Development and implementation of club specific ambulance referral guidlines
Previously developed 'club guidelines' developed for club owners and promoters have tended to focus more on the legislative aspects of clubs, rather than the medical management of unwell clubbers within club environments. Despite this lack of guidance on the management of unwell clubbers, a significant proportion of clubs have 'club medic' rooms for managing these individuals. However, due to the lack of specific guidance on the training of staff working in these rooms and guidelines on when an ambulance should be called for an unwell clubber, there have been instances previously where clubbers have been inappropriately managed within the club environment, and often referred to hospital only after significant physiological derangement has occurred, thereby leading to an increased risk of morbidity and mortality.
To develop guidelines detailing indications for ambulance transfer to hospital for clubbers with recreational drug toxicity and to train club medic staff to use the guidelines.
The guidelines are based on an assessement of various club medic rooms, facilities available, and the background and previous training of staff working within these rooms and on a literature review. Prior to implementing the guidelines we ran a training session for all club medics to introduce the guidelines and discuss general issues in the management of patients with recreational drug toxicity, using case scenarios.
After introduction of the initial referral guidelines, management of all individuals attending a club medic room with recreational drug related toxicity was assessed using a standardised proforma, completed by medic room staff over an 18 day period in November 2006. Presenting clinical parameters (heart rate, blood pressure, conscious level as assessed using the AVPU score and temperature), fulfilment of defined transfer criteria and final disposition were recorded. These forms were returned directly by individual clubs using anonymous pre-paid envelopes addressed to the principal investigator. Based on these data the guidelines were revised to a final version.
After receiving training on how to use the final guidelines, all the club medic staff were confident in their ability to assess unwell clubbers with recreational drug toxicity, the use of the guidelines and also when to call an ambulance.
Following the initial development of a pilot set of guidelines, an audit of their use identified training needs relating to the assessment of unwell clubbers with recreational drug toxicity and revisions required to the pilot version of the guidelines. After training related to the revised guidelines, all the club medic staff were confident in their ability to assess unwell clubbers with recreational drug toxicity, the use of the guidelines and also when to call an ambulance.
Staff working in 'club medic' rooms
Within the UK, the "Safer Clubbing" guidelines have been developed for nightclub owners and promoters; these focused more on the legislative and security aspects of clubs, rather than the medical management of unwell clubbers within club environments, particularly those with recreational drug toxicity.Some authors have discussed the provision of 'first aid' facilities within club venues, although this has not been specifically for problems relating to recreational drugs.Despite the lack of guidance concerning the management of individuals with toxicity following recreational drug use, a significant proportion of clubs now have dedicated 'club medic' rooms where individuals with recreational drug toxicity can be assessed and managed. These rooms have a range of medical equipment available for the assessment of individuals, and the experience of club medic room staff ranges from basic first aid training to paramedic/nursebased training.Our experience has been that club owners/promoters maybe reluctant to call an ambulance for clubbers with recreational drug toxicity, because of concerns that this could affect their licence. This has led to clubbers being inappropriately managed within the club environment, and potentially being referred to hospital only after significant physiological derangement has occurred, thereby leading to an increased risk of morbidity and mortality.
The recommended equipment inventory for the 'club medic' rooms is: a bed, thermometer, sphygmomanometer, watch/clock with second hand, cold water and that the facility should be housed in a quiet environment with adequate ventilation.
Training, usability, and effectiveness of guidelines
All 16 club medic room staff who attended the training session run at the time of introduction of the updated guideline completed a questionnaire at the end of the session. 14 (87.5%) felt confident in assessing unwell clubbers following use of recreational drugs; the remaining 2 (12.5%) felt 'generally confident'. 100% of individuals felt confident in using the referral guidelines in deciding when a clubber with recreational drug toxicity should be referred to ED/an ambulance called. No individuals surveyed felt that additional training was required following this 'one off' training session.
The major problems identified following the introduction of the initial referral guidelines related to the non-referral to hospital of those individuals with an AVPU score of P or U (11, 23.9%), those having had a 'seizure' following use of recreational drugs (5, 10.9%) or those who were agitated or aggressive in the club medic room (7, 15.2%).
Where the clinical parameters had been correctly completed on the form (n = 30; 71.4%), the management and final disposition of the patient on review of the form was deemed to be appropriate in 22 (73.3%) of cases. For the 8 remaining cases, management was deemed inappropriate due to non-referral to hospital for seizures (n = 2; 25%), an AVPU score of P or U (n = 5; 62.5%) or both seizures and an AVPU score of P or U (n = 1; 12.5%).
Wood, D.M., Greene, S.L., Alldus, G., Huggett, D., Nicolaou, M., Chapman, K., Moore, F., Heather, K., Drake, N., Dargan, P.I. (2008). Improvement in the pre-hospital care of recreational drug users through the development of club specific ambulance referral guidelines. Substance Abuse Treatment, Prevention, and Policy, Jun 6;3:14.