HomeMy WebLinkAboutHUR130-032 Naloxone Program
Procedure
Procedure Title: Naloxone Program Procedure Number
HUR 130-032
Reference
HUR 130 Occupational Health &
Safety Policy
Date Originated (m/d/y)
June 20, 2024
Date Revised (m/d/y)
Pages
5
Approval: Chief Administrative Officer
Point of Contact
Director, Community Services
Procedure Objective
The naloxone program outlines measures in place to train First Responders, establishes proper
storage and supply protocols, and ensures readiness for accessing and administering it in the
event of an opioid overdose in City of Pickering operated buildings.
Index
01 Definitions
02 Roles and Responsibilities
03 Procedures
01 Definitions
01.01 Auto External Defibrillator (AED) Attendant – the employee responsible for
maintaining the AED unit in their proximity by ensuring the pads and battery are
not expired, and that the communication data is downloaded from the device.
01.02 First Responder – a First Responder is an employee within a workplace
designated to be the first response to serious injuries and incidents. A First
Responder has the responsibility to organize and manage the response to such
an incident, and to direct the contact of emergency services personnel, and
administer first aid.
01.03 First Responder Coordinator – the employee responsible for overseeing the
maintenance and operation of AEDs in the workplace and track inventory and
supply of naloxone. The First Responder Coordinator is responsible for arranging
training for personnel, managing the budget related to the program, and ensuring
an adequate number of First Responders are assigned to each facility.
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Procedure Number: HUR 130-032
01.04 Naloxone Hydrochloride (Naloxone) – a medicine that temporarily prevents or
reverses the effects of an opioid overdose. Specifically, it can help restore
breathing during an opioid overdose.
01.05 Opioids – a broad group of drugs intended to treat pain that work by attaching to
specific receptors in the brain, depressing the central nervous system potentially
impacting breathing, heart rate, and level of consciousness. Common opioids
include heroin, fentanyl, morphine, methadone, codeine, and oxycodone.
01.06 Opioid Overdose – a state that occurs when the body is overwhelmed by opioids
and the central nervous system can no longer control basic life functions
(breathing, heart rate, temperature), which can lead to unconsciousness and even
death if untreated.
02 Roles and Responsibilities
02.01 Designated First Responders are to:
a) participate in Naloxone training, use PPE and follow all safety measures
to protect themselves in the administration of Naloxone;
b) recognize the signs and symptoms of an opioid overdose including, but
not limited to:
• slow, irregular or not breathing
• slow or no heartbeat
• very small pupils
• cold and clammy skin
• extreme drowsiness
• unconsciousness, or unable to arouse
• hypotension (unusually low blood pressure)
• hypoxia (a lack of oxygen which can lead to brain damage, cardiac
arrest, and death)
• blue or grey lips or nails
c) call 911 immediately
• put on personal protective equipment (PPE) provided with the kit;
• if the person is unresponsive and not breathing or has irregular
breathing, perform CPR if it is safe to do so;
• check for a medical alert tag to see if the person is known to be
allergic to Naloxone;
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Procedure Number: HUR 130-032
• give the person the Naloxone in one nostril. It may take about one to
five minutes for breathing to return to normal;
• monitor the person’s condition while waiting for emergency
assistance. Naloxone lasts for about 20 to 90 minutes. Since opioids
may remain in the person’s system longer, symptoms may return and
a second dose may be required; and
• remove PPE once care of the person has been assumed by EMS and
wash hands.
d) complete an incident report under the Observation Type – Customer
Medical Issue and be sure to include:
• time, date and location of incident
• identity and contact information of customer (if known)
• signs and symptoms presented by customer
• actions taken including when 911 was called, whether Naloxone was
administered, and number of doses
• outcome/status of customer’s health once emergency services took
over the scene
• if there was a potential exposure to hazardous substances including
bio hazards; and
e) complete Naloxone Kit Order Form to replenish supply.
02.02 First Responder Coordinator is to:
a) order replacement naloxone kits as needed and distribute accordingly;
b) track expenses related to the naloxone program; and
c) coordinate naloxone training for First Responders.
02.03 Supervisors are to:
a) ensure naloxone kits are inspected monthly as part of the first aid kit and
AED inspection;
b) provide support to a worker who has administered Naloxone if required;
c) refer impacted staff to Employee Family Assistance Program;
d) ensure Incident Report is filed for review and tracking; and
e) ensure training is completed by First Responders.
02.04 Chief Administrative Officer is to:
a) support the Naloxone Program and approve any amendments thereto; and
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Procedure Number: HUR 130-032
b) review, amend and approve all standard operating procedures related to
the Naloxone Program.
03 Procedures
03.01 Training
First Responders shall complete assigned training and annual refresher
training that will acquaint them with the signs and symptoms of an opioid
overdose, the steps to respond, how to administer Naloxone safely, the
hazards associated with doing so, and the application of the Good Samaritan’s
Act.
03.02 Naloxone Kits
a) The First Responder Coordinator will distribute naloxone kits for
placement in or near AED stations. Each kit shall contain one hard shell
zipper case, two doses of naloxone hydrochloride intranasal spray
(4mg/0.4ml), non-latex gloves, one card that identifies the person trained
to give the Naloxone, written instructions on how to administer it, eye
protection, and a one-way rescue breathing barrier.
b) The inventory of kits must be maintained by the AED Attendant and
replacement kits shall be ordered using the Naloxone Kit Order Form
(Appendix I) and will be billed back to Facilities Maintenance - Fire & Life
Safety Budget.
c) Naloxone kits have a shelf life of 24 months and must be stored below 25°
Celsius.
Appendices
Appendix 1 Naloxone Kit Order Form