Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections

Abstract

Background: Patients with injection drug use (IDU)-associated infections traditionally experience prolonged hospitalizations, which often result in negative experiences and bad outcomes. Harm reduction approaches that value patient autonomy and shared decision-making regarding outpatient treatment options may improve outcomes. We sought to identify health care professionals (HCPs) perspectives on the barriers to offering four different options to hospitalized people who use drugs (PWUD): long-term hospitalization, oral antibiotics, long-acting antibiotics at an infusion center, and outpatient parenteral antibiotics. Methods: We recruited HCPs ( n = 19) from a single tertiary care center in Portland, Maine. We interviewed HCPs involved with discharge decision-making and other HCPs involved in the specialized care of PWUD. Semi-structured interviews elicited lead HCP values, preferences, and concerns about presenting outpatient antimicrobial treatment options to PWUD, while support HCPs provided contextual information. We used the iterative categorization approach to code and thematically analyze transcripts. Results: HCPs were willing to present outpatient treatment options for patients with IDU-associated infections, yet several factors contributed to reluctance. First, insufficient resources, such as transportation, may make these options impractical. However, HCPs may be unaware of existing community resources or viable treatment options. They also may believe the hospital protects patients, and that discharging patients into the community exposes them to structural harms. Some HCPs are concerned that patients with substance use disorder will not make ‘good’ decisions regarding outpatient antimicrobial options. Finally, there is uncertainty about how responsibility for offering outpatient treatment is shared across changing care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with IDU-associated infections, but with appropriate interventions to address their concerns, may be open to considering more options. This study provides important insights and contextual information that can help inform specific harm reduction interventions aimed at improving care of people with IDU-associated infections.

“I know my body better than anyone else”: a qualitative study of perspectives of people with lived experience on antimicrobial treatment decisions for injection drug use-associated infections

“…5 We reported in a previous study that most HCPs were supportive of providing patients with outpatient options, but still had concerns about selfdirected discharges, "non-traditional" antimicrobial treatment efficacy, and use of a PICC line to inject drugs. 15 In this study, patients and community partners emphasized patient autonomy and suggested that, while patients may not make the choice their care team prefers, taking this choice away can have negative short-and long-term consequences. Furthermore, patients demonstrate that they prioritize their health when they choose to remain in the hospital.…”

“…10 Though many healthcare professionals (HCPs) are open to discussing these options with patients, there are some who are concerned that patients will not complete antibiotic courses after discharge, increasing the risk for antimicrobial resistance, infectious complications, and hospital readmission. 15 Shared decision making has been used with some success with PWID and may be useful in the context of treatment for IDU-associated infections, but studies on this topic specifically are limited. 16 Sikka et al 17 described an interprofessional provider conference to increase discharge options for patients with IDU-associated infections.…”

Community-Based Services for Hospitalized Patients With Serious Injection-Related Infections in Alabama: A Brief Report

“…Previous studies have demonstrated the effectiveness of in-hospital dissemination of harm reduction strategies, referrals to existing community-based services, and patient navigation at discharge [ 17 , 30 ]. While hospital providers are willing to present outpatient treatment options, many are not aware of existing community resources [ 31 ].…”

‘I feel like they’re actually listening to me’: a pilot study of a hospital discharge decision-making conversation guide for patients with injection drug use–associated infections

“…Based on earlier research conducted with health care professionals (HCPs), 9 patients, and community partners (Eckland et al personal communication, 31 January 2023), we developed a conversation guide ( Supplemental Appendix 1 ). We built on existing decision matrices and risk assessments developed by infectious diseases (ID) and palliative care experts, with real-time guidance and technical advice.…”

“… 8 In practice, many inpatient-based health care professionals recommend that people with IDU-associated infections remain hospitalized for prolonged periods because of the concern that they will inject drugs into indwelling central venous catheters, thereby risking another infection or death. 9 While prolonged hospitalizations might be justified to prevent self-harm, they may also infringe on patient autonomy. Patient autonomy is one of the central principles of medical ethics; 10 however, patients are often not given the ability to choose among medically feasible options which align with their values.…”