Implementing statewide emergency department care pathways for addiction recovery after opioid overdose

项目总结 罗德岛(RI)是美国阿片类药物过量死亡率最高的地区之一， 在减少阿片类药物过量死亡的创新战略方面处于领先地位。2017年3月，罗德岛(RI) 卫生部(RIDOH)和国际扶轮行为健康、发育障碍和 医院发布成人护理的医院和急诊科(ED)治疗标准 阿片类药物使用障碍和阿片类药物过量患者：RI急诊科和 治疗过量用药和阿片类药物使用障碍的医院(护理级别)。这些标准规定了三个级别 用于医院和急诊科治疗阿片类药物使用障碍、预防过量用药、转介治疗以及 流行病学监测。三个护理级别(LOCS)中的每一个都要求急诊科医生开出纳洛酮，提供 同伴康复支持服务，并为经历过阿片类药物的患者提供转介治疗 服药过量。获得最高级别(1级)认证的设施提供更全面的治疗服务， 包括开始用药治疗成瘾(MAT)。本地的各个组件已经被 进行了审查，但尚未评估国家总体政策的有效性。严格的政策评估 需要为持续的政策、实践和战略提供信息。 自全州范围的任务执行以来，据报道，向 患者在阿片类药物过量后接受治疗，但接受ED行为咨询、MAT启动和转诊至 治疗没有显著增加(急诊室50%的过量用药病例都得到了推荐 过量用药后护理的组成部分)。尽管存在这些差距，但国际扶轮的阿片类药物过量比率在最近几年一直处于平稳状态 尽管全国利率不断上升，但几年来，试点数据表明，政策变化导致了 因阿片类药物过量而进行急诊后的治疗参与度。考虑到阿片类药物的快节奏和高风险 疫情期间，我们将同时全面审查国际扶轮政策的执行情况和效果 动力类型III的实施--在整个国际扶轮的9个EDS进行有效性研究。这9个急救人员关心的是 每年向RI ED提供的所有阿片类药物过量的95%(n~1500)，创造了巨大的机会 预防阿片类药物过量死亡，并评估国际扶轮的护理标准。 来自国际扶轮最大的医疗保健系统、布朗大学公共卫生学院和RIDOH的研究人员 正在合作执行一项混合实施-有效性研究，该研究将：(1)完善和测试 旨在提高ED服药过量后护理的保真度的实施战略，因为它涉及到国家的 护理水平政策，以及(2)测试政策驱动的以ED为基础的过量用药后护理的有效性。我们会 具体目标是实施4项ED指标：出院时收到纳洛酮；收到同伴恢复 支持服务；急诊科转介治疗；以及在急诊科启动MAT。

PROJECT SUMMARY Rhode Island (RI) has one of the highest rates of opioid overdose death in the United States and has been a leader in innovative strategies to reduce opioid overdose deaths. In March 2017, the Rhode Island (RI) Department of Health (RIDOH) and the RI Department of Behavioral Health, Developmental Disabilities, and Hospitals (BHDDH) released hospital and emergency department (ED) treatment standards for care of adult patients with opioid use disorder and opioid overdose: Levels of Care for RI Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care). These standards specify three levels for hospital and ED treatment of opioid use disorder, overdose prevention, referral to treatment, and epidemiologic surveillance. Each of the three Levels of Care (LoCs) require EDs to prescribe naloxone, provide peer recovery support services, and offer referrals to treatment for patients that have experienced an opioid overdose. Facilities certified at the highest level (Level 1) provide more comprehensive treatment services, including initiation of medication for addiction treatment (MAT). Individual components of the LoCs have been examined, but the effectiveness of the state’s overall policy has not been evaluated. A rigorous policy evaluation is needed to inform ongoing policy, practice, and strategy. Since implementation of the statewide-mandate, there has been high reported offering-of-services to patients treated after opioid overdose, but uptake of ED behavioral counseling, MAT initiation, and referral to treatment have not significantly increased (<50% of overdose cases in EDs receive all recommended components of post-overdose care). Despite these gaps, RI’s rate of opioid overdose has plateaued in recent years despite rising rates nationally and pilot data suggest that policy changes have resulted in increased treatment engagement after an ED visit for opioid overdose. Given the fast pace and high stakes of the opioid epidemic, we will simultaneously examine both the implementation and effectiveness of RI’s policy in a fully powered type III implementation-effectiveness study conducted at 9 EDs throughout RI. These 9 EDs care for >95% of all opioid overdoses that present to RI EDs annually (n~1500), creating tremendous opportunity to prevent opioid overdose deaths and also evaluate RI’s standards of care. Investigators from RI’s largest health care system, Brown University’s School of Public Health, and RIDOH are partnering to perform a hybrid implementation-effectiveness study that will: (1) refine and test an implementation strategy that aims to improve the fidelity of ED post-overdose care as it relates to the state’s Levels of Care policy, and (2) to test the effectiveness of policy-driven ED-based post-overdose care. We will specifically target implementation of 4 ED metrics: naloxone received at discharge; receipt of peer recovery support services; ED referral to treatment; and initiation of MAT in the ED.