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Peters H, Liaukovich A, Grace N, Ausman C, Kiepek N. Opportunities to improve inpatient services and reduce rates of patient-direct discharge among people who use substances. Hosp Pract (1995) 2024; 52:64-76. [PMID: 39081137 DOI: 10.1080/21548331.2024.2386924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE Patients who use substances (PWUS) report experiencing stigmatizing encounters and undertreatment of pain and withdrawal symptoms that increase the likelihood of patient-directed discharge (PDD). This scoping review examines North American literature to gain insights about how institutional factors intersect with patient experiences and contribute to PDD. METHODS A scoping review was conducted using MEDLINE, CINAHL, Scopus, and EMBASE databases. Screening was completed by two reviewers. A data extraction tool developed by the research team was used to collect demographic information and explore patients' experiences and reasons for PDD. RESULTS We present four themes related to PDD: i) effective management of pain and withdrawal symptoms, ii) therapeutic alliance with healthcare providers, iii) hospital policies, protocols, and procedures, and iv) recommendations. Notably, all patients in all qualitative studies reported predominant experiences of uncaring, stigmatizing interactions with healthcare providers. DISCUSSION Findings suggest that transformations are required at individual and institutional levels. At an individual level, to provide equitable care to all patients, healthcare providers in all practice settings should be competent to effectively and compassionately care for PWUS. At an institutional level, policies need to be re-envisioned to support the implementation of effective practices. CONCLUSION Hospitals are faced with the challenges to ensure respectful care environments guided by harm reduction policies that will improve engagement of PWUS in services.
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Affiliation(s)
- Hannah Peters
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alex Liaukovich
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nardeen Grace
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christine Ausman
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Niki Kiepek
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
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Ho K, Sanjoy S, Kassir S, Srivatsav V, Yeung C. Analysis of Transesophageal Echocardiography Appropriateness for Diagnosing Infective Endocarditis: Insights From Two Tertiary-Care Hospitals. CJC Open 2024; 6:1013-1020. [PMID: 39211758 PMCID: PMC11357786 DOI: 10.1016/j.cjco.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/25/2024] [Indexed: 09/04/2024] Open
Abstract
Background Echocardiography plays a key role in the diagnosis of infective endocarditis (IE), and recommendations have been published regarding the appropriate use of transesophageal echocardiography (TEE). The objective of this study is to evaluate the utilization of TEE in Regina, Saskatchewan, in the diagnosis of IE. Methods A retrospective chart review was performed on patients aged ≥ 18 years who received a TEE test for the diagnosis of IE from January 1 to December 31, 2019. The primary outcome included the proportion of TEE uses that complied with the American College of Cardiology Foundation and American Society of Echocardiography (ACCF and ASE) recommendations and the European Society of Cardiology (ESC) recommendations. Results A total of 204 admissions involving 188 patients who had TEE performed for the diagnosis of IE occurred within the study period. The mean age was 53.1 ± 17.1 years. Of the 204 TEE uses, 152 (74.5%) were considered appropriate by the ACCF and ASE recommendations. Having at least one predisposing condition (adjusted odds ratio [aOR] 4.30 [95% confidence interval [CI] 2.11-9.04), P < 0.001]) was more likely to be associated with appropriate TEE use, per the ACCF and ASE criteria. Of the 204 TEE uses, only 80 (39.2%) were considered appropriate by the ESC recommendations. Having a history of intravenous drug use (aOR 3.08 [95% CI 1.08-9.27], P = 0.04) and having blood cultures positive for IE-related organisms (aOR 2.31 [95% CI 1.16-4.80], P = 0.02)) were more likely to be associated with appropriate TEE use, per ESC recommendations. Conclusions The current study suggests that the use of TEE in the diagnosis of IE demonstrated variable levels of adherence to recommendations published by the ACCF and ASE and by the ESC, with significant discrepancy between the two.
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Affiliation(s)
- Karen Ho
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shubrandu Sanjoy
- Research Department, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Sandy Kassir
- Research Department, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Varun Srivatsav
- Division of Cardiology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Colin Yeung
- Division of Cardiology, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
- Department of Medicine, University of Saskatchewan College of Medicine, Regina, Saskatchewan, Canada
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Sardiwalla Y, Nachmani O, Price E, Huynh M, Coroneos C, McRae M. Upper Extremity Infection Related to Intravenous Drug Use: Considering the True Cost of the COVID-19 Pandemic and Lockdown. Hand (N Y) 2023; 18:999-1004. [PMID: 35193427 PMCID: PMC10470235 DOI: 10.1177/15589447221077377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The COVID-19 pandemic caused significant morbidity and mortality in people who inject drugs (PWID). Upper extremity soft tissue infections are frequently associated with intravenous drug use (IVDU) due to poor compliance with aseptic technique. In Canada, multiple safe injection sites providing clean injection supplies closed, leaving many PWID with no alternatives to inject safely. It was hypothesized that these closures will correspond with increased morbidity and mortality among PWID. The main objective of this study was to determine the effect of the COVID-19 pandemic on the incidence of upper extremity infections in PWID. METHODS This was a retrospective chart review study. The primary outcome of interest was the frequency of upper extremity infections in PWID. Data were filtered to include only those patients presenting to the emergency department between March to June of 2019 and 2020. Chi-squared analysis was used to compare the number of IVDU patients among patients with upper extremity skin infections between these time periods. RESULTS The number of IVDU patients treated for upper extremity infections in Hamilton significantly increased during the pandemic, relative risk = 2.0 (95% confidence interval [CI]: 1.3-2.9, P = .0012,) while total upper extremity infections numbers have decreased overall. During the pandemic, PWID made up a larger proportion of upper extremity infections (χ2 = 10.444, P = .00123). Demographic data such as age and sex of IVDU patients presenting with upper extremity infection was not significantly affected by the pandemic. CONCLUSIONS The effect of the pandemic on accessing harm reduction services has led to evident increases in morbidity as described by this study. Further research on the impact of closures in PWID is needed to quantify these harms and work toward mitigation strategies.
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Affiliation(s)
| | | | | | - Minh Huynh
- McMaster University, Hamilton, Ontario, Canada
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Keynan Y, Haworth-Brockman M, Laupland KB, Rueda ZV. Beyond HIV: An urgent need for a syndemic and gender-based approach in the Prairie provinces in Canada. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2023; 8:1-6. [PMID: 37008586 PMCID: PMC10052900 DOI: 10.3138/jammi-2022-10-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
- Yoav Keynan
- Department of Medical Microbiology and Infectious Diseases, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- National Collaborating Centre for Infectious Diseases, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- The Manitoba HIV Program, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Margaret Haworth-Brockman
- National Collaborating Centre for Infectious Diseases, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Australia
| | - Zulma Vanessa Rueda
- Department of Medical Microbiology and Infectious Diseases, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study. Addict Sci Clin Pract 2023; 18:8. [PMID: 36747268 PMCID: PMC9902242 DOI: 10.1186/s13722-023-00363-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/25/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention. METHODS Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs. RESULTS Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing. CONCLUSION Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.
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Levy S, Bassler J, Gagnon K, Prados M, Jeziorski M, McCleskey B, Crockett K, Li L, Bradford D, Cropsey K, Eaton E. Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis. Open Forum Infect Dis 2022; 10:ofac708. [PMID: 36726543 PMCID: PMC9879754 DOI: 10.1093/ofid/ofac708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Background Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention. Methods We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use. Results A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum. Conclusions The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.
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Affiliation(s)
- Sera Levy
- Correspondence: Sera Levy, MS, Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, UAB, The University of Alabama at Birmingham, L107 Volker Hall, 1670 University Blvd, Birmingham, AL 35233 ()
| | - John Bassler
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly Gagnon
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myles Prados
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Madison Jeziorski
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brandi McCleskey
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kaylee Crockett
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Li Li
- Department of Psychiatry, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Davis Bradford
- Department of Internal Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karen Cropsey
- Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, UAB, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Brothers TD, Mosseler K, Kirkland S, Melanson P, Barrett L, Webster D. Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis. PLoS One 2022; 17:e0263156. [PMID: 35081174 PMCID: PMC8791472 DOI: 10.1371/journal.pone.0263156] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. METHODS Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. RESULTS We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. CONCLUSIONS Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.
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Affiliation(s)
- Thomas D. Brothers
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- UCL Collaborative Centre for Inclusion Heath, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Kimiko Mosseler
- Dalhousie Medicine New Brunswick, Dalhousie University, Saint John, New Brunswick, Canada
| | - Susan Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patti Melanson
- Mobile Outreach Street Health (MOSH), Halifax, Nova Scotia, Canada
| | - Lisa Barrett
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Saint John Regional Hospital and Dalhousie University, Saint John, New Brunswick, Canada
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