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Badke K, Small SS, Pratt M, Lockington J, Gurney L, Kestler A, Moe J. Healthcare provider perspectives on emergency department-initiated buprenorphine/naloxone: a qualitative study. BMC Health Serv Res 2024; 24:211. [PMID: 38360620 PMCID: PMC10870432 DOI: 10.1186/s12913-023-10271-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Take-home buprenorphine/naloxone is an effective method of initiating opioid agonist therapy in the Emergency Department (ED) that requires ED healthcare worker buy-in for large-scale implementation. We aimed to investigate healthcare workers perceptions of ED take-home buprenorphine/naloxone, as well as barriers and facilitators from an ED healthcare worker perspective. METHODS In the context of a take-home buprenorphine/naloxone feasibility study at a tertiary care teaching hospital we conducted a descriptive qualitative study. We conducted one-on-one in person or telephone interviews and focus groups with ED healthcare workers who cared for patients given take-home buprenorphine/naloxone in the feasibility study at Vancouver General Hospital from July 2019 to March 2020. We conducted 37 healthcare worker interviews from December 2019 to July 2020. We audio recorded interviews and focus groups and transcribed them verbatim. We completed interviews until we reached thematic saturation. DATA ANALYSIS We inductively coded a sample of transcripts to generate a provisional coding structure and to identify emerging themes, which were reviewed by our multidisciplinary team. We then used the final coding structure to analyze the transcripts. We present our findings descriptively. RESULTS Participants identified a number of context-specific facilitators and barriers to take-home buprenorphine/naloxone provision in the ED. Participants highlighted ED conditions having either facilitative or prohibitive effects: provision of buprenorphine/naloxone was feasible when ED volume was low and space was available but became less so as ED volume increased and space decreased. Similarly, participants noted that patient-related factors could have a facilitative or prohibitive effect, such as willingness to wait (willing to stay in the ED for study-related activities and buprenorphine/naloxone initiation activities), receptiveness to buprenorphine/naloxone, and comprehension of the instructions. As for staff-related factors, time was identified as a consistent barrier. Time included time available and time required to initiate buprenorphine/naloxone (including time building rapport). Healthcare worker familiarity with buprenorphine/naloxone was noted as either a facilitating factor or a barrier, and healthcare workers indicated that ongoing training would have been advantageous. Many healthcare workers identified that the ED is an important first point of contact for the target patient population. CONCLUSION Integrating a buprenorphine/naloxone program into ED care requires organizational supports (e.g., for managing buprenorphine/naloxone within limitations of ED volume, space, and time), and ongoing education of healthcare workers to minimize identified barriers.
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Affiliation(s)
- Katherin Badke
- Lower Mainland Pharmacy Services, Vancouver, BC, Canada.
- Pharmacy Department, Vancouver General Hospital, 899 W 12th avenue, Vancouver, BC, V5Z 1M9, Canada.
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
| | - Serena S Small
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Megan Pratt
- Social Work Department, Vancouver General Hospital, Vancouver, BC, Canada
| | - Julie Lockington
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Lara Gurney
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Andrew Kestler
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
- Department of Emergency Medicine, St. Paul's Hospital, Vancouver, BC, Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
- Department of Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada
- BC Centre for Disease Control, Vancouver, BC, Canada
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Abstract
The "wobble room" is a wellness intervention designed to guide staff through unpredictable times that are not going away quickly. Emergency department teams are accustomed to trauma events and trauma debriefing, but the prolonged uncertainties and fears associated with COVID-19 have posed a unique challenge for healthcare workers. The wobble room has become a place where staff can make sense of how the pandemic is affecting them and create a "new normal" with respect to personal safety and team cohesion.
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Affiliation(s)
- Lara Gurney
- Head Nurse Educator Emergency Department, Vancouver General Hospital, Vancouver, BC
| | - Julie Lockington
- Nurse Clinician, Emergency Department, Vancouver General Hospital, Vancouver, BC
| | - Lori Quinn
- Manager, Emergency Department, Vancouver General Hospital, Vancouver, BC
| | - Maura MacPhee
- Professor, School of Nursing, University of British Columbia, Vancouver, BC
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Moe J, Badke K, Pratt M, Cho RY, Azar P, Flemming H, Sutherland KA, Harvey B, Gurney L, Lockington J, Brasher P, Gill S, Garrod E, Bath M, Kestler A. Microdosing and standard-dosing take-home buprenorphine from the emergency department: A feasibility study. J Am Coll Emerg Physicians Open 2020; 1:1712-1722. [PMID: 33392580 PMCID: PMC7771760 DOI: 10.1002/emp2.12289] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Emergency department (ED)-initiated buprenorphine may prevent overdose. Microdosing is a novel approach that does not require withdrawal, which can be a barrier to standard inductions. We aimed to evaluate the feasibility of an ED-initiated buprenorphine/naloxone program providing standard-dosing and microdosing take-home packages and of randomizing patients to either intervention. METHODS We broadly screened patients ≥18 years old for opioid use disorder at a large, urban ED. In a first phase, we provided consecutive patients with 3-day standard-dosing packages, and then we provided a subsequent group with 6-day microdosing packages. In a second phase, we randomized patients to standard dosing or microdosing. We attempted 7-day telephone follow-ups and 30-day in-person community follow-ups. The primary feasibility outcome was number of patients enrolled and accepting randomization. Secondary outcomes were numbers screened, follow-up rates, and 30-day opioid agonist therapy retention. RESULTS We screened 3954 ED patients and identified 94 with opioid use disorders. Of the patients, 26 (27.7%) declined participation: 10 identified a negative prior experience with buprenorphine/naloxone as the reason, 5 specifically cited precipitated withdrawal, and none cited randomization. We enrolled 68 patients. A total of 14 left the ED against medical advice, 8 were excluded post-enrollment, 21 received standard dosing, and 25 received microdosing. The 7-day and 30-day follow-up rates were 9/46 (19.6%) and 15/46 (32.6%), respectively. At least 5/21 (23.8%) provided standard dosing and 8/25 (32.0%) provided microdosing remained on opioid agonist therapy at 30 days. CONCLUSIONS ED-initiated take-home standard-dosing and microdosing buprenorphine/naloxone programs are feasible, and a randomized controlled trial would be acceptable to our target population.
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Affiliation(s)
- Jessica Moe
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of Emergency MedicineVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Katherin Badke
- Department of Pharmaceutical SciencesVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Megan Pratt
- Social WorkVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Raymond Y Cho
- Faculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Pouya Azar
- Department of PsychiatryUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Complex Pain and Addiction ServicesVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Heather Flemming
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of Emergency MedicineVancouver General HospitalVancouverBritish ColumbiaCanada
| | - K. Anne Sutherland
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of Emergency MedicineVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Barbara Harvey
- Department of Emergency MedicineVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Lara Gurney
- Department of Emergency MedicineVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Julie Lockington
- Department of Emergency MedicineVancouver General HospitalVancouverBritish ColumbiaCanada
| | - Penny Brasher
- Centre for Clinical Epidemiology and EvaluationVancouverBritish ColumbiaCanada
| | - Sam Gill
- Rapid Access Addiction ClinicSt. Paul's HospitalVancouverBritish ColumbiaCanada
| | - Emma Garrod
- Urban Health Program, Providence Health CareVancouverBritish ColumbiaCanada
| | - Misty Bath
- Regional PreventionVancouver Coastal Health AuthorityVancouverBritish ColumbiaCanada
| | - Andy Kestler
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of Emergency MedicineSt. Paul's HospitalVancouverBritish ColumbiaCanada
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Vanstone M, Neville TH, Swinton ME, Sadik M, Clarke FJ, LeBlanc A, Tam B, Takaoka A, Hoad N, Hancock J, McMullen S, Reeve B, Dechert W, Smith OM, Sandhu G, Lockington J, Cook DJ. Expanding the 3 Wishes Project for compassionate end-of-life care: a qualitative evaluation of local adaptations. BMC Palliat Care 2020; 19:93. [PMID: 32605623 PMCID: PMC7325646 DOI: 10.1186/s12904-020-00601-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs. METHODS Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program. RESULTS Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose. CONCLUSIONS The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other. TRIAL REGISTRATION NCT04147169 , retrospectively registered with clinicaltrials.gov on October 31, 2019.
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Affiliation(s)
- Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Thanh H Neville
- Department of Medicine, Division of Pulmonary & Critical Care, University of California Los Angeles, California, Los Angeles, USA
| | - Marilyn E Swinton
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marina Sadik
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - France J Clarke
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Allana LeBlanc
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Benjamin Tam
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Alyson Takaoka
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Neala Hoad
- Department of Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | | | - Sarah McMullen
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Brenda Reeve
- Department of Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | | | - Orla M Smith
- Critical Care Department, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Gyan Sandhu
- Critical Care Department, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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