Chan Carusone, Cobb, Cooper, Guta, Kandel, Stewart, Strike - - PowerPoint PPT Presentation

 

Chan Carusone, Cobb, Cooper, Guta, Kandel, Stewart, Strike

 Experience of PHAs who use substances in hospital (Carol, Soo, Adrian)

• Background –problem issue and basic stats
• Present data from two studies
• Overview of AIMED intervention

 Case examples (Chris Kandel)  Small group discussion (35 minutes)

• Small group discussion for 4 of 5 AIMED elements, moderated by a team

member (Soo, Adrian, Curtis, Ann)

• Discuss how to modify AIMED for inpatient settings and challenges of

doing so

• AIMED based on AMA as the trigger; what is the ‘trigger’ for acute care

stay?

 Report back and group discussion  Discuss next steps

 Prevalence of drug and alcohol use is higher than gen pop

• Estimated up to 70% of people living with HIV/AIDs (PHAs) used illicit drugs or

reported hazardous alcohol use, past year

 Present at ED and are admitted to hospital more frequently than the

general population

• ~ 8 to 11% of all ED presentation in Canada are related to substance use

 Report poor access to care from health service providers and perceive

their care to be inferior to the care received by non‐users.

 Labelled as ‘challenging, manipulative, drug‐seeking and demanding’

• Health care providers, often feel they are not prepared, trained or willing to meet

needs of people who use substances

 High rates of leaving AMA/patient initiated or premature discharge among

people who use substances

• 25% to 30% of PWID – Vancouver (Chan et al., 2004; Jafari et al., 2015; Riddel et al.,

2006)

 Correlates of premature

departure

• Drug and alcohol use
• Aboriginal ancestry
• Weekends
• Welfare cheque day

 Motivators

• Experiences of

stigma/discrimination

• Withdrawal/desire to use
• Poor pain management
• Poor management of addiction
• Increased suffering

 Outcomes

• Increased mortality
• Increased health care costs

(readmissions)

 Correlates non‐premature

discharge

• Older age
• In‐hospital methadone
• Referral to transition team to

manage deep tissue infection

Ti and Ti. Leaving the hospital against medical advice among people who use illicit drugs: a systematic

• review. AJPH. 2015, 105 (12): e53‐e59.)

1

• Experience

Experience of being

• f being client

client in a hospital in a hospital (Case (Casey House) with HR House) with HR policy (OHTN) policy (OHTN)

• (Strike et al., International Journal of Drug Policy 2014 May;25(3):640-9 doi:

10.1016/j.drugpo.2014.02.012)

2

• Clinician per

Clinician perspectiv pective and e and practice practices in s in ac acut ute c e care set settings (CIH ngs (CIHR) R)

• How does substance use among PHA/HCVs influence care and relationships
• What strategies are used negotiate/manage patients’ substance use
• What are the key ethical issues and challenges

3

• Patient per

Patient perspectiv pective and e and practices practices in acut in acute e care care se settin ttings (OHT (OHTN) N)

• How do PHA/HCVs experiences in acute care setting
• What policies and practices are necessary to improve care experience

4

• AIMED (assess, in

AIMED (assess, investi stigat ate, mitiga e, mitigate, e , explain, and plain, and document; CIHR) document; CIHR)

• Use case scenarios to adapt AIMED.
• Conduct formative evaluation (acceptability, duration, salience, format and length).
• Develop a research proposal to pilot test the adapted AIMED at selected site

1

• Community driv

Community driven t en topics using a pics using a CBR model designed and CBR model designed and test sted f ed for PHA who use substances r PHA who use substances

2

• Multi-disciplinar

Multi-disciplinary t teams – ams – community

• mmunity, clinicians, resear

, clinicians, researcher chers s

3

• It

Iterativ erative – e – use se evidence fr idence from one

• m one pr

project t

• ject to guide the

guide the ne next xt

• Goal is

Goal is to de develop e lop evidence-based recommendations f idence-based recommendations for changes r changes to practice practice and policy and policy

 Stigma experienced and care impacted regardless of

me/type of drug history → strategies: ‘good paent’, ‘squeaky wheel’, avoid certain organizations.

 Lack of communication, trust and consistency contributes to

unsafe use and compromises health & care.

 Pain management is insufficient and unreliable.  Pain management impacts: satisfaction with care; behaviour

and interactions with staff; ability to stay in hospital; use of non‐prescribed drugs, and; willingness to seek care.

(Substance use DOES happen during admissions.)

I was scared, because I wasn't sure whether I should really be doing this. But my whole body just ached, and ah, and the ibuprofen wasn't doing anything for me. (PAT39)

You want to be free to be able to tell but you're also afraid to tell them, because then you know they're going to cut you down, or they're not going to give you what you want. And, that is a serious reality, because, yeah, I mean, like, you don't want to tell them that 'Oh yeah, I smoke crack.' or 'I do this and I do that.' because immediately you're screwed. Oh, now you're reduced to Percocets instead. But I need morphine. I don't need Percocets. I need

• morphine. But try to tell them that, right? And this is what happens. (PAT29)

 Education: understand drugs, effect of drugs, mental health,

harm reduction

 Respect  Engage in a conversation  Harm reduction approach  Individualized: medical context & role of substance use  Pain/withdrawal managed  Environment: ER; something to do; ensure confidentiality Maybe being a little bit more comfortable with your patients. Like, talk to them and find out about, that, we're still, even though we're drug user and we have HIV or hepatitis C and whatever, we are still

• people. And we don't need to be treated

like criminals. (PAT31)

 Stigma: Participants described ongoing stigma towards and

questions about the trustworthiness of substance use/users, and shifted blame for this stigma and resulting poor care between physicians and nurses.

 Knowledge: Many did not understand how illicit drugs are used,

effects of drugs, and interactions with prescribed medications

 On‐site use: Many acknowledged substance use happens during

admissions (including on‐site) and posed a risk.

 Policies: Participants were generally unaware of any policies in their

• rganizations to inform how to respond to or manage substance

use and/or prescribing (e.g. for opiates and benzodiazepines)

 Responses: Participants responded in a range of ways from

ignoring, punishing, to accommodating and *contracting

 Discharges: Participants recognized that hospital conditions and

cultures led to early and unplanned discharges.

 Participants described challenges they experienced

communicating with patients about their substance use and many questioned whether they could trust patients.

It depends upon is whether they're honest; whether they're actively using

• r not really affects care. Whether

you can get rapport; whether they will trust you, um, to tell you the truth, so that you can maybe connect and at least talk about harm reduction. (OT- MD)

I think, as a provider, one of the things that also is hard for people is that you have accept that [patients] are going to lie to you, right? And people who use substances, sort of, I think, frequently learn that to sort of get around, you have to hide certain things from people. So, and until you sort of enter into their circle of trust, they're going to lie to you. TO-MD

 Some participants described accommodating substance use

(especially opiates) by matching doses used in the community to prevent or lesson withdrawal symptoms in hospital; others were opposed to this practice

I've done this for a long time and my personal philosophy is that if somebody comes in the hospital for a medical problem and is addicted to drugs, I'm not going to be able to change them with one hospital

• stay. So I tend to try and take the easy route and

provide them what I think they need, what they crave, because otherwise, you just run into trouble and they leave hospital against medical advice. MD-TO I'm more concerned about under dosing these drugs in people that chronically abuse these types of medications than

• ver prescribing. I've never heard of

anybody who has ah, drug addictions to be overdosed in the hospital. I think it happens in these, ah, opiate naive

• patients. PH-TO

 Participants identified the need for harm reduction and

integrated it in their practice; others advocated for a treatment approach

So we need a harm reduction approach, which means we need to teach people how to inject if they insist on injecting…Like, if nurses or doctors can say 'Okay, you need to get your water from here. This is how you're going to inject. This is how you're going to put the tourniquet on. This is how you're going to look for….' Like that whole stuff, I think is really important. The educational component should be happening in the hospitals. Should be happening everywhere. It can be everywhere there's a point of connection. MD-OT

You know, the patient who is injecting through her PICC, I told her just to be really careful, like, cleaning her PICC, because if she gets an infected PICC, it's just going to make things much worse. MD-TO

 Many participants recognized that hospital conditions (e.g.,

hospital culture and zero tolerance polices) resulted in ‘premature’ discharges. Some care providers had practices in place to mitigate the health risks of these discharges (e.g., having prescriptions for antibiotics ready).

It's frustrating. You know, I mean, I wish that they would stay or find some way to, you know, communicate with us and say “Look, this is what it's going to take for me to stay.” So, it is, especially when you go through a lot of work, to try and make them better, it's frustrating. MD- Toronto Making sure they have adequate follow up

• arrangements. So, and giving them medications to

treat whatever it is, make sure they have a prescription or the meds with them as they leave. With their permission, telling their primary care providers and/or their family that they're leaving, just so that someone knows. MD-TO

 Need for substance use/addiction training  Need for organizational policies to ensure continuity of care

(e.g., same level of pain management within a stay)

 Need for harm reduction based policies for inpatients  Need more research and dialogue about the range of informal

practices in use (what works well, doesn’t work well)

 Assess, Investigate, Mitigate, Explain, Document

• Clark MA, Abbott JT, Adyanthaya T. Ethics Seminars: A Best‐practice

Approach to Navigating the Against‐Medical‐Advice Discharge. Academic Emergency Medicine 2014; 21(9): 1050‐7

 Solicit suggestions for adaptations to AIMED (Today).  Conduct a small formative evaluation of the adapted

AIMED model with five patients to assess appropriateness

• f the intervention (acceptability, duration, salience,

format and length).

 Develop a research proposal to pilot test the adapted

AIMED at selected site

AIMED: Adaptation Based on case examples, discussion and your practice:

 How does AIMED need to

be adjusted for in‐patient hospital care?

 What are barriers to

achieving AIMED with people living with HIV who use substances?

 What are facilitators to

achieving AIMED with people living with HIV who use substances?

 What implementation gaps

do you see in achieving AIMED in the in‐patient hospital setting?

 

Christopher Kandel

 Four groups

• Assess
• Investigate
• Mediate
• Evaluate

 Discuss AIMED and how it might be adapted

• Use questions to guide discussion
• Record discussion on form – please hand in
• Identify one KEY topics you discussed about how to adapted AIMED to

report back

Assess Investigate Mitigate Explain

 Adjustments for in‐patient

hospital care?

 Barriers for achieving AIMED

with people living with HIV who use substances?

 Facilitators to achieve AIMED

with people living with HIV who use substances?

 Implementation gaps ?  What would ‘trigger’ the

initiation of AIMED within inpatient settings?

 Who should be involved in

implementing AIMED?

 What is missing from AIMED?

 