Introduction
Objective
Methods
Theoretical framework
Study design
Provider interviews
Setting
Participants and sampling
Procedure
Researcher characteristics and reflexivity
Qualitative analysis
Results
Interviews
Identifying barriers, facilitators, and intervention functions
BCW Source | Agent | Barrier/Facilitator | Quote | Intervention Function and Proposed Intervention |
---|---|---|---|---|
Capability (Psychological) [Barrier] | MD/NP/ RN | ED staff are unaware that NTX can be used to treat AUD. | “I just don’t think that a lot of us feel very comfortable with it because we don’t really have a lot of training in it. It’s not something covered in medical school and it’s not something that we currently do in the emergency department.” -Resident | Education: Lecture for residents during Grand Rounds. Presentation for faculty at faculty meeting. |
Education: Creation of posters describing NTX and treatment algorithm. | ||||
Education: Presentation for nurses during morning huddles. | ||||
Education: Establish champions among MDs and RNs that staff can approach with questions. | ||||
Enablement: Creation of AUD & AWS order set that includes educational material about indications, dosing, side effects, and contraindications. | ||||
Enablement: Creation of AUD & AWS guidelines. | ||||
Capability (Psychological) [Barrier] | MD/NP/ RN/CSW | ED staff unfamiliar with screening tools to identify AUD. | “Well, I think alcohol use disorder population is actually kind of a broad-- it’s a broad spectrum of disease. I think alcohol use disorder hits all groups, all populations. So there isn’t one specific population that will have it... It’s like, it’s really hard to have a uniform approach to it” -Attending | Training: Train providers on the use of AUDIT-C assessment. |
-“Are there specific scales or questionnaires used to diagnose alcohol use disorder in the emergency department?” -“I feel like that’s relatively limited in the emergency department. I think oftentimes we either catch on either their presenting complaints in one facet or another, as we just discussed, or the residents uncover it as part of the review of systems.”-Attending | Training: Create a script that staff can use when asking patients about their alcohol use. | |||
Capability (Psychological) [Barrier] | MD/NP/ RN/CSW | ED staff find it difficult to identify a patient’s stage of change. | “Again, you have to admit it’s a gray area. They’re not either, ‘Oh, they’re ready now.’ Versus, ‘They’re not ready.’ There may be that gray area, that’s where I think you’re truly speaking to your patient and how to figure out--would he be receptive to it? -Attending | Training: Train staff in motivational interviewing to better identify patient’s stage of change. |
BCW Source | Agent | Barrier/Facilitator | Quote | Intervention Function and Proposed Intervention |
---|---|---|---|---|
Opportunity (Physical) [Barrier] | MD/NP | Pharmacy pre-approval for IM NTX discourages providers from prescribing. | “No, I don’t know what the restrictions or authorizations are. If it was a prior auth situation, that will be a substantial hurdle” -Attending | Enablement: Eliminate or streamline pre-approval form for IM NTX. |
Enablement: Remind providers the oral form of NTX is available if pre-approval for the IM form is unsuccessful. | ||||
Opportunity (Physical) [Barrier] | MD/NP/ RN/CSW | Lack of adequate discharge materials that are easily understood by patients. | “I would leave it as language is not the only barrier. Things like health literacy, world view and a lot of those things often go hand in hand, which makes it a triple whammy in terms of communicating with someone, particularly on a subject that I’m not truly an expert” -Attending | Enablement: Have patient educational materials appropriate for patients with low health literacy available in multiple languages (English, Spanish, Chinese, Tagalog). |
“I get phone calls sometimes and they tell me, “I don’t understand this instruction.” Even if the primary language is English. And I have to explain to them in layman’s terms, how they can understand.” -RN | ||||
Opportunity (Physical) [Barrier] | MD/NP/ RN/CSW | Perception from staff that they are unable to effectively communicate with patients because of language barriers. | “The majority of my patients with alcohol use disorder speak Spanish, and I’m a certified bilingual but I’m not truly bilingual. Even with a translator, it’s a lot harder to have a subtle conversation either via a translator or in another language than it is with a native speaker. Querying somebody’s motivations by giving subtle instructions and consent is a lot harder. We keep things a bit simpler.” -Attending | Environmental Restructure: Hire more bilingual CSW and SUNs. Hire more in-person interpreters. |
Environmental Restructure: Recruit and retain more residents and physicians who are bilingual. | ||||
Opportunity (Physical) [Barrier] | Pharmacy | Limited supply of NTX available to the ED. | “Oh, yeah. We keep like absolutely nothing of the intramuscular, or very, very few, so if we actually did roll out our true protocol for patients, then we would have to really get in touch with the line management to get them to know we’re going to be rolling out this protocol and we need to have this many on hand, we’re expecting this much usage of this medication.” -Pharmacist | Environmental Restructure: Work with pharmacy to increase supply of IM NTX. |
Opportunity (Physical) [Barrier] | MD/NP/ CSW | Unable to follow-up with provider who can continue NTX treatment. | “I guess my concern would be, like anything you start, is having the back-end follow it up. It’s easy start things but if we prescribe naltrexone, you say, “Here’s your prescription,” if they’re coming back in a week for refills or two weeks because there is poor substance use disorder assistance in the community.” -Attending | Environmental Restructuring: Utilize Substance Use Bridge Clinic to bridge AUD patient to next prescriber. |
Enablement: Compile list of inpatient and outpatient AUD treatment options. | ||||
Environmental Restructuring: Perform warm hand-offs with organization that provides AUD treatment. | ||||
Enablement: Increase number of Substance Use Navigators (SUNs) to help AUD patients access resources. | ||||
Enablement: Encourage use of existing adjunct programs, such as community health workers, to help AUD patients access more care. | ||||
Opportunity (Physical) [Barrier] | MD/NP/ CSW | Patients often have unreliable access to a phone. | “I’m wasting my time on doing something, if no one else help me to do something, because I can’t get a hold of the patient. Giving resources, it works probably 10% of the time, if that, because maybe 10% of patients have a phone” -CSW | Enablement: Establish connection to cell phone distribution program |
Opportunity (Physical) [Barrier] | CSW | Social workers feel they don’t have enough time with the patients. | “The time constraint is also an issue. Let’s say, for example, patients being interested in being referred for detox. That is a lengthy process because right now, the only detox referral we use is Tarzana Treatment Center. We have to get the information they want, and they’ll have the patient sign a consent and then fax it over. Then you have to wait for them to review it and then call you back and then to let you know if they have a bed or not. Most of the times they don’t even have a bed.” -CSW | Enablement: Ensure enough time is given for social workers to work with AUD patients. Refer to CSW early in the process. |
Enablement: Hire more SUNs. | ||||
Opportunity (Physical) [Barrier] | MD/NP | Cost of IM NTX is high. | “With the intramuscular injection, it’s ten times more expensive per month, so that’s one issue right there. And I’m not sure in terms of insurance how well that would work for some patients.” -Pharmacist | Enablement: Seek out cost-saving programs or subsidies offered by manufacturers. |
Opportunity (Physical) [Barrier] | MD/NP/ RN/CSW | Sobering patients can remain in the ED for many hours, and the task of assessing for AUD can be missed prior to discharge. | “...you try to get them to the point where, clinically, they’re relatively sober in their clinical state and they’re safely able to discharge. Oftentimes I feel like the piece that’s missing is once you reassess them, [...] we would miss that opportunity to ask them, “Hey, now that I’m finally cognitively meeting you for the first time, are you interested in quitting?” -Attending | Environmental Restructure: Add screening for AUD to checklist of items to fulfill before discharge for patients who presented with intoxication. |
Opportunity (Social) [Barrier] | MD/NP/ RN/CSW | Staff opposition to ED as source of long-term treatment. | “It’s easy to start things but if we prescribe naltrexone, you say, “Here’s your prescription,” and they’re coming back in a week for refills or two weeks because there is poor substance use disorder assistance in the community, then we’re becoming a continuity clinic, which-- no. It’s not how the ED is supposed to be” -Attending | Enablement: Strengthen communication between primary care and the emergency department. |
Modeling: Demonstrate a culture of providing all needed care in the ED, including initiating treatment and connection to care, in addition to immediate medical emergencies. | ||||
Opportunity (Social) [Barrier] | MD/NP/ RN/CSW | Roles and responsibilities not clearly defined, specifically, which staff will assess AUD and stage of change. | “It’s mostly by consult. Essentially, the doctor or the nurse contact the social worker if the patient is interested in resources... So they know we’re stopping by. Because a lot of times they consult us without asking the patient and we show up and they’re like, ‘Why are you here?’” -CSW | Environmental Restructuring: Clearly define and assign roles in the management algorithm in advance of the implementation. |
Opportunity (Physical) [Facilitator] | CSW | Clinical Social Workers and Substance Use Navigators (SUNs) in the ED are available for referral most days 24/7. | “About four years ago [...] there was no substance abuse counselor, no social workers, no medical case workers at the ED. Comparing that from four years to about to now, what we have is we have 24/7 social worker and case workers as well as occasional substance abuse counselors 8–12 h a day.” -Attending | Enablement: Encourage consultation with on-site CSWs and SUNs, who can help with assessment of patients’ stage of change, treatment center referrals, phone acquisition, and connect the patient to other assistance programs. |
Opportunity (Physical) [Facilitator] | Pharmacy | Pharmacists in the ED 24/7 for assistance with medications. | “Before there had only been one pharmacist in afternoon and then one at night for graveyard. And there were some hours where there were no ED pharmacists. They were able to change that though. So now we have 24-h coverage.” -Pharmacist | Enablement: Encourage discussion with pharmacists, who can help with details of Naltrexone prescription. |
Opportunity (Physical) [Facilitator] | MD/NP | SUD Treatment Centers like Tarzana exist in the area for referral. | “I think we’re doing better. For example, for opioids use disorder we do have a substance abuse counselor. We have, for example, something set up with Tarzana Treatment Center, which I think even more have played a big part.” -NP | Enablement: Encourage connection to outside treatment centers and strengthen referral relationship and data sharing. |
Opportunity (Physical) [Facilitator] | MD | Weekly Grand Rounds for MDs offers an established opportunity for new education and initiatives. | “I think that conference might be the best avenue just because you’ve got everyone, or more people there at once, who are more likely to be paying attention...” -Resident | Enablement: Leverage existing dedicated education time, i.e. departmental conference |
Opportunity (Physical) [Facilitator] | RN | RN daily huddles, with longer huddles on weekends to address more complicated in-service topics. | “We always have daily huddles. So we can educate our staff that way.” -RN | Enablement: Leverage existing dedicated education time, i.e. RN huddles |
“During the weekends in the morning is when we have huddles that are lengthy. During the week the huddles are shorter, so we’ll do a lot of other stuff with short topics.” -RN |
BCW Source | Agent | Barrier/Facilitator | Quote | Intervention Function and Proposed Intervention |
---|---|---|---|---|
Motivation (Automatic) [Barrier] | MD/NP | Perception that primary care providers are unfamiliar with Naltrexone for AUD. | “Anytime you have a service like this, the clinics [...] outside the hospital in different cities, basically, just refuse to deal with it and send everybody to the hospital... Whenever we establish one of these services, the clinic starts sending us those patients rather than referring through the usual mechanism” -Attending | Persuasion: Dispel ED provider misconceptions of primary care and reassure that AUD management exists in primary care. |
Motivation (Automatic) [Barrier] | MD/NP/ RN/CSW | Staff feel powerless in helping AUD patients, and that attempting to treat them is futile. | “I guess I find it a challenge that I’m good at managing short-term, but I feel basically helpless in helping them get more definitive management of their problem.” -Attending | Persuasion: Use of encouraging examples and vignettes in conference. Liken to management of other chronic conditions, where success is expected to be gradual and is measured by progress. |
Modeling: Establish champions among MDs, Residents, and RNs that will model behavior and reiterate success stories. | ||||
Motivation (Automatic) [Barrier] | MD/NP/ RN/CSW | Staff bias against patients who use alcohol. | “There’s that coarse and vulgar term used, that goes ‘metabolize to freedom,’ where you try to get them to the point where, clinically, they’re relatively sober in their clinical state and they’re safely able to discharge.” -Attending | Modeling: Model alternative terminology, i.e. replace “metabolize to freedom” with “metabolize to screening.” |
Motivation (Automatic) [Barrier] | MD/NP/ RN/CSW | Staff implicit bias of non-English speakers may be affecting their care. | “Our patients specifically, probably a language barrier. I think foremost. Just because we deal with a huge Hispanic population. For a lot of people, English isn’t their first language. So that’s going to be a big barrier. You know, Not quite understanding why, if they’re drinking a 12-pack a day for 10 years straight, and they decide to stop suddenly—they don’t quite understand why they’re shaking and anxious. So that’s one. I think that’s quite a big barrier” -RN | Modeling: Demonstrate cultural humility in approach to AUD management. Avoid “othering” of non-English speakers and AUD patients. |
Training: Regular implicit bias training for ED staff. | ||||
Motivation (Automatic) [Facilitator] | MD/NP/ RN/CSW | Positive opinion of medication assisted treatment and new initiatives among staff. | “More so, recently, I feel like there’s just more resources and potentially more knowledge and more advocates for these patients and I feel like there’s a higher rate of success in getting these patients to the next tangible step and not necessarily leaving them out into the void.” -Attending | Modeling: Continue to use the Bridge Clinic’s OUD management precedent as a model that can be used for AUD treatment. |
Enablement: Use positive opinion of opioid use disorder MAT to encourage the adoption of naltrexone as a treatment option for AUD. |
Capability (physical and psychological)
ED staff also felt they lacked capacity to identify patients with AUD and to discern the patient’s interest in AUD treatment or stage of change. In order to address these gaps in knowledge, these barriers were mapped to educational, training, and enabling interventions to build providers’ capacity. Details of the educational, training, and enabling interventions can be found in Table 1.“I just don't think that a lot of us feel very comfortable with it [Naltrexone] because we don't really have a lot of training in it. It’s not something covered in medical school and it's not something that we currently do in the emergency department.”
Opportunity (physical and social)
Many physicians and clinical social workers assumed the other was responsible for initiating a discussion on AUD with patients. The BCW suggests an environmental restructure to address this barrier, which can be fulfilled by clearly defining the roles of all staff with regards to AUD treatment, and increasing dialogue between providers and clinical social workers. Some raised concern about the role of EDs in providing care that would require long-term management:“It’s mostly by consult. Essentially, the doctor or the nurse contacts the social worker if the patient is interested in resources. [...] So they know we're stopping by. Because a lot of times they [the providers] consult us without asking the patient and we [clinical social workers] show up and they're like, ‘Why are you here?’”
Although many expressed support for MAT and were enthusiastic about the possibility of offering more for AUD patients from the ED, others were hesitant about the ED becoming a source of long-term management for SUD. To address this barrier, the BCW suggests modeling and enablement interventions. Selecting champions to model the behavior of NTX prescription to demonstrate the potential of NTX is one potential remedy. Better processes that enable transition to the primary care setting by coordinating AUD treatment and sharing educational materials with primary care colleagues are additional options.“It’s easy to start things but if we prescribe naltrexone, you say, ‘Here's your prescription,’ and they're coming back in a week for refills or two weeks because there is poor substance use disorder assistance in the community, then we're becoming a continuity clinic, which– no. It's not how the ED is supposed to be.”
Enablement in this case might entail bringing phone access programs into medical centers."I'm wasting my time on doing something, if no one else help me to do something, because I can't get a hold of the patient. Giving resources, it works probably 10% of the time, if that, because maybe 10% of patients have a phone"
Modifying costs and streamlining processes are potential solutions. We sought out pharmaceutical company cost reduction programs and recommended removing the pre-approval form in addition to focusing the intervention design on the oral version of naltrexone, which was significantly more affordable and did not require authorization.“With the intramuscular injection, it’s ten times more expensive per month, so that’s one issue right there. And I’m not sure in terms of insurance how well that would work for some patients.”
Motivation (automatic and reflective)
This emotion was reinforced by an experience of futility and a stigma against patients with AUD, assuming that such patients either did not want to quit or were unable:“I have my streamlined protocol but I guess I'm aware that my streamlined protocol works for me for short-term management of severe withdrawal symptoms, but doesn't address the underlying problem. I guess I find it a challenge that I'm good at managing short-term, but I feel basically helpless in helping them get more definitive management of their problem.”
Furthermore, providers expressed fear that if the ED started offering more AUD services, that primary care clinics would start referring more patients with AUD to the ED, creating an influx of “difficult patients”:“You know, it’s a loop. We see it all the time. They get out of the ER, they go to 7-Eleven, they buy the alcohol at 7-Eleven, they go outside, they drink it, they get drunk, 7-Eleven calls 911, they come back to the ER, and then from the ER, they go back to 7-Eleven.”
The BCW mapped these barriers to intervention functions of modeling, enablement, and persuasion. We will augment trainings to educate ED providers about the capability of our primary care providers to treat AUD in the clinics, draw analogies to how AUD treatment is similar to other chronic diseases, like diabetes, and celebrate examples of providers and patients who made progress through using the new treatment and referral pathways.“Anytime you have a service like this, the clinics [...] outside the hospital in different cities, basically, just refuse to deal with it and send everybody to the hospital.”
We propose modeling using alternative catch-phrases such as “metabolize to screening” to emphasize the need to reevaluate intoxicated patients once they have sobered, including screening for AUD and assessing patient interest in treatment. A significant facilitator related to motivation is the pre-existing culture that views MAT positively, likely due to an existing successful program for opiate use disorder.“There’s that coarse and vulgar term used that goes ‘metabolize to freedom,’ where you try to get them to the point where, clinically, they're relatively sober in their clinical state and they’re safely able to discharge. Oftentimes I feel like the piece that's missing is, once you reassess them, they can eat, they could walk, they’re safe to be discharged, I feel like oftentimes we miss that opportunity to ask them, "Hey, now that I’m finally cognitively meeting you for the first time, are you interested in quitting?"