Implementation of buprenorphine initiation and warm handoff protocols in emergency departments: A qualitative study of Pennsylvania hospitals

Background: Emergency departments (ED) are a critical touchpoint for patients with opioid use disorder (OUD). In 2019, Pennsylvania had the fifth highest drug overdose mortality rate in the United States. State efforts have focused on implementing evidence-based ED care protocols, including induction of buprenorphine and warm handoffs to community treatment.Objective: We examined hospital staff's perspectives on the processes, challenges, and facilitators to buprenorphine initiation and warm handoff protocols in the ED.Methods: We used a qualitative case study design to focus on six Pennsylvania hospitals. The study selected hospitals using purposive sampling to capture varying hospital size, rurality, teaching status, and phase of protocol implementation. The study staff interviewed hospital staff with key roles in OUD care delivery in the ED, which included administrators, physicians, nurses, recovery support professionals, care coordinators, a social worker, and a pharmacist. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured virtual interviews with 21 key informants from June to November 2020. Interviews were transcribed, deductively coded, and analyzed using CFIR domains and constructs to summarize factors influencing implementation of OUD ED care protocols and warm handoff to care protocols, as well as suggestions that emerged between and across cases.Results: Despite variation in the local context between hospitals, we identified common themes that influenced buprenorphine and warm handoffs across sites. Attention to hospital OUD care through state-level initiatives like the Hospital Quality Improvement Program generated hospital leadership buy-in toward implementing best OUD care practices. Factors at the hospital-level that influenced implementation success included supporting interdisciplinary OUD care champions, addressing knowledge gaps and biases around patients with OUD, having data systems that capture OUD care and integrate clinical protocols, incorporating patient comorbidities and nonmedical needs into care, and fostering community provider linkages and capacity for warm handoffs. Although themes were largely consistent among hospital and staff types, protocol implementation was tailored by each hospital's size, patient volume, and hospital and community resources.Conclusions: By understanding frontline staff's perspectives around factors that impact OUD care practices in the ED, stakeholders may better optimize implementation efforts.