transport.

Across the United States, EMS clinicians are categorized into four different levels: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and paramedic. Individual states maintain the authority to regulate the education and training of EMS clinicians and to grant licensure. EMS clinicians’ initial and ongoing training certification are often in accordance with the National Registry of Emergency Medical Technicians (NREMT). ³ NREMT is an independent organization that provides certification and testing of EMS clinicians in 46 states throughout the United States. ³

Opioid‐related education has been integrated into the training curricula for each level of EMS training. Topics covered in these curricula are in accordance with the national EMS education standards. ⁴ This document outlines educational standards for EMS clinicians at each level of training and adheres to National EMS Scope of Practice Model. ⁵ Opioid‐related topics are covered within the topic heading of toxicology. The depth and level to which these topics are covered is commensurate with each level of EMS clinician. For example, for basic life support personnel (including EMR and EMT levels of certification), educational topics cover the most fundamental concepts of overdose recognition and management, such as simple airway management, oxygenation and ventilation, and intranasal naloxone administration. Whereas for advanced life support personnel (such as AEMTs and paramedics), additional and more sophisticated clinical topics are covered, such as recognition of hypercarbic respiratory failure, capnography, advanced airway management, titration of parental naloxone administration, and the social and personal impact of the opioid epidemic.

While the National EMS Education Standards list toxicology knowledge areas, it does not identify specific toxicology educational objectives or competencies. In other words, the Standards tell education programs what toxicology topics to cover, but do not specify which material should be covered or how it should be taught. For example, according to the Standards, an AEMT should be familiar with “opiate toxidrome” and a paramedic should be familiar with “anatomy, physiology, pathophysiology, psychosocial impact, presentation, prognosis, and management” of opioids, but the Standards do not identify specific learning objectives.

We sought to gather expert input to develop learning objectives for an opioid overdose curriculum for EMS clinicians. The Delphi method (DM) is a structured communication technique that uses systematic, iterative data gathering to reach consensus among experts. The DM was originally developed to incorporate expert input into policy decision making, but it has been applied to dozens of other fields. ⁶ , ⁷ There is no single way to apply the technique, but all Delphi processes survey an expert panel over a series of rounds, sharing results from prior rounds in each successive one to move toward group agreement. ⁷ , ⁸ , ⁹

Objective

Our primary objective was to use the DM to identify educational objectives for an opioid overdose curriculum for EMS clinicians.

METHODS

We used the DM to reach expert consensus on a list of model educational objectives for an opioid overdose curriculum for EMS clinicians. This project was considered to be “exempt research” by the Johns Hopkins Hospital Institutional Review Board. The process was coordinated by study team member JT, who did not share individual responses with other study team members. Questions about the process were adjudicated by study team members AS and ML. Neither JT, AS, or ML served as experts. All surveys were conducted using Google Forms (Alphabet, Inc.) We compiled preliminary educational objectives from U.S. EMS programs. We searched websites from U.S. EMS training programs and extracted educational objectives related to opioids. Redundant objectives were eliminated.

We assembled a panel of experts in EMS, medical toxicology, medical education, and emergency medicine. We chose prospective experts based on authorship of relevant scholarship and membership in the professional network of investigators. We invited prospective experts by e‐mail. Prospective experts were given a brief description of the project, objectives, expected response timeline, and expected time commitment. Prospective experts were given the opportunity to decline participation and to name other potential experts that could substitute. All eight individuals invited to serve as experts accepted. Each expert had expertise in at least one of the following disciplines: EMS, medical toxicology, medical education, or emergency medicine. The expert characteristics are represented in Table 1.

Table 1.

Expert characteristics

Expert	Area(s) of Expertise	Years of Professional Experience	Gender
A	Emergency medicine, EMS	11–20	M
B	Emergency medicine, EMS	11–20	M
C	Emergency medicine, medical toxicology	5–7	F
D	Prehospital EMS clinician	>20	M
E	Emergency medicine, EMS	5–10	M
F	Emergency medicine, medical toxicology	>20	M
G	Prehospital EMS clinician	>20	M
H	Emergency medicine, medical toxicology, addiction medicine	3	F

We asked the expert panel to identify the desirable number of educational objectives for an opioid overdose curriculum for EMS clinicians and calculated the mean response to determine our goal for number of objectives. In successive rounds, we asked the expert panel to rate preliminary objectives by a 5‐point Likert scale from “strongly agree” to “strongly disagree.” Experts were blinded to each other’s answers. In each round, experts had the opportunity to create new objectives for inclusion. When greater than 75% of experts agreed with a preliminary objective, the objective was considered accepted and thus retained. When greater than 75% of experts disagreed with preliminary objectives, those objectives were considered rejected and thus discarded. Preliminary objectives that were not accepted or rejected in a round were only allowed to carry over to subsequent rounds a single time—otherwise, they were considered rejected and thus discarded. Both retained and rejected preliminary objectives were not considered in subsequent rounds. Remaining objectives were carried over to subsequent rounds.

We continued the process until we reached a final number of approved objectives. In the final round, these final objectives were presented in domains (airway, breathing, signs/symptoms/treatment, miscellaneous, psychomotor, and affective) to the experts, who were asked to rank them. The top three ranking objectives from each category were retained in a final list of objectives. We presented the final list to the expert panel for approval.

RESULTS

Our 2019 Internet search of U.S. EMS training programs generated 107 opioid‐related preliminary objectives (Table 2). We eliminated 26 redundant preliminary objectives, leaving 81 preliminary objectives (Table 3). The expert panel identified the desirable number of educational objectives for an opioid overdose curriculum for EMS clinicians. The mean response was calculated to determine our goal for number of objectives. The panel responses for the final number of objectives ranged from 10 to 30 (median = 20, mean = 17.5). Rounding up the mean, 18 objectives were chosen as a target number of final objectives.

Table 2.

Preliminary 107 Objectives

1. Define substance abuse, substance dependence, tolerance, withdrawal, and addiction.

2. List the most commonly abused opioid drugs by chemical name/street names.

3. Describe pathophysiology of commonly abused opioid drugs.

4. Recognize signs and symptoms related to opioid drug abuse.

5. Describe the treatment and interventions in management of opioid abuse.

6. Describe equipment needed, techniques used, precautions, and general principles of applicable medication administration (ETT, IM, IV, IN) for opioid abuse.

7. Identify airway adjuncts (i.e., oral airway) and, if applicable, the oxygen flow requirements needed for their use (facemask, nasal cannula).

8. Describe emergencies encountered in opioid drug ingestion.

9. Describe mechanisms of injury/nature of illness in opioid ingestion.

10. Describe methods of assessing altered mental status in the adult, child, and infant patient.

11. Describe methods of assessing the airway in the adult, child, and infant patient.

12. Describe methods for assessing if a patient is breathing.

13. Describe methods for managing the respirations in a hypoventilating adult, child, and infant patient.

14. Describe normal and abnormal findings when assessing a patient's pulse, skin temperature, respiratory rate, work of breathing, and mental status.

15. Describe the needs for assessing an individual who is unresponsive.

16. Describe what clues can point you toward considering an opioid overdose or ingestion.

17. Describe the components of an ongoing assessment for a patient with opioid ingestion or overdose.

18. Discuss the communication skills that should be used to interact with the patient, family, bystanders, and health care providers when managing a patient with potential opioid ingestion or overdose.

19. Identify which medications will be carried on the unit by their trade and generic name for opioid ingestion.

20. Identify which medications may be administered by different levels of EMT for opioid ingestion.

21. Identify a nonrebreather facemask and state the oxygen flow requirements needed for its use.

22. Describe the indications for using a nasal cannula versus a nonrebreather facemask.

23. Identify a nasal cannula and state the flow requirements needed for its use.

24. Describe common hazards found at the scene of an ingestion patient.

25. Determine ways to determine if a scene is safe.

26. Discuss common mechanisms of injury/nature of illness in opioid ingestion.

27. Discuss methods of assessing altered mental status in opioid ingestion patients.

28. Differentiate between assessing the altered mental status in the adult, child, and infant patient with respect to opioid ingestion.

29. Discuss methods of assessing the airway in the adult, child, and infant patient.

30. Describe methods used for assessing if a patient is breathing.

31. State what care should be provided to the adult, child, and infant patient with adequate breathing.

32. State what care should be provided to the adult, child, and infant patient without adequate breathing or with respiratory distress.

33. Differentiate between a patient with adequate and inadequate breathing.

34. Distinguish between methods of assessing breathing in the adult, child, and infant patient.

35. Compare the methods of providing airway care to the adult, child, and infant patient.

36. Differentiate between obtaining a pulse in an adult, child, and infant patient.

37. Describe normal and abnormal findings when assessing skin temperature.

38. Describe the needs for assessing an individual who is unresponsive.

39. Differentiate between the assessment that is performed for a patient who is unresponsive or has an altered mental status and other medical patients requiring assessment.

40. Discuss the components of the detailed physical examination in opioid ingestion.

41. Discuss the reasons for repeating the initial assessment as part of the ongoing assessment.

42. Describe the components of the ongoing assessment.

43. Identify the essential components of the verbal report.

44. Discuss communication skills that should be used to interact with the patient.

45. Define the special considerations concerning patient refusal.

46. List the various ways that opioids enter the body.

47. List the signs and symptoms associated with opioid ingestion.

48. Discuss the emergency medical care for the patient with possible overdose.

49. Describe the steps in the emergency medical care for the patient with suspected poisoning.

50. State the generic and trade names, indications, contraindications, medication form, dose, administration, actions, side effects, and reassessment strategies for activated charcoal.

51. Establish the relationship between the patient suffering from poisoning or overdose and airway management.

52. Differentiate between respiratory distress and respiratory failure.

53. Summarize emergency medical care strategies for respiratory distress and respiratory failure.

54. Identify which medications will be carried on the unit for opioid ingestion.

55. State the medications carried on the unit for opioid ingestion by the generic name.

56. Discuss the forms in which the medications may be found for opioid ingestion.

57. List the structure and function of the respiratory system.

58. State the signs and symptoms of a patient with breathing difficulty.

59. Describe the emergency medical care of the patient with breathing difficulty with respect to opioid ingestion.

60. Recognize the need for medical direction to assist in the emergency medical care of the patient with breathing difficulty.

61. Describe the emergency medical care of the patient with breathing distress.

62. Establish the relationship between airway management and the patient with breathing difficulty.

63. List signs of adequate air exchange.

64. Distinguish between the emergency medical care of the infant, child, and adult patient with breathing difficulty.

65. Recognize signs and symptoms of opioid overdose.

66. Discuss the forms in which naloxone may be found.

67. Understand and describe the actions of naloxone.

68. Understand the need for airway management.

69. Understand good Samaritan law.

70. Identify characteristics of an opioid overdose.

71. Recognize, identify, and interpret the role of capnography in the obtunded patient.

72. Demonstrate steps in performing head‐tilt‐chin‐lift and jaw thrust.

73. Demonstrate suctioning technique.

74. Demonstrate utilization of a bag–valve mask.

75. Demonstrate how to ventilate a patient with a stoma.

76. Demonstrate how to insert an oral airway.

77. Demonstrate how to insert a nasopharyngeal airway.

78. Demonstration use of oxygen tank.

79. Demonstrate use of nonrebreather face mask and oxygen flow requirements needed for its use.

80. Demonstrate use of nasal cannula.

81. Demonstrate techniques for assessing the airway.

82. Demonstrate techniques for assessing of a patient is breathing.

83. Demonstrate techniques for prioritizing patients in the case of multiple ingestions.

84. Demonstrate the patient assessment skills that should be used to assist a patient who is unresponsive or has an altered mental status.

85. Observe various scenarios and identify potential hazards.

86. Demonstrate ability to perform a toxicologic examination.

87. Perform an organized, concise patient report to give to staff at the receiving facility.

88. Demonstrate steps for giving medications or instructing patients on self‐administration of medications.

89. Demonstrate the steps in the emergency medical care for the patient with possible overdose or suspected poisoning.

90. Demonstrate the necessary steps required to provide a patient with activated charcoal.

91. Demonstrate ability to ventilate infant, child, and adult with bag–valve mask.

92. Demonstrate administration of medication via endotracheal tube.

93. Demonstrate administration of an IM injection.

94. Demonstrate administration of an IN medication.

95. Demonstrate management of a patient with opioid overdose.

96. Demonstrate general steps for naloxone administration.

97. Explain the rationale for airway protective skills taking priority over most other basic life support skills.

98. Explain the rationale for crew members to evaluate scene safety.

99. Explain the importance of forming a general impression of the patient.

100. Explain the value of performing an initial assessment.

101. Explain the value of performing an ongoing assessment.

102. Recognize and respect the feelings that patients may experience during assessment and treatment.

103. Explain the rationale for using medical terminology correctly.

104. Explain the rationale for route of administration of medications.

105. Explain the rationale for contacting poison control.

106. Attend to feelings of family when dealing with patient with suspected overdose.

107. Explain the rationale for administration of naloxone.

ETT = endotracheal tube; IM = intramuscular; IN = intranasal; IV = intravenous.

Table 3.

Preliminary 81 Objectives

1. Identify airway adjuncts (i.e., oral airway) and, if applicable, the oxygen flow requirements needed for their use (facemask, nasal cannula).

2. Describe methods of assessing the airway in the adult, child, and infant patient.

3. Compare the methods of providing airway care to the adult, child, and infant patient.

4. Establish the relationship between the patient suffering from poisoning or overdose and airway management.

5. Establish the relationship between airway management and the patient with breathing difficulty.

6. List the structure and function of the respiratory system.

7. Understand the need for airway management.

8. Describe methods for managing the respirations in a hypoventilating adult, child, and infant patient.

9. Describe the indications for using a nasal cannula versus a nonrebreather facemask.

10. State what care should be provided to the adult, child, and infant patient with adequate breathing.

11. State what care should be provided to the adult, child, and infant patient without adequate breathing or with respiratory distress.

12. Distinguish between methods of assessing breathing in the adult, child, and infant patient.

13. Differentiate between respiratory distress and respiratory failure.

14. Summarize emergency medical care strategies for respiratory distress and respiratory failure.

15. Describe the emergency medical care of the patient with breathing difficulty with respect to opioid ingestion.

16. Recognize the need for medical direction to assist in the emergency medical care of the patient with breathing difficulty.

17. List signs of adequate air exchange.

18. Recognize, identify, and interpret the role of capnography in the obtunded patient.

19. Discuss the emergency medical care for the patient with possible overdose.

20. Recognize signs and symptoms related to opioid drug abuse.

21. List the signs and symptoms associated with opioid ingestion.

22. Describe the treatment and interventions in management of opioid abuse.

23. Describe equipment needed, techniques used, precautions, and general principles of applicable medication administration (ETT, IM, IV, IN) for opioid abuse.

24. Describe emergencies encountered in opioid drug use.

25. Describe mechanisms of injury/nature of illness in opioid ingestion.

26. Describe what clues can point you toward consider an opioid overdose or use.

27. Describe the components of an ongoing assessment for a patient with opioid ingestion or overdose.

28. Discuss the components of the detailed physical examination in opioid ingestion.

29. Describe the steps in the emergency medical care for the patient with suspected poisoning.

30. State the generic and trade names, indications, contraindications, medication form, dose, administration, actions, side effects, and reassessment strategies for activated charcoal.

31. Describe pathophysiology of commonly abused opioid drugs.

32. Define substance abuse, substance dependence, tolerance, withdrawal, and addiction.

33. List the most commonly abused opioid drugs by chemical name/street names.

34. Describe normal and abnormal findings when assessing a patient's pulse, skin temperature, respiratory rate, work of breathing, and mental status.

35. Describe methods of assessing altered mental status in the adult, child, and infant patient.

36. Describe the needs for assessing an individual who is unresponsive.

37. Discuss the communication skills that should be used to interact with the patient, family, bystanders, and health care providers when managing a patient with potential opioid ingestion or overdose.

38. Identify which medications may be administered by different levels of EMT for opioid ingestion.

39. Identify which medications will be carried on the unit by their trade and generic name for opioid ingestion.

40. Discuss the reasons for repeating the initial assessment as part of the ongoing assessment.

41. Describe the components of the ongoing assessment.‐

42. Identify the essential components of the verbal report.

43. Discuss communication skills that should be used to interact with the patient.

44. Define the special considerations concerning patient refusal.

45. List the various ways that opioids enter the body.

46. Demonstrate steps in performing head‐tilt‐chin‐lift and jaw thrust.

47. Demonstrate suctioning technique.

48. Demonstrate utilization of a bag–valve mask.

49. Demonstrate how to ventilate a patient with a stoma.

50. Demonstrate how to insert an oral airway.

51. Demonstrate how to insert a nasopharyngeal airway.

52. Demonstration use of oxygen tank.

53. Demonstrate use of nonrebreather face mask and oxygen flow requirements needed for its use.

54. Demonstrate use of nasal cannula.

55. Demonstrate techniques for assessing the airway.

56. Demonstrate techniques for assessing of a patient is breathing.

57. Demonstrate techniques for prioritizing patients in the case of multiple ingestions.

58. Demonstrate the patient assessment skills that should be used to assist a patient who is unresponsive or has an altered mental status.

59. Observe various scenarios and identify potential hazards.

60. Demonstrate ability to perform a toxicologic examination.

61. Perform an organized, concise patient report to give to staff at the receiving facility.

62. Demonstrate steps for giving medications or instructing patients on self‐administration of medications.

63. Demonstrate the steps in the emergency medical care for the patient with possible overdose or suspected poisoning.

64. Demonstrate the necessary steps required to provide a patient with activated charcoal.

65. Demonstrate ability to ventilate infant, child, and adult with bag–valve mask.

66. Demonstrate administration of medication via ETT.

67. Demonstrate administration of an IM injection.

68. Demonstrate administration of an IN medication.

69. Demonstrate management of a patient with opioid overdose.

70. Demonstrate general steps for naloxone administration.

71. Explain the rationale for airway protective skills taking priority over most other basic life support skills.

72. Explain the rationale for crew members to evaluate scene safety.

73. Explain the importance of forming a general impression of the patient.

74. Explain the value of performing an initial assessment.

75. Explain the value of performing an ongoing assessment.

76. Recognize and respect the feelings that patients may experience during assessment and treatment.

77. Explain the rationale for using medical terminology correctly.

78. Explain the rationale for route of administration of medications.

79. Explain the rationale for contacting poison control.

80. Attend to feelings of family when dealing with patient with suspected overdose.

81. Explain the rationale for administration of naloxone.

ETT = endotracheal tube; IM = intramuscular; IN = intranasal; IV = intravenous.

The 81 preliminary educational objectives were presented to the experts (panel members). For round 1, of the 81 preliminary objectives, 28 were rejected and 53 were kept, with an additional three objectives added by the panel members, for a total of 56 objectives to start round 2. For round 2, of the 56 objectives, 21 were accepted, 33 were rejected, and two were kept, with an additional three objectives added by the panel members, for a total of five objectives to start round 3. For round 3, of these five objectives, two were accepted, 0 were rejected, 0 were added, and three objectives were removed by the authors due to similarity to objectives that had already been accepted.

In the final round, the 51 accepted objectives were presented to the experts in categories (airway, breathing, signs/symptoms/treatment, miscellaneous, psychomotor, and affective). The experts were asked to rank the objectives. The top three objectives from each category were kept and the rest were discarded. A final total of 18 were selected after redundant objectives were eliminated. The final list of 18 objectives was presented to the experts and unanimously approved. The above process is presented in Figure 1, and the final list of objectives can be visualized in Table 4.

Figure 1.

Objective selection process. *The authors removed three objectives due to redundancy with existing accepted objectives.

Table 4.

Final Objectives

Airway

1. Understand the need for airway management.

2. Describe methods of assessing the airway in the adult, child, and infant patient.

3. Identify airway adjuncts (i.e., oral airway) and, if applicable, the oxygen flow requirements needed for their use (facemask, nasal cannula).

Breathing

4. Describe the emergency medical care of the patient (adult, child, or infant) with breathing difficulty with respect to opioid ingestion

5. Recognize, identify, and interpret the role of capnography in the obtunded patient.

6. Summarize emergency medical care strategies for respiratory distress and respiratory failure.

Signs/Symptoms/Treatment

7. List and recognize the signs and symptoms associated with opioid use.

8. Discuss the emergency medical care for the patient with possible overdose.

9. Describe what clues can point you toward considering an opioid overdose or use.

Psychomotor

10. Demonstrate the steps in performing head‐tilt‐chin lift and jaw‐thrust.

11. Demonstrate the ability to ventilate an infant, child, or adult with bag–valve mask.

12. Demonstrate techniques for suctioning and naloxone administration.

Affective

13. Explain the value of performing an initial assessment.

14. Explain the rationale for crew members to evaluate scene safety.

15. Explain the rational for airway protective skills taking priority over most other basic life support skills.

Miscellaneous

16. Describe the needs for assessing an individual who is unresponsive.

17. Describe how to manage a patient that refuses to come to the ED after naloxone administration.

18. Describe normal and abnormal findings when assessing a patient’s pulse, skin temperature, respiratory rate, work of breathing, and mental status.

DISCUSSION

Identifying Educational Objectives for an Opioid Overdose Curriculum for EMS Clinicians

A nationally standardized approach to EMS education and training about the management of opioid overdose is essential to helping ensure consistent educational content development. Through use of the DM, our expert panel produced 18 educational objectives to serve as a framework for an opioid overdose curriculum for EMS clinicians. These objectives are categorized into six domains: airway, breathing, signs/symptoms/treatment, psychomotor, affective, and miscellaneous. Seventeen of these objectives were culled from a list of 107 preliminary objectives gathered from existing curriculum. One new objective, “Describe how to manage a patient that refuses to come to the ED after naloxone administration,” was drafted by our experts during this process.

We originally organized the final objectives into four domains. Three domains were based on Bloom’s taxonomy (cognitive, psychomotor, affective), and a final miscellaneous category was then created for objectives that fit in multiple or neither of the aforementioned categories. ¹⁰ Cognitive objectives focus on remembering, synthesizing, analyzing, and applying knowledge. Psychomotor objectives focus on performing tasks and utilizing motor skills. Affective objectives focus on the learners’ feelings, values, and attitudes. Due to the overwhelming presence of cognitive objectives, cognitive was further broken down into airway, breathing, and signs/symptoms/treatment.

The expert panel reached consensus that most of the preliminary objectives culled from U.S. EMS programs were reasonable. We planned to reject objectives that were voted down by greater than 75% of the experts, but no objectives were rejected in this manner. Although some preliminary objectives reached 50% disapproval (example: “Demonstrate administration of medication via endotracheal tube”), no objective reached 75%. This indicates that our initial list of objectives was adequate, which is reasonable given that they were taken from existing curricula.

Although the final list of objectives may have a similar focus as other existing EMS objectives, with priority being airway and breathing, our final list has some key differences. First, there is a focus on opioid‐specific objectives—for example, objective 4 acknowledges recognizing breathing difficulty with respect to opioid ingestion. The task for the EMS provider is not just to recognize someone with difficulty breathing—it becomes targeted and focused. In addition to being opioid focused, our objectives also address key facets that are encountered by EMS providers frequently but may not always be the topic of discussion in an educational environment—objective 17 discusses the difficult topic of managing a patient that refuses to come to the ED after naloxone has been administered.

New Objectives Created

Although the initial list of preliminary objectives was broad, we asked experts to recommend additional objectives at the end of each round (Table 5). By allowing experts to provide their own insights and recommendations, we were able to improve the scope and breadth of our objectives. Objective 17 (Table 4) was the only expert‐recommended objective that was ultimately approved by the expert panel. Five other objectives were recommended by panel members but not adopted explicitly by the Delphi panel. The objectives recommended by individual but not accepted by the panel addressed naloxone dosing, “naloxone overdose,” refusal of transport, and two objectives on stigma and terminology regarding opioid use disorder. Naloxone administration and refusal care were reflected in other objectives (12 and 17). However, our panel did not ultimately include an objective on opioid stigma or terminology.

Table 5.

Objectives Suggested by Experts

Describe how to manage a patient that refuses to come to the ED after naloxone administration	Accepted by panel for inclusion as final objective
Understand the nuances of refusal of EMS transport after opioid overdose	Not accepted by panel for inclusion as a final objective in this form, but concepts covered by other objectives
Understand the appropriate doses when administering naloxone
Understand the signs and symptoms of naloxone overdose
Appreciate ways to reduce stigma associated with opioid use disorder	Not accepted by panel for inclusion as final objective
Discuss the importance of terms such as “addiction,” “abuse,” and “opioid use disorder”

Prehospital Opioid Exposure

Our panel did not choose an objective that explicitly addresses EMS exposure to opioids. Nevertheless, we believe that EMS provider safety is paramount. Objectives related to scene safety (objective 14) and emergency management of the potentially opioid overdose patient (objective 8) should also cover education on choosing the correct PPE prior to providing care. ¹¹ These objectives should, additionally, indirectly cover the environmental concerns about dermal or inhalational exposure to fentanyl and its analogs. ¹² , ¹³

Scene Safety

The safety of EMS clinicians is of utmost importance. Traditional aspects of scene safety include having appropriate PPE, being vigilant about the potential for ongoing and emerging threats on scene, and understanding the feasibility and safety of certain actions. Furthermore, after receiving naloxone, patients may be agitated or combative, the risk of needle sticks and other injuries can increase, and the need for humane restraint may be needed. Objective 14 exists to encompass and reinforce the importance of scene safety, especially with respect to opioids and reversal.

Consolidation of Objectives

Some approved objectives were consolidated or removed after approval to reduce redundancy. For example, both “List the signs and symptoms associated with opioid ingestion” and “recognize signs and symptoms related to opioid drug abuse” were both approved individually and were consolidated by the authors to a single objective, “list and recognize the signs and symptoms associated with opioid use.” A similar process was employed for the final objective 12.

STRENGTHS AND LIMITATIONS

Overall, our procedure has several strengths. We followed best practices for use of the DM. A 2012 systematic review of 80 reports using DM for health care quality indicators identified best recommendations for execution of the DM: ⁷

1. Gather heterogeneous panel of experts and report their characteristics.

2. Define study objective and expert consensus.

3. Send questionnaires electronically.

4. Construct subsequent rounds based on results of prior rounds, excluding measures without consensus.

5. End Delphi process when consensus is reached.

For this project, we followed each of the recommendations: Using the DM provided a standardized way to systematically collect our results until we arrived at our final list of objectives. Although DM can be performed faster in person, we blinded experts to each other’s responses by conducting surveys online. When an expert recommended an objective to be included, the included objective did not have any personal identifiers. Blinding prevented a single expert from holding disproportionate influence on the basis of professional reputation or personality traits.

Our initial objectives were limited by what was publicly available online. Although we tried to address this by asking authors for new objectives, most of our final objectives were drawn from online sources. It is possible that topics and objectives may have been overlooked simply because they were not available online.

We also identified limitations in the composition of the expert panel. Our panel was limited only to those within the professional circle of the authors—it is possible that this narrowed our scope of input. We had a total of eight experts. Although there is no consensus on the ideal number of experts to include in a Delphi panel (panels have ranged from five to over 1,000 individuals), small Delphi panels have proven to be as reliable as larger panels. ¹⁴ Our expert panel was limited to the following related disciplines: emergency medicine, medical toxicology, emergency medical services, and addiction medicine. We considered whether including experts in public health, psychiatry, and other fields may have improved our results. Nevertheless, we feel that the experts we have chosen have first‐hand knowledge of EMS training needs (prehospital/EMS), our patient population (emergency medicine, EMS, prehospital EMS), and the pharmacology of opioids (medical toxicology, addiction medicine). Furthermore, all of our experts are involved with academic institutions or instructive environments and are familiar with teaching and education.

One final limitation is that regarding compassion fatigue. Although our Delphi panel did not identify explicit objectives for compassion fatigue, we believe that this concept is of utmost importance and must be a part of any education program designed to train people to care for patients with opioid use disorder. Because our objectives identified by the Delphi panel are more focused on the clinical elements, we strongly encourage the inclusion of a social worker and/or addiction counselor during course creation to address compassion fatigue and related social components such as dealing with death and loss of empathy in addition to dispelling myths surrounding substance abuse.

CONCLUSION AND FUTURE DIRECTIONS

We hope that these objectives can be utilized as a framework to design an opioid training course for emergency medical services. Although instructors could utilize these objectives at a local level and make a course from these themselves, there would undoubtedly be variability in the courses from instructor to instructor. One such option is to utilize these objectives to establish a didactic training program that could be embraced by emergency medical services training programs nationwide. Several platforms exist that could allow for dissemination of such a course. One potential avenue for course design would be to create a two‐part course, similar to an option that currently exists for advanced cardiac life support training ¹⁵ —an online course focused on knowledge and interpretation, and an in‐person course then focused on psychomotor skills. Implementation strategies include online, in‐person, and blended learning options. Regardless of course delivery options, standardized course validation techniques (including pre/post tests and skill assessments) should be used to ensure the proper delivery of course materials and effect conveyance of course objectives.

AEM Education and Training 2021;5:1–11