Table 3.
Barriers to implementation of PRCs in emergency departments
| Barriers | Description | Quote |
|---|---|---|
| ED setting | The intense and often busy hospital ED setting with limited space | “We've got 22,000 visits a year and we've only got [a] 12-bed [ED]. So it's a mad house there at all times. It’s not a great location to have conversation.” Hospital Supervisor, February 14, 2019 |
| Limited access | Limited PRC access to ED patients | “I had an issue where one doctor…didn't think it was appropriate because the grandmother was in the room with the patient, and did not know of his drug use.” PRC, September 27, 2018 |
| Staff cooperation | Lack of cooperation from some hospital ED staff | “I think the challenges at [the ED] is just basically getting the doctors to see that there’s a possibility that we can make a difference [for patients] meeting with the peer.” PRC, October 11, 2018 |
| Staff attitude | Poor attitude of some hospital staff toward OUD patients and MOUD as clinical practice | “[T]he attitude of some of the [ED] staff… it's a little bit of stigma with the addiction population.” Hospital Supervisor, October 25, 2018 |
| Limited MOUD availability | The three forms of MOUD were not available in all service areas for various reasons, including lack of physicians waivered to prescribe buprenorphine, and vendor preference for naltrexone. | “[A barrier is] trying to get [MOUD] prescribers that are like really wanting to dedicate themselves. So, there are two prescribers that we have, [who] also juggle primary care and infectious disease, so sometimes their availability is very limited.” CMH Administrator, January 16, 2020 |
| External communication | Inability of PRCs to communicate with departments outside ED regarding patients | “And we have been told that we need to stay behind what we call ‘the glass,’ and that [Peer Recovery Coaches] will have to break the glass to get in, and that – in theory – they shouldn't be breaking the glass” Hospital Administrator, September 27, 2018 |
| Geographic distance | Long geographical distances to EDs for PRCs and to treatment locations for patients | “[The patient] was from [another] county [from the treatment]. We don't have any drivers from that area. Some of the rural counties are still struggling with that.” CMH Supervisor, March 28, 2019 |
| Patient finances | Lack of financial resources of OUD patients to pay for treatment and transportation costs | “[Our physician’s] concern is – of course, in a medical office setting, you’re asking for copays prior to seeing – his thing is he doesn’t want that deterring patients from not coming in if they do not have funds.” Hospital Administrator, December 20, 2018 |
| COVID-19 | Multiple barriers to the implementation of PRC work in EDs due to the pandemic, including overwhelmed EDs and no PRC in-person contacts with patients | “All of our team was sent home at the end of March. So we all work remotely... And since the hospital in the emergency rooms have kind of shut down to most people except if you’re showing COVID-19 symptoms, we haven’t had a lot [of OUD patients] this month come into our ED.” Hospital Supervisor, April 9, 2020 |
ED emergency department; MOUD medication for opioid use disorder; PRC peer recovery coach; RCPSI Recovery Coach and Peer Support Initiative; OUD opioid use disorder.