Jacka Brendan P, Ziobrowski Hannah N, Lawrence Alexis, Baird Janette, Wentz Anna E, Marshall Brandon D L, Wightman Rachel S, Mello Michael J, Beaudoin Francesca L, Samuels Elizabeth A
Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.
Acad Emerg Med. 2022 Mar;29(3):294-307. doi: 10.1111/acem.14409. Epub 2021 Nov 23.
Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation.
We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression.
Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time.
ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.
基于急诊科（ED）的纳洛酮分发及同伴间行为咨询已被证明是可行的，但对于随着时间推移的使用维持情况以及影响实施的临床医生、患者和就诊层面因素，我们了解甚少。
我们对一项急诊科过量用药预防项目进行了回顾性队列研究，该项目为2017年至2020年在罗德岛州两家急诊科接受阿片类药物过量治疗的患者提供纳洛酮带回家、行为咨询及治疗联系服务：一家三级转诊中心和一家社区医院。利用“覆盖、效果、采纳、实施和维持”（RE-AIM）框架，我们使用逻辑回归和泊松回归评估了项目覆盖范围、采纳情况、实施调节因素及维持情况。
742名患者在阿片类药物过量后出院，共966次就诊（中位数：每月32次就诊；四分位间距：29，41）。在大多数（86%，826/966）就诊中至少提供了一项干预措施。69%的就诊（637/919）提供了纳洛酮带回家服务。超过半数（51%，495/966）接受了行为咨询和治疗转诊（65%，609/932）。几乎所有主治医生至少提供过一次纳洛酮带回家服务（97%，105/108）、行为咨询（95%，103/108）或治疗转诊（95%，103/108）。大多数住院医生和高级实践从业者（APP）至少提供过一次纳洛酮带回家服务（住院医生78%；APP 72%）、行为咨询（住院医生76%；APP 67%）和治疗转诊（住院医生80%；APP 81%）。大多数临床医生为他们所护理的超过半数阿片类药物过量患者提供了这些服务。与仅由主治医生治疗相比，患者在由主治医生与住院医生和/或APP联合治疗时接受行为咨询的可能性高出两倍（调整后的优势比：2.29；95%置信区间，1.68，3.12）。随着时间推移使用情况没有下降。
急诊科纳洛酮分发、行为咨询及治疗转诊可成功整合到常规急诊护理中，并随着时间推移以高覆盖范围和采纳率得以维持。需要进一步开展工作以确定低成本的实施策略，以改善服务使用情况并在各临床环境中推广。
