Structural stigma within inpatient care for people who inject drugs: implications for harm reduction.

BACKGROUND:  Individuals suffering with addiction have historically experienced disproportionally high levels of stigma. The process of inpatient care for those with substance abuse disorder (SUD) is multifaceted, shaped by the interplay of human interactions within the healthcare team and overarching structural factors like policy. While existing literature predominantly addresses personal and interpersonal stigma, the influence of structural stigma on care delivery practices remains understudied. Our research aims to investigate the impact of structural stigma on care processes for individuals with SUD admitted to acute medicine units. METHODS:  We conducted a secondary analysis of observation notes and interview transcripts utilizing an analytic framework related to structural stigma adapted from previous research. Data was collected from June 2019 to January 2020 in 2 hospitals. 81 participants consented to observation and 25 to interviews. Interviews were conducted with patients (n = 8), healthcare staff (n = 16), and caregivers (n = 1). RESULTS:  Each aspect of care for people with SUD is adversely influenced by structural forms of stigma. There was evidence of a gap in accessing care and time pressures which deteriorated care processes. Structural stigma also manifested in the physical spaces designed for care and the lack of adequate resources available for mental health and addictions care. We found that structural stigma perpetuated other forms of implicit and explicit stigma. CONCLUSIONS:  Structural stigma and other forms of stigma are interconnected. Improving care for people with SUD in hospital settings may require addressing structural forms of stigma such as how physical spaces are designed and how mental healthcare is integrated with physical healthcare within inpatient settings.

Chlorhexidine Gluconate Bathing Program to Reduce Health Care-Associated Infections in Both Critically Ill and Non-Critically Ill Patients.

BACKGROUND: Critical care nurses take care of patients with complicated, comorbid, and compromised conditions. These patients are at risk for health care-associated infections, which affect patients' lives and health care systems in various ways. OBJECTIVE: To gauge the impact of routinely bathing patients with 4% chlorhexidine gluconate solution on the incidence of health care-associated infections in a medical-surgical intensive care unit and a postoperative telemetry unit; to outline the framework for a hospital-wide presurgical chlorhexidine gluconate bathing program and share the results. METHODS: A standard bathing protocol using a 4% chlorhexidine gluconate solution was developed. The protocol included time studies, training, monitoring, and surveillance of health care-associated infections. RESULTS: Consistent patient bathing with 4% chlorhexidine gluconate was associated with a 52% reduction in health care-associated infections in a medical-surgical intensive care unit. The same program in a postoperative telemetry unit yielded a 45% reduction in health care-associated infections. CONCLUSION: A comprehensive daily 4% chlorhexidine gluconate bathing program can be implemented with standardized protocols and detailed instructions and can significantly reduce the incidence of health care-associated infections in intensive care unit and non-intensive care unit hospital settings.

Corrigendum to "Mixed methods feasibility study for the surviving opioid overdose with naloxone education and resuscitation (SOONER) trial" [Resuscitation Plus 6 (2021) 100131].

[This corrects the article DOI: 10.1016/j.resplu.2021.100131.].

Mixed methods feasibility study for the surviving opioid overdose with naloxone education and resuscitation (SOONER) trial.

AIM: We plan to conduct a randomised clinical trial among people likely to witness opioid overdose to compare the educational effectiveness of point-of-care naloxone distribution with best-available care, by observing participants' resuscitation skills in a simulated overdose. This mixed methods feasibility study aims to assess the effectiveness of recruitment and retention strategies and acceptability of study procedures. METHODS: We implemented candidate-driven recruitment strategies with verbal consent and destigmatizing study materials in a family practice, emergency department, and addictions service. People ≥16 years of age who are likely to witness overdose were randomized to point-of-care naloxone distribution or referral to an existing program. We evaluated participant skills as a responder to a simulated overdose 3-14 days post-recruitment. Retention strategies included flexible scheduling, reminders, cash compensation and refreshments. The primary outcome was recruitment and retention feasibility, defined as the ability to recruit 28 eligible participants in 28 days, with <50% attrition at the outcome simulation. Acceptability of study procedures and motivations for participation were assessed in a semi-structured interview. RESULTS: We enrolled 30 participants over 24 days, and retained 21 participants (70%, 95%CI 56.7-100). The most common motivation for participation was a desire to serve the community or loved ones in distress. Participants reported that study procedures were acceptable and that the outcome simulation provided a supportive and affirming environment. CONCLUSION: The planned trial is ready for implementation. Recruitment and retention is feasible and study processes are acceptable for people who are likely to witness overdose. (Registration: NCT03821649).

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada.

BACKGROUND: There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender. METHODS: Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender. RESULTS: Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men. CONCLUSION: Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

Lessons Learned After Losing my Brother to an Overdose: A Call to Action for Nurse Leaders.

The current overdose epidemic we are facing in Canada and internationally calls on nursing leaders to prioritize holistic and compassionate care for people who use drugs (PWUD) and their families. Nurses are well positioned to provide person-centred care and advocate with and for this population. To do so requires an examination of one's personal values and beliefs surrounding drugs and the people who use them. As a nurse leader, I was forced to confront my views about illicit drug use following the untimely death of my brother Brad from overdose. This paper chronicles my personal experience with his death and subsequent journey into advocacy for drug policy reform amidst an emerging overdose crisis. This short paper is written from my personal perspective, and informed by both personal and professional experiences in drug policy reform. It addresses strategies for challenging stigma and opportunities for partnering with PWUD through engagement in harm reduction.

Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital.

OBJECTIVE: To review the effect of interventions, including a complete restriction in the use of fluoroquinolones (FQs), used to control an outbreak of hospital-onset Clostridium difficile infection (HO-CDI) caused primarily by the epidemic North American pulsed-field gel electrophoresis type 1 strain. DESIGN: Retrospective cohort and case-control study of all episodes of HO-CDI both before and after 2 interventions. SETTING: Community hospital; January 1, 2005, through March 31, 2007. Interventions. Complete, 5-month, facility-wide restriction of fluoroquinolone use, during which a change in the environmental-services contractor occurred. RESULTS: During a 27-month period, 319 episodes of HO-CDI occurred. The hospital-wide mean defined daily doses of antimicrobials decreased 22% after restricting FQ use, primarily because of a 66% decrease in the use of FQs. The interventions were also associated with a significant change in the HO-CDI incidence trends and with an absolute decrease of 22% in HO-CDI cases caused by the epidemic strain (from 66% before the intervention period to 44% during and after the intervention period; P=.02). Univariate analysis revealed that case patients with HO-CDI due to the epidemic strain were more likely than control patients, who did not have diarrhea, to receive a FQ, whereas case patients with HO-CDI due to a nonepidemic strain were not. However, FQ use was not significantly associated with HO-CDI in multivariable analysis. CONCLUSIONS: An outbreak of epidemic-strain HO-CDI was controlled at a community hospital after an overall decrease in antimicrobial use, primarily because of a restriction of FQ use and a change in environmental-services contractors. The restriction of FQ use may be useful as an adjunct control measure in a healthcare facilities during outbreaks of epidemic-strain HO-CDI.

A critical analysis of the benefits and limitations of an applied degree in undergraduate nursing education.

The purpose of this paper is to present a critical analysis of the applied degree in nursing as an alternative to collaborative models of undergraduate education delivery by different post-secondary institutions. The notion of having multiple levels of entry into nursing (Northrup et al. 2004) and the authority of colleges to award degrees in nursing (Skolnik 1994) have important practical implications for the profession. Since there is a paucity of Canadian literature about applied degrees in nursing, this paper will make an important contribution to the field of nursing education. Due to the collaborative partnerships that have emerged in many jurisdictions in order to meet the baccalaureate degree as the entry-to-practice requirement, an analysis of the Applied Degree in Nursing is relevant and timely. The paper provides a brief history of the baccalaureate degree as the entry-to-practice requirement for nursing, along with an overview of the rationale for the baccalaureate degree from regulatory, research, academic and practice perspectives. Through an analysis of the benefits, limitations and implications of the applied degree, we conclude that this new applied baccalaureate challenges nursing's status as an academic discipline.

Sexual health education group for adolescents with mental problems.

1. Providing sexual health education for adolescents with mental health problems presents a difficult but important clinical task. 2. Using a group format for this task is an effective way to provide information about sexual health and promote positive coping strategies related to relationships and sexual issues. 3. Group leaders need to be aware of their own values related to sexual issues and have the ability to be frank and nonjudgmental.