Battling the Opioid Crisis With Data in Boston
It’s no secret that the opioid crisis has hit hard in cities across the U.S., and Boston is no exception. But one way Boston stands out is its dedication to using data to monitor trends in overdoses and help battle the crisis.
According to James Salvia, EMT-P, ePCR Project Manager for Boston EMS, the care that his agency exercises over its database, and its dedication to sharing its findings, make the information valuable not just for Boston EMS, but for the entire city. “It’s a resource for the mayor; it’s a resource for Recovery Services,” he said.
Boston EMS’ opioid database began in 2006, when the agency was granted a special project waiver through the state Office of Emergency Medical Services for EMTs to give naloxone. “Part of what we had to do then was keep a database for when we gave Narcan, who we gave Narcan to, and what we found with those people — heart rate, respiratory rate,” Salvia said. As the epidemic emerged and new tactics were added to battle it, the database grew in sophistication, quality, and utility.
The value of data
Salvia describes one particular case that underscores the value of data in saving lives, from his days in the field as a paramedic: “I started going to this one particular location multiple times,” he recalled. After treating and transporting a male patient for consistent overdoses, he noticed that the patient wasn’t really getting services, likely because the hospital wasn’t realizing the repetition. After finding the patient in a nonviable condition – i.e., deceased – Salvia later returned to the same location, this time for the patient’s sister. “This is when we decided we’d pull the pin,” he said. Leveraging Boston EMS’ status as part of the city’s public health commission, “We reached laterally to … outreach people on the street who knew her and her back story, and were able to get her into a recovery program,” he said. “It’s about looking at your data and paying attention to your data and [asking] ‘How can we make a change for some of the people we’re dealing with?’”
To do that, the Boston EMS opioid database tracks such factors as
- Patient encounter data
- Frequency of encounters
- Location information (useful for heat mapping)
- Health/medical intelligence (insight that allows deeper understanding of trends, or that facilitates action)
Case Definition & Methodology
Boston EMS defines a narcotic-related illness (NRI) as “a clinical incident identified as suspected to be related to narcotic use after a review of patient care reports,” with key factors such as confirmation of pinpoint pupils and altered mental status. To categorize data, the agency’s NRI taxonomy includes cardiac; referred to medical examiner; drug use heroin; drug use other abuse; drug use heroin mentioned; respiratory; sick; and stupors.
As part of its decision tree for what goes into its database, Boston EMS queries records for such entries as the word needle in the narrative, which triggers a manual read-through to see if it fits the case definition.
The agency follows stringent rules for what goes into its database – and what doesn’t. “Yes, we have some fields that are in our ePCR systems, and if our providers would always choose the right dropdowns, always choose the right answers that we want to know, we’d all be so much happier,” said Salvia. “But there are the times when somebody’s trying to [get back in service], they put it down as a minor illness…and certain things will go through the cracks. Methodology means following the method for the data you provide and the way you provide it to your stakeholders is meaningful, consistent and reliable.”
To ensure data integrity, a daily data QA process includes reconciling CAD data with ePCR data on a daily basis. Boston EMS provides its data on a weekly basis for monitoring trends. Worse, better, same and heat map. “This is a way that we can ensure that we have a real-time understanding of what’s actually going on with the trend,” Salvia said, adding that the data doesn’t offer explanations of why something is happening, just what the trend is.
The Key Role of Liaison
Boston EMS staffs a liaison position at the Boston Regional Intelligence Center (BRIC), housed in the Boston Police Department, ensuring communication among BPD, Boston EMS, and the Boston Public Health Commission’s Office of Recovery Services. This individual reconciles EMS cases with CAD records and performs manual reviews of NRI cases (scrubbed for HIPAA compliance), among other functions. But Salvia noted perhaps an even more valuable aspect to the role: “The liaison knows medically what’s going on; they know how to speak to the compassion of the outreach person, and they also know how to speak police language sometimes,” he said. “That can be a complicated thing when you’re worried about people’s identities, when what we’re really trying to do is help someone, not arrest them or get them in trouble, because we want them to always feel like they can call 911.”
Data alone has the greatest value when it’s shared, Salvia said. Boston EMS provides a feed to city hall, where the mayor can observe opiate trends on a dashboard in his office, following outreach, recovery services, police and the front line of EMS. The agency also makes information available to the public, to raise awareness about the opioid crisis and what Boston is doing to combat it.
A sample Boston EMS weekly NRI report included data such as:
- 279 total cases of NRI for the month of 12/17, a 79% increase over the same period one year earlier
- Three times as many cases were classified Referred to Medical Examiner in December 2017, again compared to the same month one year earlier
- Narcan was administered in 168 cases during the reporting period, a 93% increase over the same period one year prior
- In 2017, 71% of NRI patients were male, with age distribution as follows: 21% 19-29; 34% 30-39; 22% 40-49; 16% 50-59; 7% 60 or older
A CDC review of a sample set of Boston opioid data for RME cases [referred to medical examiner] revealed that not every definite narcotic-related death was being included. However, Salvia attributes the discrepancy to stringent requirements and being sticklers for the case definition. “It gives us a consistency and a quality of data that we can feel confident to be able to say, ‘This is meaningful, and it works for being able to understand.’”
Going Beyond: Other Uses for the Database Model
In addition to battling the opioid epidemic, Boston EMS has used its database model to examine bicycle, pedestrian, and motor vehicle incidents; track cardiac arrests; monitor RSI; and support suicide risk reduction.
View a presentation on Boston’s response to the opioid crisis from ESO’s Wave Conference.