1 Identification and Treatment of Opioid Use Disorder in the Emergency Department Alisha McKay College of Nursing Michigan State University NUR 995 Dr. Jackeline Iseler April 20, 2024 2 Table of Contents Abstract ........................................................................................................................................... 4 Introduction ..................................................................................................................................... 5 Background and Significance ......................................................................................................... 6 Organizational Assessment ............................................................................................................. 9 Organizational Mission, Vision, and Values ............................................................................... 9 Organization Strengths, Weaknesses, Opportunities, and Threats (SWOT)............................. 10 Strengths ................................................................................................................................ 10 Weaknesses ............................................................................................................................ 11 Opportunities ......................................................................................................................... 11 Threats ................................................................................................................................... 12 Gap Analysis ............................................................................................................................. 13 Framework .................................................................................................................................... 14 PICO Question .............................................................................................................................. 15 Synthesis of Evidence ................................................................................................................... 15 Search Strategy .......................................................................................................................... 15 ED Interventions ....................................................................................................................... 16 Medications ........................................................................................................................... 16 Referrals ................................................................................................................................. 16 Evidence Integration ..................................................................................................................... 17 Setting and context .................................................................................................................... 17 Stakeholders .............................................................................................................................. 18 Facility ................................................................................................................................... 18 Community Partners .............................................................................................................. 18 Patient Selection .................................................................................................................... 18 Implementation Team ............................................................................................................... 19 Measurement Plan ..................................................................................................................... 19 Resources ............................................................................................................................... 19 Approvals .................................................................................................................................. 20 Implementation Strategies ......................................................................................................... 21 Standard of Care Development .............................................................................................. 21 Standard of Care Components ............................................................................................... 21 Training and Education ............................................................................................................. 22 3 Facilitators ................................................................................................................................. 23 Barriers ...................................................................................................................................... 23 Resources .................................................................................................................................. 24 Evaluation Plan ......................................................................................................................... 24 Sustainability Plan ..................................................................................................................... 25 Results/Analysis ............................................................................................................................ 25 Outcomes Measured .................................................................................................................. 25 Data Collected ........................................................................................................................... 26 Data Analysis ............................................................................................................................ 26 Interpretation ............................................................................................................................. 27 Sustainability ............................................................................................................................. 28 Implications for Practice ............................................................................................................... 28 Dissemination ............................................................................................................................... 29 Discussion ..................................................................................................................................... 30 Limitations ................................................................................................................................ 30 Conclusion .................................................................................................................................... 31 Appendix A: Quality Improvement/EBP Project Evidence Critique Table ................................. 38 Appendix B: SWOT Analysis ....................................................................................................... 39 Abstract 4 Background: Opioid Use Disorder (OUD) is a common comorbidity in emergency department (ED) settings. This study aimed to introduce a standard of care that incorporates medication- assisted treatment and facilitates referrals for continuous therapy among individuals with OUD seeking assistance in the ED. Methods. A search was conducted on the Cumulative Index to Nursing and Allied Health (CINAHL) (62), PsycINFO (20), and PubMed (49) using keywords in the title "ED" or "emergency room" and "OUD" with other keywords of treatment, intervention, therapy, or management. The project involved developing, implementing, and assessing a new OUD treatment standard and incorporating an interdisciplinary team approach to ensure precision and triumph. Results: Implementing the OUD care standard in the ED successfully increased access to treatment and improved patient outcomes. The findings of this project have significant implications for future practice and research on the treatment of OUD in emergency department settings. Conclusions: This project provides valuable insights into the potential benefits of introducing a Standard of Care for treating OUD in EDs. By emphasizing the importance of early intervention, evidence-based treatment, and comprehensive staff training, the project offers a roadmap for enhancing OUD management practices in emergency healthcare settings. Keywords: opioid use disorder, OUD, substance abuse, substance use disorder, emergency department, emergency room, medication-assisted treatment, MAT, recovery 5 Identification and Treatment of Opioid Use Disorder in the Emergency Department Introduction The United States is facing an opioid epidemic, a serious public health problem affecting millions of people with Opioid Use Disorder (OUD), causing thousands of deaths from opioid overdoses every year (CDC, 2023). Many patients with OUD seek help from emergency departments (EDs), but EDs may not be well-equipped or prepared to offer the best possible care (Kaczorowski et al., 2020). One way to improve care for patients with OUD in EDs is to introduce medication-assisted treatment (MAT), which combines medications with counseling and behavioral therapies to treat patients with OUD (U.S. Food and Drug Administration, 2023). Utilization of MAT has demonstrated effectiveness in decreasing opioid usage, lowering the risk of overdose and mortality, enhancing treatment retention rates, and improving overall quality of life (Hawk et al., 2021). However, MAT is not widely available or accessible in EDs owing to various barriers, such as lack of knowledge, training, resources, and protocols (Hawk et al., 2023). To address this gap, a team of healthcare professionals designed and implemented an evidence-based practice change project to identify and implement an OUD standard of care in the ED setting. This study aimed to delineate and assess an evidence-based practice change initiative that introduces a standard of care incorporating medication-assisted treatment and facilitating referrals for continuous treatment among individuals with Opioid Use Disorder (OUD) seeking assistance in the Emergency Department (ED) setting. This paper reports the methodology and results of the project, which aimed to improve the care and outcomes of patients with OUD, as well as the implications and recommendations for future research. In this paper and project, the terms "protocol" and "standard of care" are used interchangeably, 6 recognizing that their interpretations may differ from those presented in the research literature and their practical implementation within the organization. Background and Significance Opioid Use Disorder (OUD) is a persistent medical condition characterized by the compulsive use of opioids, even in the face of adverse consequences (Oswald et al., 2021). These opioids encompass both prescription painkillers, such as oxycodone and hydrocodone, as well as illicit substances, such as heroin (Addiction Resource Guide, 2023). Recent data from the Michigan Department of Health and Human Services (MDHHS) in 2023 underscore increased OUD prevalence within the state. In 2020, Michigan recorded 2,036 opioid-related overdose fatalities, a 16.9% surge from the previous year (MDHHS, 2023). Furthermore, in 2022, the trend persisted, with Michigan reporting 2,424 opioid-involved overdose fatalities, as documented by the CDC's National Center for Health Statistics (2023). Simultaneously, 8,040 hospitalizations were linked to opioid use in 2022 (MDHHS, 2023). Notably, specific demographic groups within Michigan bear a disproportionate burden of OUD, with African Americans experiencing the highest opioid-related overdose deaths in 2020, followed by their Caucasian counterparts. Age-wise, individuals aged 25–34 and 35–44 years had the highest and second-highest opioid-related overdose death rates, respectively (MDHHS, 2023). Genetic predisposition, social and environmental factors, and opioid exposure play a role in the multifaceted process of OUD development. Genetic variations can render some individuals more susceptible to opioids, thereby increasing their sensitivity to these substances (Pergolizzi et al., 2020). Social and environmental factors also play substantial roles in the development of OUD. For example, individuals who have experienced traumatic events such as physical or sexual abuse are more inclined to turn to drugs to cope with emotional distress (Wadekar, 2020). 7 Moreover, residing in regions characterized by high opioid prescription rates or easy access to opioids increases the risk of OUD (Wadekar, 2020). Exposure to opioids is a fundamental risk factor for the development of OUD, stemming from both the legitimate medical use of prescription painkillers and the illicit use of opioids such as heroin (Oswald et al., 2021). Repeated exposure to opioids leads to alterations in the brain, making it exceedingly challenging for individuals to discontinue opioid use even when they genuinely desire to quit (Wadekar, 2020). Opioid-related fatalities encompass a broad spectrum, including deaths attributed to prescription opioids, illicit opioids, such as heroin, and synthetic opioids, such as fentanyl (Ostling et al., 2018). The opioid epidemic is a significant and urgent public health crisis in the United States, with Michigan reflecting the adverse effects of many other states (CDC, 2023). Substantial efforts are underway in Michigan and the United States to address this crisis. The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services (2021) has initiated various comprehensive strategies aimed at expanding access to addiction treatment and harm reduction services. These strategies also target the reduction of opioid overprescription and the advancement of pain management practices. A critical approach involves using EDs as the first point of contact to identify and treat patients with OUD (SAMHSA, 2021). Enhancing the identification and treatment of OUD within EDs holds significant potential for improving the outcomes of individuals struggling with OUD. Various strategies exist through which EDs can work towards these objectives. According to Hawk et al. (2022), these include the creation of protocols, thorough screening procedures, incorporating evidence-based MAT, seamless referral mechanisms to specialized treatment programs, and provision of education and 8 counseling services. MAT, which involves administering drugs such as methadone buprenorphine, is highly effective in reducing illicit drug use and cravings and improving the continuation of treatments (SAMHSA, 2021). The provision of MAT in the ED increases access to treatment, reduces the risk of relapse, and minimizes the potential for overdose (Hawk, 2022). EDs are also pivotal in facilitating referrals for individuals struggling with OUD to various treatment programs, including outpatient and inpatient treatments, detoxification regimens, and counseling services. These referrals ensure that individuals contending with OUD receive the requisite care and support to effectively manage their addiction and embark on a path toward sustained recovery. In addition, EDs are well-positioned to deliver education and counseling services to individuals affected by OUD, including their families and caregivers. This education involves the dissemination of crucial information regarding the inherent risks and benefits of opioid use, implementation of harm reduction strategies, and provision of resources for ongoing support. Notably, the early identification and treatment of OUD within the ED environment confer additional benefits, including the potential to reduce healthcare expenditures, prevent hospital readmissions, and enhance the overall quality of life of individuals with OUD (Lowenstein et al., 2022). Given the paramount importance of early recognition and treatment of OUD within EDs, this project will evaluate data concerning opioid-related ED visits over the past 12 months, collected from January 1, 2022, to January 1, 2023, which revealed 454 opioid-related ED visits, averaging thirty-seven per month (Ascension, 2023). This dataset includes all visits that received a discharge diagnosis of OUD as determined by the provider, as well as chief complaints related to OUD, such as overdose, with the exclusion of non-opioid-related overdose. Establishing a standard of care for identifying and treating OUD within EDs and close collaboration with 9 community-based treatment providers are imperative to ensure comprehensive care and support for individuals, fostering long-term recovery. Organizational Assessment The project site is a teaching hospital with 392 beds that serves over 12,000 inpatients and over 32,000 ED patients annually (Ascension, 2023). The ED provides 24/7 medical care and critical services to many patients. The hospital also offers residency programs that train healthcare professionals in various specialties. The hospital's mission is to deliver compassionate, excellent, patient-centered care to its diverse community (Ascension, 2023). Organizational Mission, Vision, and Values The organization's mission is to provide comprehensive care to all individuals, focusing on those who "are underserved and vulnerable" (Ascension, 2023). Its commitment to delivering holistic, spiritually centered care that enhances the well-being of individuals and their communities is rooted in a Catholic health ministry. It is committed to supporting treating patients with OUD presenting to the ED (Ascension, 2023). The organization's visionary goal is to establish a thriving Catholic health ministry in the United States that spearheads the evolution of healthcare (Ascension, 2023). This vision entails providing services prioritizing communities' health and well-being and addressing individuals' unique needs throughout their lifespans. This vision is in harmony with their dedication to supporting OUD treatment in the ED and enhancing care for this vulnerable population. The project's success is deeply rooted in the organization's core values of service, respect, and compassion for the dignity and diversity of life (Ascension, 2023). With the support of ED nursing and physician leaders, a concerted effort to develop and implement a standard of care for OUD treatment within the ED was supported and initiated. The organization's commitment to 10 improving care for this population will extend across multiple sites, with plans to implement this standard of care throughout its regional hospitals. Organization Strengths, Weaknesses, Opportunities, and Threats (SWOT) A SWOT analysis is a strategic planning tool used to identify an organization or project's strengths, weaknesses, opportunities, and threats. A thorough analysis can help an organization or project team understand its internal and external environments and make informed decisions about its future direction (Terhaar et al., 2021). This SWOT analysis assesses the organization's readiness to implement an OUD treatment standard of care in the emergency department. Strengths For an OUD treatment program in the ED to succeed, it was imperative to garner support from the broader health system, departmental leadership, and clinical staff, encompassing nurses and healthcare providers. The presence of skilled and proficient medical staff laid a strong foundation for implementing the treatment program. At this hospital, numerous healthcare providers have undergone ongoing training to identify and treat OUD. These providers are deeply dedicated to ensuring their colleagues receive the requisite support and training to care for this demographic effectively. Furthermore, all DEA prescribers must complete 8 hours of education regarding the treatment and management of opioid use or other substance use disorders to maintain their licenses (SAMHSA, 2023). The hospital's commitment to serving vulnerable populations is in harmony with addressing the opioid crisis and underscoring its dedication to service and responsibility. The organization confirmed this project as worthy of ongoing organizational support. Additionally, the hospital's access to various resources and collaboration with the community has supported the sustainability of successful ongoing care for this population. 11 Weaknesses One potential weakness of starting an OUD treatment program in the ED is the limited time for comprehensive interventions. As with most EDs, this hospital prioritizes its resources for acute care, which can restrict its ability to adequately address the complex needs of patients with OUD. Moreover, only a small number of clinical staff in the emergency department have received specialized training in addiction medicine. This lack of training can result in gaps in knowledge about treatment options and contribute to the stigma surrounding substance use disorders (SUD) such as OUD. Consequently, these knowledge gaps may hinder the initiation of discussions about treatment options and finding resources for patients. The limited resources would challenge the continuity of care for patients with OUD. Specifically, the availability of critical resources, such as social workers and case managers, proved insufficient to meet the essential follow-up needs within the organization, forcing alternative external resources to be identified. Sometimes, there are no staff members from these roles, necessitating other healthcare professionals, such as bedside nurses or providers, to secure proper hands-off and follow-up care. These weaknesses were addressed to ensure minimal impact on the quality and consistency of care provided to patients with OUD. Opportunities Implementing an OUD treatment standard of care within the ED offers several promising opportunities. Early intervention in the ED can facilitate timely treatment, potentially mitigating OUD severity and preventing its progression. To enhance patient care, the hospital can collaborate with addiction specialists and treatment facilities to establish an appropriate continuum of care for individuals with OUD following their initial ED visit. The local medical college features a family medicine clinic with a substance use disorder (SUD) fellowship 12 program catering to the underserved and uninsured community. Partnering with this institution can significantly enhance the ongoing care for these patients. The college's commitment to innovation and dedication provides a unique opportunity to customize treatment approaches tailored to the specific needs of patients with OUD within an emergency care context. Additionally, the facility was asked to join and has been active in the Kalamazoo County Department of Health and Human Services Opioid Coalition Steering Committee, which encompasses diverse professionals from the community, including medical experts, peer support groups, social services partners, and various government agencies. This collaboration comprehensively addressed the ongoing OUD crisis and underscored the hospital's commitment to making a meaningful impact in this critical area. Threats There are potential threats that this hospital should consider when initiating an OUD treatment program in the ED. Stigma and bias surrounding addiction can hinder the program's effectiveness and discourage patients from seeking help. The project team must address these barriers to promote empathy and understanding among the staff and the community. The hospital must also be mindful of regulatory challenges related to opioid prescriptions and controlled substances, ensuring compliance with guidelines while providing effective pain management. Additionally, patient follow-up and compliance with treatment plans could be challenging because some patients living with OUD may face difficulties in adhering to prescribed medications or engaging in ongoing care (Hawk et al., 2021). The hospital's strengths in providing immediate medical attention, having qualified staff, and being committed to the service of people experiencing poverty align well with initiating an OUD treatment program in the ED. However, the limited time for interventions and the potential 13 lack of expertise in addiction medicine are weaknesses that the team must account for. The hospital has several opportunities to innovate, collaborate, and enhance patient care; however, it must also navigate potential threats related to stigma, regulatory compliance, and patient follow- up. By carefully strategizing and leveraging its strengths, this hospital can successfully implement a comprehensive OUD treatment program in the ED, contributing significantly to combating opioid crises in the community. Gap Analysis OUD identification and treatment in the ED face gaps that affect patient outcomes and quality of care. Emergency departments frequently serve as the initial encounter for individuals with OUD; however, there is a lack of established quality measures or best practices to guide research and improve outcomes related to OUD mortality or morbidity. (Samuels et al., 2019). These quality measures could improve other gaps that may hinder the success of treatment protocols, such as time constraints, specialized training, and lack of resources. (Samuels et al., 2019). These quality measures could improve other gaps that may hinder the success of treatment protocols, such as time constraints, specialized training, and lack of resources. One prevalent gap is the limited time available for comprehensive interventions in emergency settings (Hawk & D'Onofrio, 2018; Samuels et al., 2019). EDs often prioritize acute care, which may hinder their capacity to address the complex needs of patients with OUD adequately. Brief encounter time may limit the healthcare team's ability to conduct thorough assessments and develop personalized treatment plans, potentially affecting the effectiveness of the interventions (Hawk & D'Onofrio, 2018; Samuels et al., 2019). Another critical gap exists concerning the need for specialized addiction medicine training among ED staff (SAMHSA, 2021). Inadequate training and understanding of evidence- 14 based treatment approaches can impair the quality and consistency of care provided to patients with OUD. This gap may result in missed opportunities for early intervention and appropriate management (SAMHSA, 2021). Moreover, the absence of addiction medicine training could foster stigmatization of patients with OUD, leading to biased attitudes and suboptimal care delivery. It is paramount that ED staff undergo comprehensive education in addiction medicine to guarantee that patients receive the highest quality of care and support available (SAMHSA, 2021). Finally, resources and support services tailored to patients with OUD are often lacking in the EDs. This scarcity includes access to behavioral health specialists, addiction counselors, and essential medications (Duber et al., 2018). This fragmented care approach can hinder engagement and successful recovery. Targeted training programs can enhance staff expertise in addiction medicine and improve the quality of care. While stakeholders and the literature support specialized staff training, hospital systems often cannot prioritize resources for populations that may not provide a significant return on investment through reimbursement and paid-for performance measures (Duber et al., 2018). Focusing on these gaps can help EDs to better address OUD patients' needs, enhance care outcomes, and contribute to combating the opioid epidemic. Framework The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model will guide this project due to its "open system" design (Dang & Dearholt, 2021, p. 53). This model will enable the team to incorporate organizational factors into the project, using evidence to guide inquiry, learning, and practice, driving the project forward. This model highlights the importance of 15 partnerships and interprofessional collaboration in Evidence-Based Practice (EBP) (Dang & Dearholt, 2021). PICO Question To address the OUD crisis, we formulated the following population, intervention, comparison, and outcome (PICO) question: In adult patients with untreated OUD who present to the ED, will an ED-specific multidisciplinary standard of care increase access to OUD treatment compared with no ED standard of care. Synthesis of Evidence Search Strategy A search was conducted on the Cumulative Index to Nursing and Allied Health (CINAHL) (62), PsycINFO (20), and PubMed (49) using keywords in the title "ED" or "emergency room" and "OUD" with other keywords of treatment, intervention, therapy, or management to identify studies and articles related to OUD treatment in the ED. The results were refined to include peer-reviewed articles published within the past ten years. The selected articles adhered to the inclusion criteria on interventions conducted within ED across health centers of varying sizes. The literature review revealed recurring findings and themes, notably highlighting interventions suitable for ED applications such as MAT. It also underscored the significance and influence of ensuring continuity of care through seamless hand-offs and referrals to peer coaches, SUD centers, and primary care providers specializing in addiction medicine. From the initial pool of 131 articles, a rigorous selection process using the JHNEBP appraisal tool included 10 articles based on their evidence level, quality, and relevance to the research problem. It is worth noting that the availability of high-quality studies was limited, with only 2 of the 10 meeting the criteria as level I randomized control trials (RCTs). These two specific studies, conducted by D'Onofrio et al. (2015) and Srivastava et al. (2019), consistently demonstrated that the initiation of buprenorphine within the ED context led to improved treatment engagement among patients, as observed in the 30-day post-initiation period. 16 ED Interventions Medications The two Level I studies conducted by D'Onofrio et al. (2015) and Srivastava et al. (2019) consistently demonstrated improved treatment engagement within the ED context following the initiation of buprenorphine, as evidenced by the 30-day post-initiation period. In a systematic review, Kaczorowski et al. (2020) compared Opioid Agonist Treatment (OAT), including buprenorphine, methadone, and naltrexone, versus non-OAT interventions in the ED. They concluded that while substantial evidence supports Opioid Agonist Treatment (OAT) in the ED, further research is necessary to ascertain its effectiveness. This observation was echoed in the remaining eight articles, emphasizing the importance of standardized treatment protocols to ensure appropriate prescription and utilization of medications. The need for standardized interventions and measures is paramount. Despite these limitations, the implementation of ED OAT programs remains vital for addressing the ongoing opioid epidemic and existing evidence gaps. In summary, among ED-based interventions for Opioid Use Disorder (OUD), Opioid Agonist Treatment (OAT) is the intervention with the most substantial supporting evidence. Referrals Across the various levels of evidence reviewed, there was a consistent emphasis on the importance of referrals to enhance the continuity of care for individuals with Opioid Use Disorder (OUD). D’ Onofrio et al. (2015) demonstrated that patients who received coordinated referrals for ongoing treatment in addition to buprenorphine experienced improved treatment 17 engagement and cost-effectiveness compared to those who received only brief interventions and referrals. Faude et al. (2023) opted for a standardized protocol that included direct access to opioid treatment programs (OTPs) to establish a patient-centered model of care. Similarly, Hawk et al. (2021) recommended the initiation of buprenorphine, coupled with referrals specific to continued medication management for patients with untreated OUD presenting to the ED, resulting in higher engagement in formal addiction treatment after 30 days. Supporting the importance of referrals, the American College of Emergency Physicians (ACEP) consensus recommendation aligns with these findings (Hawk et al. 2021). Evidence Integration Setting and context This project introduced the Opioid Use Disorder (OUD) standard of care as an electronic order set for adults with OUD seeking medical help in the ED based on the evidence and collaboration of the interdisciplinary healthcare team. Implementation of this project increased access to MAT and improved referrals to aid ongoing treatment (Hawk et al., 2021). The project included developing, implementing, and assessing the standard of care based on the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, which incorporates an interdisciplinary team approach to ensure precision and triumph (Dang & Dearholt, 2021, p. 53). Utilizing the JHNEBP model, healthcare professionals from various disciplines collaborate to provide comprehensive and effective care for individuals with OUD. This approach enhanced the accuracy of the protocol and increased the likelihood of successful outcomes in patients seeking treatment in the emergency room. 18 Stakeholders Facility At the facility level, the core team comprises a wide range of professionals, such as ED providers, attending and resident doctors, physician assistants, nurse practitioners, and ED clinical staff including nurses, case managers, pharmacists, and leaders. The ED medical director and assistant director agreed to serve as the organization's principal investigator (PI). It is important to note that the PI must be an organization associate or licensed physician with privileges at the institution. Community Partners To ensure the project's success, we actively involved community partners, encompassing carefully selected entities, such as peer support and recovery centers and primary care referral centers specializing in expediting OUD treatment. Facilitating same-day and next-day appointments was supported by identifying dedicated centers that prioritized accommodating individuals who could use different payment methods, including Medicare, Medicaid, and self- pay. Regardless of organizational alignment, we established affiliations with inpatient and outpatient treatment centers to provide comprehensive care options. The manager of the organization's ambulatory care management team facilitated the coordination of care for those without a primary care provider (PCP) or already established patients. This proved to be an invaluable resource as the project progressed. Patient Selection The patient selection criteria for this project are clear and specific. Adult patients aged 18 years or older identified by the provider or nurse during the OUD screening assessment were selected. In addition, adult patients aged 18 years or older who experienced opioid withdrawal 19 once stabilized were also considered for this project. Those not yet prepared for immediate treatment after discussion with the provider were given resources for follow-up and referral options and education regarding OUD treatment. This approach helped to ensure that everyone received personalized care and guidance based on their circumstances. Implementation Team The ED's medical and assistant directors agreed to assist with this project by facilitating provider education, encouraging adherence, and providing follow-up with providers regarding fallouts or missed opportunities. The pharmacy assistant director facilitated the addition of necessary medications to the department's medication-dispensing machine and provided support within their scope for creating the order set. The ED nursing director is committed to prioritizing training and implementation for clinical staff. The implementation team will also include a representative from the IT department to ensure smooth integration of any required software or technology. The nursing supervisor also guides and supports the nursing staff throughout the implementation process. Measurement Plan Resources Charts were reviewed by the project lead using an electronic report that captured all adult ED patients at risk of or diagnosed with OUD upon discharge. Capturing five non-exclusive conditions in the EHR generated an electronic report: patients with a discharge diagnosis of OUD, patients who screened positive for the initial triage screen, provider use of the ED OUD standard of care order set, patients with an order for buprenorphine, or a discharge prescription for buprenorphine. This measurement plan provided a structured framework for the project team to meticulously examine and pinpoint patients with OUD who might have encountered 20 overlooked opportunities in the ED. These could range from not utilizing the OUD order set to failure to initiate suitable follow-up plans. The team can offer consistent support and constructive feedback to enhance a project's efficiency by identifying such instances. Approvals Obtaining approval is a crucial step in ensuring the ethical and regulatory integrity of the project. To secure the necessary endorsements, the project team sought written approval from various key stakeholders, including the organization’s Internal Review Board (IRB), executive leaders, and college’s IRB. The organization and college IRBs provided oversight and approval, ensuring that the project adhered to ethical standards and protected the rights and welfare of the participants involved. Their endorsement underscored the project's commitment to a rigorous research methodology and adherence to ethical guidelines. The Regional Vice President of Nursing also approved the project, acknowledging its potential impact on the region's nursing practices and patient care. Their endorsement signaled alignment with the project's goals and objectives, reinforcing the importance of nursing leadership in driving initiatives for quality improvement and patient-centered care. Approval from the Regional Chief Medical Officer carried significant weight, indicating endorsement from the highest medical authority within the region. Their support affirmed the project's clinical relevance and potential to contribute to advancements in patient care and healthcare. 21 Implementation Strategies Standard of Care Development A diverse team comprising a pharmacist, ED medical director, IT analyst, ED nursing director, manager, supervisor, and case management leader. Through regular meetings and document-sharing software, the team crafted a standard of care informed by the current research and customized for the fast-paced, resource-limited environment of the ED. The main components of this standard of care include an initial brief triage screen, comprehensive provider assessment, medication treatment options, and emphasis on follow-up care. Standard of Care Components Initial Screen and Assessment. The initial screening process involved a brief triage assessment followed by an ongoing provider and primary nurse evaluation. The triage questions were concisely designed to facilitate the rapid flow of the ED triage process. The questions were drawn from a case study by Lowenstein et al. (2022) and comprised no more than two questions. If the screening indicates a positive result or an active overdose, the nurse proceeds to inquire about active withdrawal symptoms and conduct objective measurements using the Clinical Opiate Withdrawal Scale (COWS) to gauge the severity of withdrawal (Lowenstein et al., 2022). This meticulous process was designed to maximize the chances of success for each patient, ensuring that they were accurately identified and thoroughly screened for readiness to continue treatment. By carefully identifying individuals who could benefit from intervention and support, healthcare teams can tailor their approach to suit each patient's unique needs and readiness levels (Hawk et al., 2021). 22 Treatment Options. Treatment included active withdrawal as well as continuation and follow-up treatments. Buprenorphine was administered to the patients with symptomatic opioid withdrawal. Upon discharge, a five-day prescription for buprenorphine was administered in addition to a prescription for naloxone rescue. Education was provided to include medications used for buprenorphine and naloxone and to emphasize the importance of prompt follow-up care. Follow-up Care. Nurses were trained to discuss barriers to prompt follow-up, such as access to transportation, and were provided with resources to mitigate these barriers. While a social worker or case manager may have been the preferred clinician to provide this information, the nurses were given resources to aid in this shortcoming. Follow-up care with community partners, including peer recovery and after-care, was initiated specific to the patient's clinical circumstances (Whiteside et al., 2022). A warm hand-off was recommended when possible, ideally using an electronic referral system to begin within 72 hours (about three days) of ED evaluation (Whiteside et al., 2022). Connection with a peer recovery coach in the ED could lead to better outcomes and long-term care management (Hawk et al., 2021). Training and Education A thorough training and educational program for the OUD standard of care was provided to all staff members in the ED. This program encompasses two key components: stigma reduction and standard of care utilization training. Stigma reduction efforts were incorporated into the staff training using materials provided from the "Overcoming Stigma, Ending Discrimination" guide supplied for use by SAMHS (2023). Specifically, it covered the purpose and objectives of the standard of care, the necessary procedures to follow, documentation requirements, and instructions on the proper use of medications, such as buprenorphine and 23 naloxone rescue kits. The educational process was multifaceted and involved various channels for delivery, including online learning modules, email communication, staff huddles, and departmental meetings. Additionally, the ED medical directors played a pivotal role in facilitating learning and ensuring the effective use of the standard of care among the provider team. Facilitators The primary facilitators of this project were the assistant medical director and project lead. While resources were scarce, the Assistant Medical Director shared enthusiasm and determination to improve access to and care for this patient population, contributing to the success of this project. He served as a key resource and collaborator to improve provider buy-in by training and communication with department providers, as well as ambulatory and inpatient provider teams to improve communication and continuity of care. Barriers The project's referral and follow-up components required resources from case management and social work departments, which were limited and posed challenges. These components are crucial for coordinating patient care and providing necessary support services. Their limitations have hindered the smooth implementation of the standard of care, impacting the overall success of the educational process. Additionally, some providers and staff members resisted or lacked buy-in, posing a barrier to effectively implementing and utilizing the standard of care to ensure that all stakeholders are engaged in and committed to the project's goals. Ongoing communication and collaboration between case management, social work departments, and the provider team are crucial in overcoming these barriers and ensuring a successful referral and follow-up process. Providers and nursing staff play a vital role in ensuring adherence to the continuation of care and making a successful handoff to community partners. Community partner resources were identified to manage timely follow-up, and a referral from our facility containing precise identification was necessary. This component required working with the 24 EMR, which was delayed. Resources The EMR was used to initiate screening tools, develop and run reports, and enable the use of the order set to facilitate the successful application of the standard of care. Providers played an essential role in developing, utilizing, and maintaining this standard of care by helping to develop and use the order set. Additionally, the EMR enabled seamless communication between different healthcare providers involved in the patient's continuum of care. This ensured that all relevant information was shared accurately and promptly, preventing delays or miscommunication. Furthermore, EMR allows for easy tracking and monitoring of patient outcomes, allowing for continuous evaluation and improvement of the standard of care. Overall, the EMR was a crucial resource that enhanced the effectiveness and efficiency of the standard of care, leading to improved patient outcomes. Evaluation Plan This report served as the basis for a biweekly standard of care review, focusing on utilizing treatment and follow-up components while ensuring the de-identification of all health information. In situations requiring follow-up by one of the Principal Investigator (PI) providers with an ED provider, exceptions to de-identification may have been applied. The review process involved reporting the outcomes to stakeholders and assessing ongoing improvements to ensure sustainability and adherence to the standard of care. An evaluation of adherence to the treatment guidelines was also conducted, involving data analysis and comparisons with baseline 25 measurements. Healthcare providers participated in monthly meetings to provide feedback and to identify areas of improvement. Regular reviews of data and feedback enabled necessary adjustments to the standard of care. This evaluation plan aimed to provide valuable insights into the effectiveness of the standard of care and to guide future enhancements. Sustainability Plan A monthly project meeting was set up to bring the team and stakeholders together to review the project goals and data. During these meetings, the team reviewed the progress of the project, including any challenges or barriers to standard care implementation, and identified strategies to overcome them. Regular communication channels will also be established to ensure ongoing support and feedback from stakeholders, further promoting sustainability and adherence to the standard of care. Outcomes Measured Results/Analysis Outcome measures were limited to three chosen variables because they could be abstracted prior to implementation, which limited the overall applicability of the project but still proved to be substantial. The three outcome objectives included adult patients aged 18 years and older who presented to the ED with OUD were the use of medications for opioid use disorder (MOUD) in the ED, a prescription for continued medication given upon discharge, and a peer recovery coach consultation initiated while in the ED. Data were analyzed 12 months before implementation, and due to delays in order-set completion, only three months of post-data were available. 26 Data Collected The collected data included information on total ED visits, OUD-related visits, medication treatment in the ED, prescriptions at discharge, order set use, and peer recovery referrals. The pre-data were collected over 12 months, and the post-data were collected over three months, allowing for the analysis of trends and patterns in treating OUD in the ED. The analysis covered the periods before and after the implementation of a new standard of care, providing insights into the effectiveness of the intervention and its impact on patient care outcomes. Data Analysis Analysis of the provided data sheds light on trends and patterns in ED treatment of OUD over several months, encompassing periods before and after the introduction of a new standard of care. Before implementing the new standard, from January through December 2022, the data illustrated a relatively stable number of total ED visits, ranging from 2180 to 2848 visits monthly. The number of OUD-related visits fluctuated between 20 and 47 visits per month, showing no discernible trends. Notably, medication treatment and peer recovery referrals consistently registered zero throughout this period, indicating the absence of formalized treatment protocols for OUD within the ED. Additionally, the percentage of OUD-related visits that received treatment remained consistently low, varying from 0% to 14.29%. Post-implementation of the new standard and order set introduction: Following the adoption of the new standard of care, a noticeable increase was observed in total ED and OUD- related visits. The total number of ED visits surged from 2648 in January to 2789 in March, potentially signaling heightened patient volume. Correspondingly, OUD-related visits experienced a substantial increase, peaking at 102 visits in February. The implementation of 27 medication treatment and peer recovery referrals yielded significant improvements in OUD care in the ED. Notably, the percentage of OUD-related visits that received treatment surged dramatically to 91.18% in February. Particularly noteworthy was the remarkable increase in the percentage of OUD-related visits receiving medication treatment and peer recovery referrals, escalating from 0% to over 70% and 90%, respectively. Overall, the data indicated that implementing the new standard of care was correlated with a marked enhancement in the management of OUD within the ED. The expanded treatment options and referral services translated into a higher proportion of patients receiving appropriate care, suggesting a positive impact on patient outcomes and potentially alleviating the strain on ED resources associated with untreated OUD. Further analysis is required to evaluate the long- term effectiveness and sustainability of these interventions. The analysis of the results revealed that the success of the standard of care was due to several factors, including early intervention, the use of evidence-based MAT, and seamless referral mechanisms to specialized treatment programs. The training and education provided to the ED staff were also pivotal for the successful implementation of the new standard of care, helping to reduce stigma and bias surrounding addiction and improving the quality of care provided to patients with OUD. Overall, the results and analysis of the project indicated that implementation of the OUD standard of care in the ED successfully increased access to OUD treatment and improved patient outcomes. Interpretation The project results indicate that implementing the OUD standard of care in the ED successfully increased access to OUD treatment and improved patient outcomes. The success of the standard of care can be attributed to several factors, including early intervention, the use of evidence-based MAT, and seamless referral mechanisms to specialized treatment programs. The training and education provided to the ED staff were also pivotal in the success of this project by helping reduce stigma and bias surrounding addiction, leading to improved quality of care 28 provided to OUD patients. Sustainability The sustainability of this project initially included monthly project meetings that brought together the team and stakeholders to review the project goals and data. During these meetings, the team discussed any challenges or barriers to standard care implementation and identified strategies for overcoming them. Regular communication channels will also be established to ensure ongoing support and feedback from stakeholders, further promoting sustainability and adherence to the standard of care. The ED director and medical director have also added the OUD order set use to the quality metrics to be discussed at quarterly ED leadership meetings to ensure continued utilization. Implications for Practice Implementing the Opioid Use Standard of work orders set in the emergency room has proven to be immensely beneficial for the immediate environment, community, and others encountering similar challenges. Several key lessons have emerged during this process. First, the importance of interdisciplinary collaboration became evident as it involved stakeholders from diverse departments, such as medical, nursing, pharmacy, and information technology, ensuring the comprehensive integration of the standard of care into our existing workflows. Second, flexibility and adaptability are paramount, allowing us to navigate unexpected obstacles, such as resistance to change and technical issues with our electronic health record system. Third, 29 providing education and training to staff members is crucial for successfully adopting the new standard, fostering buy-in, confidence in implementation, and reducing stigma. In terms of implications, at the unit level, implementation has resulted in more standardized and evidence-based care for ED patients with opioid use disorders, enhanced communication and collaboration among multidisciplinary teams, and ultimately improved patient outcomes. Scaling this organization-wide implementation could yield far-reaching benefits, including enhanced patient care, reduced opioid-related harm, and optimized resource utilization, fostering a culture of continuous quality improvement and innovation. Furthermore, our experience can serve as a model for other healthcare organizations and systems grappling with similar challenges, offering insights and strategies for addressing opioid use disorders within their communities. Additionally, the principles and strategies employed in our emergency room setting could be applicable in other settings, such as community health centers or clinics, contributing to broader efforts to combat opioid epidemics both locally and globally. While challenging and frustrating at times, the overall experience of implementing the Opioid Use Disorder standard of work-order set has been instrumental in enhancing patient care and holds promise as a valuable model for others seeking to address opioid use disorder in their respective settings. Dissemination To disseminate my graduate scholarly project on implementing the Opioid Use Standard of work order set in our emergency room, I employed a comprehensive strategy encompassing internal and external channels. Internally, I shared the project findings and outcomes through institutional reports, newsletters, and internal communication channels, ensuring that staff members, administrators, and stakeholders within the healthcare organization were informed and 30 engaged. Externally, I pursued various avenues for dissemination, including publications, presentations, and posters. Additionally, I will present the project to my academic peers, professional organizations, and colleagues. I hope to pursue presentations at local, national, and international conferences on healthcare quality improvement, emergency medicine, and addiction medicine, thus providing knowledge-sharing and networking opportunities for professionals in the field. I will also create a poster summarizing project findings for presentations at conferences and other relevant events. Approvals for dissemination will be obtained, as institutional policies and guidelines require compliance with ethical standards and protection of patient privacy and confidentiality. My dissemination efforts aimed to share the story of our project implementation journey and contribute to advancing knowledge, improving practices, and addressing opioid epidemics. Discussion The project aimed to introduce a standard of care for OUD by implementing an evidence- based practice change project to introduce medication-assisted treatment (MAT) and other interventions for adults seeking treatment in the ED who also struggled with OUD. The project involved developing, implementing, and assessing a standard of care based on the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, which incorporates an interdisciplinary team approach to ensure precision and triumph (Dang & Dearholt, 2021, p. 53). The results showed a significant increase in access to OUD treatment with an increased number of patients receiving MAT and peer recall referrals. Limitations The project faced several limitations, including limited time for comprehensive interventions due to the ED's focus on acute care and the fact that not all staff may have had 31 specialized training in addiction medicine, leading to potential gaps in treatment approaches. The organizational structure supporting work with the EHR delayed the project's progress because the development of the standard of care order set was delayed. Additionally, limited organizational resources were dedicated to continuity of care, which likely affected the consistency of care provided to patients with OUD after discharge from the ED. Conclusion Implementing the OUD standard of care in the ED successfully increases access to OUD treatment and improves patient outcomes. This project demonstrated the effectiveness of early intervention, evidence-based MAT, and seamless referral mechanisms to specialized treatment programs in improving the care and outcomes of patients with OUD. The findings of this project have significant implications for future practice and research on the treatment of Opioid Use Disorder (OUD) in emergency department (ED) settings. First, the project underscores the potential effectiveness of implementing a standardized approach, or standard of care, for managing OUD within the ED context. The project highlights the importance of structured protocols in improving patient care and outcomes by demonstrating the positive outcomes associated with early intervention, evidence-based Medication-Assisted Treatment (MAT), and streamlined referral pathways to specialized treatment programs. These insights suggest that EDs can serve as crucial points of intervention for individuals with OUD, providing timely access to evidence-based treatments and initiating a continuum of care. Moreover, the project's success emphasizes the significance of comprehensive training and education programs for the ED staff. These programs equip healthcare professionals with the necessary skills and knowledge to effectively implement a standard of care and enhance the quality and consistency of OUD management in the ED setting. 32 For future practice, the project suggests the importance of the widespread adoption of standardized protocols for OUD treatment across EDs. Implementing consistent approaches can help ensure that all patients receive appropriate care regardless of the specific ED they visit. Additionally, efforts should be made to integrate MAT and referral mechanisms seamlessly into existing ED workflows, facilitating efficient and coordinated care transitions for patients with OUD. From a research perspective, this project highlights several areas for further investigation. Future studies should explore the long-term outcomes and sustainability of implementing a standard of care for OUD in the ED, including factors influencing patient adherence to treatment and follow-up. Additionally, comparative effectiveness research could evaluate different approaches to OUD management within the ED context, helping identify optimal strategies for improving patient outcomes. In summary, this project provides valuable insights into the potential benefits of introducing a standard of care for treating OUD in the ED. By emphasizing the importance of early intervention, evidence-based treatment, and comprehensive staff training, the project offers a roadmap for enhancing OUD management practices in emergency healthcare settings. This underscores the need for further research to support ongoing improvements in care delivery. References 33 Ascension (2023). Ascension's mission, vision, and values. Mission Vision Values and Ethics | Ascension Addiction Resource Guide. (2023, January 9). What drug is dope? What Drug is Dope - Addiction Resource Guide American Psychology Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Beaudoin, F. L., Merchant, R. C., & Clark, M. A. (2016). Prevalence and detection of prescription opioid misuse and prescription OUD among ED patients 50 years of age and older: Performance of the prescription drug use questionnaire, patient version. The American Journal of Geriatric Psychiatry, 24(8), 627-636. doi:https://doi.org/10.1016/j.jagp.2016.03.010 Bogan, C., Jennings, L., Haynes, L., Barth, K., Moreland, A., Oros, M., . . . Brady, K. (2020). Implementation of initiated buprenorphine for OUD in a rural southern state. Journal of Substance Abuse Treatment, 112, 73–78. doi:https://doi.org/10.1016/j.jsat.2020.02.007 Cao, S. S., Dunham, S. I., & Simpson, S. A. (2020). Prescribing buprenorphine for OUDs in the ED: A review of best practices, barriers, and future directions. Open Access Emergency Medicine, 261-274. Centers for Disease Control and Prevention. National Centers for Health Statistics. (2023). Provisional drug overdose death counts. https://www.cdc.gov/nchs/nvss/vsrr/drug- overdose-data.htm 34 Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. Sigma Theta Tau. D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., ... & Fiellin, D. A. (2015). ED–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. Journal of the American Medical Association, 313(16), 1636–1644. Duber, H. C., Barata, I. A., Cioè-Peña, E., Liang, S. Y., Ketcham, E., Macias-Konstantopoulos, W., ... & Whiteside, L. K. (2018). Identification, management, and transition of care for patients with OUD in the ED. Annals of Emergency Medicine, 72(4), 420-431. Edwards, F. J., Wicelinski, R., Gallagher, N., McKinzie, A., White, R., & Domingos, A. (2020). Treating opioid withdrawal with buprenorphine in a community hospital ED: an outreach program. Annals of Emergency Medicine, 75(1), 49–56. Faude, S., Delgado, M. K., Perrone, J., McFadden, R., Xiong, R. A., O'Donnell, N., ... & Lowenstein, M. (2023). Variability in OUD clinical presentations and treatment in the ED: A mixed-methods study. The American Journal of Emergency Medicine, 66, 53–60. Foster, S. D., Lee, K., Edwards, C., Pelullo, A. P., Khatri, U. G., Lowenstein, M., & Perrone, J. (2020). Providing incentive for emergency physician X-waiver training: an evaluation of program success and postintervention buprenorphine prescribing. Annals of Emergency Medicine, 76(2), 206–214. Guerrero, E., Ober, A. J., Howard, D. L., Khachikian, T., Kong, Y., van Deen, W. K., . . . Menchine, M. (2020). Organizational factors associated with practitioners' support for 35 treatment of OUD in the ED. Addictive Behaviors, 102, 7. doi:https://doi.org/10.1016/j.addbeh.2019.106197 Hawk, K., & D’Onofrio, G. (2018). ED screening and interventions for substance use disorders. Addiction science & clinical practice, 13(1), 1-6. Hawk, K., Hoppe, J., Ketcham, E., LaPietra, A., Moulin, A., Nelson, L., ... & D’Onofrio, G. (2021). Consensus recommendations on the treatment of OUD in the ED. Annals of Emergency Medicine, 78(3), 434-442. Hawk, K., McCormack, R., Edelman, E. J., Coupet, E., Toledo, N., Gauthier, P., ... & D’Onofrio, G. (2022). Perspectives about ED care encounters among adults with OUD. JAMA network open, 5(1), e2144955-e2144955. Herring, A. A., Vosooghi, A. A., Luftig, J., Anderson, E. S., Zhao, X., Dziura, J., Hawk, K. F., McCormack, R. P., Saxon, A., & D'Onofrio, G. (2021). High-Dose Buprenorphine Induction in the ED for Treatment of OUD. JAMA network open, 4(7), e2117128. https://doi.org/10.1001/jamanetworkopen.2021.17128 Kaczorowski, J., Bilodeau, J., M Orkin, A., Dong, K., Daoust, R., & Kestler, A. (2020). ED- initiated interventions for patients with OUD: A Systematic review. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine, 27(11), 1173–1182. https://doi.org/10.1111/acem.14054 Kilaru, A. S., Lubitz, S. F., Davis, J., Eriksen, W., Siegel, S., Kelley, D., . . . Meisel, Z. F. (2021). A state financial incentive policy to improve ED treatment for OUD: A qualitative study. Psychiatric Services, 72(9), 1048-1056. doi:https://doi.org/10.1176/appi.ps.202000501 36 Lowenstein, M., McFadden, R., Abdel-Rahman, D., Perrone, J., Meisel, Z., O'Donnell, N., Wood, C., Solomon, G., Beidas, R., & Delgado, K. (2022). Redesign of OUD screening and treatment in the ED. NEJM Catalyst Innovations in Care Delivery, 3(1). McCormack, R. P., Rotrosen, J., Gauthier, P., D'Onofrio, G., Fiellin, D. A., Marsch, L. A., . . . Hawk, K. (2021). Implementation facilitation to introduce and support ED-initiated buprenorphine for OUD in high need, low resource settings: Protocol for multi-site implementation-feasibility study. Addiction Science & Clinical Practice, 16, 14. doi:https://doi.org/10.1186/s13722-021-00224-y Michigan Department of Health and Human Services, (2023). Data. Data (michigan.gov) Rosenberg, N. K., Hill, A. B., Johnsky, L., Wiegn, D., & Merchant, R. C. (2022). Barriers and facilitators associated with establishment of ED‐initiated buprenorphine for OUD in rural Maine. The Journal of Rural Health, 38(3), 612-619. doi:https://doi.org/10.1111/jrh.12617 Samuels, E. A., D’Onofrio, G., Huntley, K., Levin, S., Schuur, J. D., Bart, G., ... & Venkatesh, A. K. (2019). A quality framework for ED treatment of OUD. Annals of Emergency Medicine, 73(3), 237-247. Spadaro, A., Long, B., Koyfman, A., & Perrone, J. (2022). Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. The American journal of emergency medicine, 58, 22–26. https://doi.org/10.1016/j.ajem.2022.05.013 Srivastava, A., Kahan, M.M., Njoroge, I.W., & Sommer, L.Z. (2019). Buprenorphine in the ED: Randomized clinical controlled trial of clonidine versus buprenorphine for the treatment of opioid withdrawal. Canadian family physician Medecin de famille canadien, 65 5, e214-e220. 37 Substance Abuse and Mental Health Services Administration. (2023). Federal guidelines for opioid treatment programs. Federal Guidelines for Opioid Treatment Programs | SAMHSA Substance Abuse and Mental Health Services Administration. (2023).Overcoming Stigma, Ending Discrimination Resource Guide (samhsa.gov) Substance Abuse and Mental Health Services Administration. (2021). Use of medication-assisted treatment in emergency departments. Use of Medication-Assisted Treatment in Emergency Departments (samhsa.gov) Terhaar, M.F., Crickman, R., & Finnell, D.S. (2021). Project management for translation. In K. White, S. Dudley-Brown, & M. Terhaar (Eds.), Translation of evidence into nursing and healthcare (pp. 199-227). New York, NY: Springer Publishing Company, LLC. Thomas, C. P., Stewart, M. T., Tschampl, C., Sennaar, K., Schwartz, D., & Dey, J. (2022). ED interventions for OUD: A synthesis of emerging models. Journal of Substance Abuse Treatment, 141, 1-8. doi:https://doi.org/10.1016/j.jsat.2022.108837 U.S. Food and Drug Administration. (2023). Information about medication-assisted treatment (MAT). https://www.fda.gov/drugs/information-drug-class/information-about- medication-assisted-treatment-mat 38 Appendix A: Quality Improvement/EBP Project Evidence Critique Table Level Type Number of Sources Overall Quality Rating Level I 2 B Synthesis of Findings (Evidence that answers the EBP PICO question) ▪ Initiation of buprenorphine in the ED increases engagement in addiction treatment. ▪ Evidence to support referral for improved continuation of Level II 1 A/B Level III 1 A/B Level IV 1 A Level V 6 A care ▪ ED tx can improve adherence follow-up with a lack of addiction tx centers ▪ There is good evidence to support buprenorphine initiation in the ED with a clinically significant effect on engagement and treatment after 30 days ▪ Addition of referral-supported ▪ Identifies the need for "tailored clinical guidance" for patients with OUD. ▪ Variations in buprenorphine dosing identified with further research recommended based on presentation ▪ Referral may be promising to create more patient- centered models of care ▪ Recommends strategies for OUD-initiated treatment in ▪ the ED. Initiation of buprenorphine in the ED effectively engages patients in formal addiction treatment. ▪ Provide linkage to ongoing medication for OUD (follow- up/referral) ▪ Suggest targeted screening for at-risk OUD, not universal screening (history, PDMP, etc.) ▪ Recommends initiation of buprenorphine in the ED with or without naloxone ▪ ED-initiated OUD MAT is effective for engaging patients in formal addiction treatment. ▪ Collaboration with community providers and resources to improve engagement in treatment. ▪ Suggest warm hand-offs and referrals to ongoing medication for OUD Appendix B: SWOT Analysis Strengths Weaknesses 39 • Immediate medical attention in the ED enables the addressing of OUD crises through treatment and prevention. • Qualified and experienced medical staff provide a solid foundation for the treatment program. • Commitment to service of the poor • Limited time for comprehensive interventions due to the ED's focus on acute care. • Not all staff may have specialized training in addiction medicine, leading to potential gaps in treatment approaches. and reverence aligns with addressing the opioid crisis and serving vulnerable populations. • Limited resources dedicated to continuity of care, specifically out of the ED • Access to resources and medical technology facilitates efficient diagnosis and intervention for OUD patients. Opportunities Threats • Early intervention can reduce the severity of OUD and prevent escalation. • Partnerships with addiction specialists and treatment facilities can establish a comprehensive continuum of care for OUD patients. • Creativity and dedication offer opportunities for innovative treatment approaches. • Telemedicine solutions can extend support and follow-up care for discharged patients. • Stigma and bias surrounding addiction may hinder program effectiveness and patient engagement. • Regulatory challenges related to opioid prescribing and controlled substances require careful compliance. • • Patient follow-up and treatment plan adherence may be challenging for some OUD patients. Implementing new protocols and workflows in a busy ED environment can encounter resistance from staff, potentially hindering the adoption and success of the OUD project.