Addressing System and Clinician Barriers to Emergency Department-initiated Buprenorphine: An Evaluation of Post-intervention Physician Outcomes.

Introduction: Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions. Methods: This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians' buprenorphine experience. Results: Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend <75% of their work week in clinical practice and to be in medical practice for <7 years. Buprenorphine knowledge (including status of buprenorphine prescribing waiver), comfort with addressing OUD, and attitudes toward OUD treatment did not differ significantly between the sites. Physicians were 4.5 times more likely to have administered buprenorphine at the intervention site (odds ratio [OR] 4.5, 95% confidence interval 1.4-14.4, P = 0.01), which remained significant after adjusting for clinical time and years in practice, (OR 3.5 and 4.6, respectively). Conclusion: Physicians exposed to interventions addressing system- and clinician-level implementation barriers were at least three times as likely to have administered buprenorphine in the ED. Physicians' buprenorphine knowledge, comfort with addressing and attitudes toward OUD treatment did not differ significantly between sites. Our findings suggest that ED-initiated buprenorphine can be facilitated by addressing implementation barriers, while physician knowledge, comfort, and attitudes may be harder to improve.

Impact of the PEARLS Healthcare Debriefing cognitive aid on facilitator cognitive load, workload, and debriefing quality: a pilot study.

BACKGROUND: The Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Debriefing Tool is a cognitive aid designed to deploy debriefing in a structured way. The tool has the potential to increase the facilitator's ability to acquire debriefing skills, by breaking down the complexity of debriefing and thereby improving the quality of a novice facilitator's debrief. In this pilot study, we aimed to evaluate the impact of the tool on facilitators' cognitive load, workload, and debriefing quality. METHODS: Fourteen fellows from the New York City Health + Hospitals Simulation Fellowship, novice to the PEARLS Healthcare Debriefing Tool, were randomized to two groups of 7. The intervention group was equipped with the cognitive aid while the control group did not use the tool. Both groups had undergone an 8-h debriefing course. The two groups performed debriefings of 3 videoed simulated events and rated the cognitive load and workload of their experience using the Paas-Merriënboer scale and the raw National Aeronautics and Space Administration task load index (NASA-TLX), respectively. The debriefing performances were then rated using the Debriefing Assessment for Simulation in Healthcare (DASH) for debriefing quality. Measures of cognitive load were measured as Paas-Merriënboer scale and compared using Wilcoxon rank-sum tests. Measures of workload and debriefing quality were analyzed using mixed-effect linear regression models. RESULTS: Those who used the tool had significantly lower median scores in cognitive load in 2 out of the 3 debriefings (median score with tool vs no tool: scenario A 6 vs 6, p=0.1331; scenario B: 5 vs 6, p=0.043; and scenario C: 5 vs 7, p=0.031). No difference was detected in the tool effectiveness in decreasing composite score of workload demands (mean difference in average NASA-TLX -4.5, 95%CI -16.5 to 7.0, p=0.456) or improving composite scores of debriefing qualities (mean difference in DASH 2.4, 95%CI -3.4 to 8.1, p=0.436). CONCLUSIONS: The PEARLS Healthcare Debriefing Tool may serve as an educational adjunct for debriefing skill acquisition. The use of a debriefing cognitive aid may decrease the cognitive load of debriefing but did not suggest an impact on the workload or quality of debriefing in novice debriefers. Further research is recommended to study the efficacy of the cognitive aid beyond this pilot; however, the design of this research may serve as a model for future exploration of the quality of debriefing.