Improving Care for Addiction-Related Endocarditis

Opioid Use Disorder (OUD) A problematic pattern of opioid use that leads to severe impairment or distress and must include at least two of the following -loss of control, social impairment, tolerance, or withdrawal. Medication Assisted Treatment (MAT)Refers to the medications used for the treatment of OUD.The most commonly used medications are buprenorphine (commonly known as suboxone) or methadone InductionThe process of transitioning from a standard opioid to MAT.This includes a period of monitored withdraw before the initiation of MAT at a medically appropriate timetypically 12-24 hours after the last dose of an opioid Infective Endocarditis (IE)Endocarditis due to an infectious organism CTS UNC Cardiothoracic Surgery Team Pain PsychologistExpert in helping individuals cope with the thoughts, feelings, and behaviors that accompany chronic pain; can diagnose and treat co-occurring mental health and substance abuse concerns Waiver training Physicians require 8-hours of training to apply to the DEA for a waiver to prescribe buprenorphine for the treatment of OUD Peer Support Specialist An individual who was lived experience in recovery and had extensive training communication, motivational interviewing, and the various treatment options (MAT). What do you hope to gain in terms of professional development by participating in the ImprovementScholars Program?Quality Improvement (QI) and Patient Safety have been a passion of mine for many years now.I assisted in the creation of a QI and Patient Safety Fellowship for residents and fellows and underwent training in Lean and Six Sigma methodologies while at Johns Hopkins from 2012-2014.I completed additional training in Patient Safety while at Duke from 2014-2016 and have been active in QI and Patient Safety work at UNC since arriving in 2016, including completing a UNC Yellow belt, UNC Purple belt, TeamSTEPPS Master Training and obtaining CPPS (Certified Profession in Patient Safety) status.While I do have substantial prior formal QI training, I have learned over the years that fostering professional connections, having the ability to successfully build and lead a team and developing positive relationship with mentors, sponsors and senior leaders within the institution at which one works, is as important, if not more so, than having the technical skills to complete a project.Participation in the IHQI Scholars Program will help me further build these connections, learn from and grow with my colleagues, and develop the team building and leadership skills I need to be successful in this work in the long-term.Further, this project will allow me to dive deeply into the work and gain a deeper understanding of the technical skills needed to tackle challenging problems and create meaningful and lasting change.Specifically, I am hoping for coaching and training on how to more accurately determine when to employ specific QI tools and how to develop and enact successful sustainment plans.Additionally, gaining the skills to present and publish improvement resultssuccessfully and more efficiently would be immensely beneficial as this is currently an area where I need further experience. Which UNC HCS improvement priority will your project address?This project will address several UNC HCS improvement priorities, including mortality reduction, reducing readmissions, improving transitions of care, reducing ED utilization, improved access to (outpatient addiction) care. Whatare you trying to accomplish?What is the problem or gap in the quality you seek to improve?What is the specific patient population your project will impact?Currently, there is a gap in the way we provide care to patients with Tricuspid valve (TV) infective endocarditis related to intravenous drug abuse (IVDA).As are the trends nationally, annual hospitalization rates in North Carolina for IE related to intravenous drug use are rising.Between 2010 and 2015, North Carolina reported a twelve-fold increase in hospitalizations in this patient population.Data from Asher et al. revealed these patients are primarily insured by Medicaid (38%) or uninsured (35%), have longer LOS (median 27 vs. 17 days) with higher median charges ($250,994 vs. $198,764).Further, it is well described in the literature that sustained abstinence is unlikely without the use of MAT.According to Chutupe et al., patients with opioid use disorder who were treated with detoxification alone had a less than 20% rate of abstinence at 30-days.In the current state at UNC, there is no systematic approach to screen for OUD in this patient population, to provide addiction and psychologically focused treatment and counseling, to initiate MAT in the inpatient setting, or a standard approach harm reduction.Additionally, a collaborative approach to care between medical and surgical teams does not currently exist.This leads to extended hospital stays, stagnant patient flow through the health system, and poor patient outcomes.This project would see to improve the delivery of care for patients with TV-IE related to IVDA through structured approach to screening for OUD, efficient transfer to a medical team at UNC Hillsborough once post-surgical needs have been met at UNC Chapel Hill, counseling on and initiation of MAT before discharge, utilization of harm reduction techniques, post-operative and pain and psychologic counseling, referral to outpatient addiction care and development of a pathway for early discharge with home IV antibiotics in low-risk, qualified patients.Additionally, this project will seek to create a roadmap for care that can be spread to other conditions associated with OUD, including, but not limited to, osteomyelitis, spinal and epidural abscesses and acute cases of hepatitis and HIV related IVDA.To best understand the gap in quality from the patient's perspective is to understand how meaningful and life-changing this type of care can be when done well.The following is a direct quote from a patient with OUD who was transitioned to MAT at Hillsborough and then successfully connected with outpatient addiction care,