(104) Stakeholder Insights on Improving Care for Trauma Patients Who Use Methamphetamines

Background & Introduction: Methamphetamine use is a risk factor for traumatic injury. Moreover, acute methamphetamine intoxication complicates the care of injured patients by confounding neurological examination, delaying surgical management, and prolonging hospital length of stay. In Hawaii, approximately 17,000 people use methamphetamine, more than twice the national average. A study from [2004] at the State’s only Level I trauma center, found that among patients presenting with major trauma activations who are screened for illicit drug use, 26.9% were positive for methamphetamine. Optimizing the medical and psychosocial care of these injured patients while hospitalized to include comprehensive substance use care may improve long-term health outcomes and reduce the risk of trauma recidivism. This study aimed to qualitatively assess facilitators and barriers to the implementation of a methamphetamine treatment program, in order to guide future improvements in patient care. As there are currently no approved medication assisted treatment for methamphetamine use disorder, the proposed program is framed around a contingency management behavioral intervention. While both healthcare stakeholder and patient perspectives were sought, this study arm focuses on healthcare stakeholder perspectives. To our knowledge, this is the first study to examine healthcare stakeholder perspectives on how to improve care for trauma patients who use methamphetamine.

Methods: A semi-structured interview guide was developed to query issues relevant to improving patient care and interrogate barriers and facilitators to program implementation. We planned to continue until 15 individuals were interviewed or when saturation was reached, whichever occurred sooner. Convenience sampling was performed to obtain a diverse group of interviewees representing different professions. For each subject, informed consent was obtained. Each interview was de-identified prior to transcription to protect participant confidentiality.
A template analysis approach was used to code the interviews; the template was constructed iteratively using a priori themes and codes relevant to the data. Coding was performed in duplicate; the first transcript was coded prior to an initial meeting to ensure completeness and consistency. All changes to the initial template were recorded in a coding log. The process was repeated after the next three transcripts were coded and again for a final time after all transcripts were coded. A consensus meeting then took place to compare and combine codes. This resulted in one merged set of codes for each interview. This process was used to ensure comprehensive, accurate, and reproducible data.

Results: We interviewed a total of 15 stakeholders: four trauma surgeons, two other trauma care providers, two substance use disorder providers, two clinical specialists in disposition planning, two surgical trainees, a nursing leader, an emergency physician, and a hospital physician leader. Themes were explored across five domains.
Domain 1: Stakeholder biases regarding patients who use methamphetamine. Five stakeholders felt that their attitudes change as a result of a positive drug screen (“It’s an additional data point to help understand the patient’s situation”), whereas 13 felt that those of their colleagues’ change (“I’ve seen team members completely disregard [these] patients”).
Domain 2: Stakeholder perspectives on patients’ experience in the hospital. 10 individuals described negative aspects of this population’s patient experience (“…what they're feeling is not taken seriously or just discounted. I think they're probably feeling like they're the lower-class citizens”), five described the overall experience as neutral (“I think they just expect to get fixed…so that they can get out of the hospital and then resume their previous behavior.”), and two described positive elements (“. . . I think that our care is pretty well-designed”).
Domain 3: Suggested improvements to care. To improve inpatient care, several individuals commented on staff education efforts to reduce stigma. Four individuals recommended having daily accessibility to addictions medicine consults (rather than two days per week). Most interviewees recommended improvements to the accessibility of outpatient addictions care, and bridge services between hospital and community-based addictions care.
Domain 4: Barriers to program treatment program implementation. These included pragmatic concerns (“[patients] might not have the best transportation to get to the programs or time or availability [to return]”), cultural concerns (“I worry about stigma associated with it”), community trust (“people [in Hawaii] are very community-centric and community-focused”), and concerns regarding sustainability, financing, and effectiveness.
Domain 5: Facilitators of program implementation. Stakeholders communicated significant interest from providers across all hospital divisions in expanding resources for patients who use methamphetamine (“I feel like everyone would be so excited”, “[many people] would be very interested if there's something available”, “I do think there's people out there that believe in it and that could support it”). Stakeholders felt that this work would be facilitated by engaging with existing community organizations (“Rather than creating something completely new, how do we align and collaborate and make the overall effort better?”) and working with motivated patients (“Many people seem fairly motivated to try to stop using.”)

Conclusion & Discussion: Stakeholders were unanimous in describing methamphetamine use as a major problem affecting hospital care for injured patients, resource use, and patient quality of life. Many individuals identified bias and stigma as barriers to optimal patient care, though interestingly, most felt that methamphetamine use did not impact their own attitudes toward patients. While “contingency management” was an unfamiliar term to thirteen individuals, once informed, most participants felt that this behavioral intervention would be of benefit to at least a subset of patients. Most participants felt that there were significant barriers to implementation, but there was a sense of optimism for forward progress based on a universal understanding of the problem of methamphetamine use. Generally, organizational culture was felt to be supportive of new programming for this patient population. There was a lack of consensus on where this programming should be housed: starting within the trauma outpatient program would be high-yield, but risked siloing an intervention that would be of broader benefit to all hospital populations. Since small numbers of stakeholders were interviewed, thematic saturation in all domains and representativeness within professions may not have been achieved. Further research will integrate this stakeholder study with a twinned study of patient perspectives.

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