Financial, Social and Clinical outcomes in Injection Drug Users administered Intravenous Antimicrobials and provided Drug rehabilitation through the Substance Abuse PICC Program
Project Description: Injection Drug Users (IDU’s) are a complex population subset and difficult to manage in the inpatient setting 1. They frequently have infectious complications and these account for as high as 60% of their admissions with infectious endocarditis (IE) accounting for 5 to 15% of these admissions(Levine, Crane et al. 1968, Scheidegger and Zimmerli 1989). The treatment of these infections is complicated by inability to administer Intravenous antibiotics safely through a peripherally inserted central catheter (PICC), in an outpatient setting or in a skilled nursing facility (SNF), due to concerns of intravenous drug abuse (IVDA). Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry and is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors; and without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death(Public Policy statement). In the hospital, addicted patients can be disruptive to the facility and other patients and make increased demands of physicians, nurses’ time with behaviors such as bartering, bargaining, self-harm to receive pain meds, exaggeration of symptoms, and triangulation of the treatment team. They also demonstrate Non-compliance by leaving the unit for several hours, obtaining drugs from visitors or other patients and PICC line tampering. They also have more frequent recurrence rates(Welton, Young et al. 1979, Alagna, Park et al. 2014). There were concerns for PICC tampering in the outpatient setting and for poor adherence to therapy; lack of supervision and potential risk of exposure of vulnerable patients in the SNF setting from visitors of IDU’s these patients historically had completed their course of IV antimicrobials through an extended stay in the hospital. The Infectious disease providers did not recommend patients be discharged on oral antimicrobials since these therapies are considered suboptimal(Al-Omari, Cameron et al. 2014). Infectious disease society of America recommends for most cases of endocarditis at least 4 to 6 weeks of IV therapy (Baddour, Wilson et al. 2015). Since the primary issue of addiction was not addressed, patients had readmissions with repeat infections. Some of these patients required expensive valve replacement surgeries and due to ongoing drug use developed complications of prosthetic valve endocarditis(Alagna, Park et al. 2014). Due to these issues, a Substance Abuse PICC Program (SAPP) was developed at University of Florida Health – Shands Hospital (UFH) in 2013 modeled on the successful program at Virginia Commonwealth University. At VCU, it was estimated that the SAPP saved 2.5 million dollars in a 6 year period to the hospital (Jewell, 2013). The goal of SAPP was to create a program that focuses on the management of the underlying diagnosis of addiction in parallel with the treatment of the active infection caused secondary to the addiction. It was postulated that successful implementation of SAPP would also decrease readmission risks, decrease demand on nursing resources and decrease length of inpatient stay in this high risk population. The program task force is a multi-disciplinary team including social work/case management, legal experts, nursing and physicians from psychiatry/addiction medicine (AM), internal medicine, and infectious disease (ID). A contractual agreement was put in place with Meridian Behavioral Healthcare, Inc for drug rehab and monitoring at the Bridge house.
QPI: Nila, Radhakrishnan, (Nila.Radhakrishnan@medicine.ufl.edu)
Collaborators: (Harry.Powers@medicine.ufl.edu); Kartikeya, Cherabuddi, (firstname.lastname@example.org)
Advisors: Nila, Radhakrishnan, (Nila.Radhakrishnan@medicine.ufl.edu); Kartikeya, Cherabuddi, (email@example.com)
UF Health Big Aims: Increase Value None