Substance use care innovations during COVID-19: barriers and facilitators to the provision of safer supply at a toronto COVID-19 isolation and recovery site.

BACKGROUND: Early in the COVID-19 pandemic, there was an urgent need to establish isolation spaces for people experiencing homelessness who were exposed to or had COVID-19. In response, community agencies and the City of Toronto opened COVID-19 isolation and recovery sites (CIRS) in March 2020. We sought to examine the provision of comprehensive substance use services offered to clients on-site to facilitate isolation, particularly the uptake of safer supply prescribing (prescription of pharmaceutical opioids and/or stimulants) as part of a spectrum of comprehensive harm reduction and addiction treatment interventions. METHODS: We conducted in-depth, semi-structured interviews with 25 clients and 25 staff (including peer, harm reduction, nursing and medical team members) from the CIRS in April-July 2021. Iterative and thematic analytic methods were used to identify key themes that emerged in the interview discussions. RESULTS: At the time of implementation of the CIRS, the provision of a safer supply of opioids and stimulants was a novel and somewhat controversial practice. Prescribed safer supply was integrated to address the high risk of overdose among clients needing to isolate due to COVID-19. The impact of responding to on-site overdoses and presence of harm reduction and peer teams helped clinical staff overcome hesitation to prescribing safer supply. Site-specific clinical guidance and substance use specialist consults were crucial tools in building capacity to provide safer supply. Staff members had varied perspectives on what constitutes 'evidence-based' practice in a rapidly changing, crisis situation. CONCLUSION: The urgency involved in intervening during a crisis enabled the adoption of prescribed safer supply, meeting the needs of people who use substances and assisting them to complete isolation periods, while also expanding what constitutes acceptable goals in the care of people who use drugs to include harm reduction approaches.

"Whatever journey you want to take, I'll support you through": a mixed methods evaluation of a peer worker program in the hospital emergency department.

BACKGROUND: People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer. METHODS: Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data. RESULTS: Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department. CONCLUSIONS: The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.

The simulated newsroom: A novel educational innovation to teach advocacy skills to resident physicians.

Need for Innovation: Advocacy is a key competency of Canadian residency education, yet physicians seldom engage with supraclinical advocacy efforts upon completion of training. Objective of innovation: The objective was to equip participants with the knowledge and skills required to engage as physician-advocates in their communities using opinion writing as a tool. Developmental process: We used Kern's six-step framework to leverage a common medical training method, simulation, to teach journalistic skills related to advocacy in our novel "simulated newsroom." Two emergency physicians with journalism training and workplace experience developed simulated newsroom workshops. The simulated newsroom consisted of participants acting as journalists and the expert facilitator acting as a news editor over two workshops. The participants were encouraged to write and workshop an article with colleagues. Evaluation: Participants were invited to participate in a semistructured focus group and to submit their article for qualitative analysis. Focus group transcripts and written work were qualitatively analyzed to understand acceptability and feasibility and how participants might engage as future health advocates. Outcomes: Twelve participants registered for the workshops and six attended. All six participated in the focus group; four submitted written work. The innovation bolstered participants' confidence in advocacy through the popular press and provided demonstrable skills in opinion writing. Participants valued the workshop as a voluntary component of residency education led by physicians with journalism expertise. Discussion: The simulated newsroom may be an effective mechanism for increasing confidence and competence in advocacy writing.

Exploring the perspectives of healthcare providers that care for non-insured individuals utilizing emergency departments in Toronto.

BACKGROUND: Non-insured individuals have different healthcare needs from the general Canadian population and face unique barriers when accessing emergency department (ED) care. This qualitative study aims to better understand the system of emergency care for non-insured individuals from the perspective of healthcare providers. METHODS: The study uses a critical realist framework to explore structural factors that facilitate or impede access to care for non-insured individuals. Semi-structured interviews were conducted with 13 interdisciplinary healthcare professionals with experience working with non-insured populations in the ED and in community health centres. Data were analyzed with the use of Braun and Clark's thematic analysis framework and organized into themes through an iterative process until thematic saturation was reached. RESULTS: Healthcare providers face distinct challenges when providing care for non-insured patients including patients presenting with increased illness complexity and providers having to navigate systemic barriers. Interview participants noted stigma and bias, lack of privacy, unclear care pathways, and access to post-ED care as challenges facing non-insured patients. Suggestions to improve the ED experience for non-insured patients include improved staff training, clearer policies, and consistency between hospitals. Most of all, healthcare providers believed that the most effective way to improve the care of non-insured patients would be to make permanent the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic. CONCLUSION: Interviews with healthcare professionals have highlighted that marginalized populations, including non-insured individuals, face multiple barriers when accessing the ED, especially during the COVID-19 pandemic. At the same time, the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic has likely improved patients' healthcare experience, which we will explore directly with non-insured patients in a future study. In this post-COVID world, we now have an opportunity to learn from our experiences and build a more equitable ED system together.

RéSUMé: CONTEXTE: Les personnes non assurées ont des besoins en matière de soins de santé différents de ceux de la population canadienne en général et sont confrontées à des obstacles uniques lorsqu'elles veulent accéder aux soins d'urgence. Cette étude qualitative vise à mieux comprendre le système de soins d'urgence pour les personnes non assurées du point de vue des prestataires de soins de santé. MéTHODES: L'étude utilise un cadre réaliste critique pour explorer les facteurs structurels qui facilitent ou entravent l'accès aux soins pour les personnes non assurées. Des entretiens semi-structurés ont été menés auprès de 13 professionnels de la santé interdisciplinaires ayant l'expérience du travail avec les populations non assurées aux urgences et dans les centres de santé communautaires. Les données ont été analysées à l'aide du cadre d'analyse thématique de Braun & Clark et organisées en thèmes par un processus itératif jusqu'à ce que la saturation thématique soit atteinte. RéSULTATS: Les prestataires de soins de santé sont confrontés à des défis distincts lorsqu'ils fournissent des soins à des patients non assurés, notamment des patients présentant une complexité de maladie accrue et des prestataires devant surmonter les obstacles systémiques. Les participants aux entretiens ont noté que la stigmatisation et les préjugés, le manque d'intimité, le manque de clarté des parcours de soins et l'accès aux soins post-urgence sont des défis auxquels sont confrontés les patients non assurés. Les suggestions visant à améliorer l'expérience des patients non assurés aux urgences comprennent une meilleure formation du personnel, des politiques plus claires et une cohérence entre les hôpitaux. Par-dessus tout, les prestataires de soins de santé ont estimé que le moyen le plus efficace d'améliorer les soins aux patients non assurés serait de pérenniser l'extension temporaire de la couverture médicale aux patients non assurés promulguée pendant la pandémie de COVID-19. CONCLUSION: Les entretiens avec les professionnels de la santé ont mis en évidence que les populations marginalisées, notamment les personnes non assurées, sont confrontées à de multiples obstacles lorsqu'elles accèdent aux urgences, en particulier pendant la pandémie de COVID-19. En même temps, l'extension temporaire de la couverture médicale aux patients non assurés, promulguée pendant la pandémie de COVID-19, a probablement amélioré l'expérience des patients en matière de soins de santé, ce que nous explorerons directement auprès des patients non assurés dans une étude future. Dans ce monde post-COVID, nous avons maintenant l'occasion de tirer les leçons de nos expériences et de construire ensemble un système d'urgence plus équitable.

Emergency physician attitudes towards illness verification (sick notes).

INTRODUCTION: Emergency physicians frequently provide care for patients who are experiencing viral illnesses and may be asked to provide verification of the patient's illness (a sick note) for time missed from work. Exclusion from work can be a powerful public health measure during epidemics; both legislation and physician advice contribute to patients' decisions to recover at home. METHODS: We surveyed Canadian Association of Emergency Physicians members to determine what impacts sick notes have on patients and the system, the duration of time off work that physicians recommend, and what training and policies are in place to help providers. Descriptive statistics from the survey are reported. RESULTS: A total of 182 of 1524 physicians responded to the survey; 51.1% practice in Ontario. 76.4% of physicians write at least one sick note per day, with 4.2% writing 5 or more sick notes per day. Thirteen percentage of physicians charge for a sick note (mean cost $22.50). Patients advised to stay home for a median of 4 days with influenza and 2 days with gastroenteritis and upper respiratory tract infections. 82.8% of physicians believe that most of the time, patients can determine when to return to work. Advice varied widely between respondents. 61% of respondents were unfamiliar with sick leave legislation in their province and only 2% had received formal training about illness verification. CONCLUSIONS: Providing sick notes is a common practice of Canadian Emergency Physicians; return-to-work guidance is variable. Improved physician education about public health recommendations and provincial legislation may strengthen physician advice to patients.

CAEP Position Statement - Sick notes for minor illness.

Employer- and school-mandated verification of minor illness leads patients to use healthcare resources solely to obtain a "sick note." This puts unnecessary strain on the patient and the emergency department (ED), and threatens to spread communicable diseases in our community.

What knowledge is needed? Teaching undergraduate medical students to "go upstream" and advocate on social determinants of health.

BACKGROUND: We rarely teach medical students the skills required to engage in policy change to address the structural factors that underpin the social determinants of health, which are driven by the unequal distribution of power and resources in society. Acquiring the knowledge and skills to influence policy can empower students to act on healthcare inequities rather than simply be aware of them. METHODS: Using Metzl and Hansen's structural competency framework, we designed and piloted an intervention for medical students. Participants attended a workshop, presented to a hypothetical political stakeholder, and wrote anopinion editorial piece. Students participated in a focus group that was audio-recorded and transcribed. We coded and analyzed presentations, editorials, and transcripts to develop a thematic analysis. RESULTS: Nine students participated in the workshop. They chose structural interventions and presented potential solutions to structural barriers in written and oral outputs. Students identified a lack of knowledge about health and political systems as a potential barrier to future advocacy work. CONCLUSION: Medical trainees require training in specific advocacy skills such as oral and written communication, however this alone may be insufficient. As future advocates, trainees must also acquire a specific skill set and associated knowledge about health systems and policy to navigate the systems in which they will practice.

CONTEXTE: Nous enseignons rarement aux étudiants en médecine les habiletésnécessaires pour participer aux changements de politique afin d'aborder les facteurs structurels sous-jacents aux déterminants sociaux de la santé, et la distribution inégale du pouvoir et des ressources dans la société. L'acquisition de connaissances et d'habiletés aptes à influencer les politiques peut encourager les étudiants à s'engagerpour contrer les inégalités en matière de soins de santé plutôt que d'en être simplement conscients. MÉTHODES: À l'aide du cadre de compétence structurelle de Metzl et Hansen, nous avons conçu et pilotéune intervention pour les étudiants en médecine. Les participants ont assisté à un atelier présenté à un décideur politique simulé pour l'occasion, à la suite duquel ilsontrédigé un article d'opinion. Les étudiants ont participé à un groupe de discussion qui a été enregistré et transcrite. Nous avons codifié et analysé les présentations, les articles d'opinion, et les transcriptions pour développer une analyse thématique. RÉSULTATS: Neuf étudiants ont participé à l'atelier. Ils ont choisi des interventions structurelles et présenté des solutions potentielles aux obstacles structurels dans leurs épreuves écrites ou orales. Les étudiants ont indiqué que le manque de connaissances sur le système de santé et le système politique représente un obstacle potentiel au futur travail de défenseur. CONCLUSION: Les stagiaires en médecine ont besoin de formation spécifique sur les habiletés de communication orale et écrite pour se porter à la défense des patients; cependant, cette formation à elle seule peut s'avérer insuffisante. En tant que futurs promoteur de la santé, les stagiaires doivent également acquérir des habiletésspécifiques et des connaissances associées aux systèmes et aux politiques de santé pour naviguer à travers les systèmes dans lequel ils exerceront leur pratique.

Surgery for Conditions of Infectious Etiology in Resource-Limited Countries Affected by Crisis: The Médecins Sans Frontières Operations Centre Brussels Experience.

BACKGROUND: Surgery for infection represents a substantial, although undefined, disease burden in low- and middle-income countries (LMICs). Médecins Sans Frontières-Operations Centre Brussels (MSF-OCB) provides surgical care in LMICs and collects data useful for describing operative epidemiology of surgical need otherwise unmet by national health services. This study aimed to describe the experience of MSF-OCB operations for infections in LMICs. By doing so, the results might aid effective resource allocation and preparation of future humanitarian staff. METHODS: Procedures performed in operating rooms at facilities run by MSF-OCB from July 2008 through June 2014 were reviewed. Projects providing specialty care only were excluded. Procedures for infection were described and related to demographics and reason for humanitarian response. RESULTS: A total of 96,239 operations were performed at 27 MSF-OCB sites in 15 countries between 2008 and 2014. Of the 61,177 general operations, 7,762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions (p<0.001), intra-abdominal infections during hospital support missions (p<0.001) and orthopedic infections during conflict missions (p<0.001). CONCLUSION: Surgical infections are common causes for operation in LMICs, particularly during crisis. This study found that infections require greater than expected surgical input given frequent need for serial operations to overcome contextual challenges and those associated with limited resources in other areas (e.g., ward care). Furthermore, these results demonstrate that the pattern of operations for infections is related to nature of the crisis. Incorporating training into humanitarian preparation (e.g., surgical sepsis care, ultrasound-guided drainage procedures) and ensuring adequate resources for the care of surgical infections are necessary components for providing essential surgical care during crisis.

Care of surgical infections by Médecins Sans Frontières Operations Centre Brussels in 2008-14.

BACKGROUND: Surgical infections represent a substantial yet undefined burden of disease in low-income and middle-income countries (LMICs). Médecins Sans Frontières (MSF) provides surgical care in LMICs and collects data useful to describe the operative epidemiology of surgical need that would otherwise be unmet by national health services. We aimed to describe the experience of MSF Operations Centre Brussels surgery for infections during crisis; aid effective resource allocation; prepare humanitarian surgical staff; and further characterise unmet surgical needs in LMICs. METHODS: We reviewed all procedures undertaken in operating theatres at facilities run by the MSF Operations Centre Brussels between July, 2008, and June, 2014. Projects providing only specialty care were excluded. Procedures for infections were quantified, related to demographics and reason for humanitarian response was described. FINDINGS: 96 239 operations were undertaken at 27 MSF Operations Centre Brussels sites in 15 countries. Of 61 177 general operations, 7762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopaedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions, intra-abdominal infections during hospital support missions, and orthopaedic infections during conflict missions. Most procedures for skin and soft tissue infections were minor (76%), whereas most operations for intra-abdominal infections were major (98%). INTERPRETATION: Surgical infections are among the most common causes for operation in LMICs. Although many procedures were minor, they represent substantial use of perioperative resources. Growing evidence shows the need for improved perioperative capacity to aptly care for the volume and variety of conditions comprising the global burden of surgical disease. FUNDING: Médecins Sans Frontières.