Q Exchange
Reducing Remote Drug-Related Harm to Outreach Proactively from Emergency Care
- Winning idea
- 2024
Meet the team
What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?
Despite incremental improvements across Scotland the number of Drug-Related Deaths in the Highlands continues to rise. Medication Assisted Treatment (MAT) Standards state that “all people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT.” Current processes and systems were not timely enough to identify and outreach those at risk.
The Caithness Drug and Alcohol Recovery Service undertook some improvement work to create, test and implement a Trigger Tool and associated outreach with police and social work, with promising results. However, there remains a need to test and implement the tool within the Emergency Department (ED) and share learning.
Reducing waits and equitability – those at risk are hard to reach and do not attend appointments nor receive equitable access to services. The project will measure engagement with the outreach service. Reducing non-fatal overdoses will also potentially reduce waits within the ED.
What does your project aim to achieve?
This project aims to do two things;
1. To test and implement the use of the Trigger Tool and assertive outreach for those at high risk of drug-related harm within the local rural ED (local improvement)
2. To understand how best to implement Trigger Tools with staff in ED to build theory around what works, for whom, why, and in what circumstances (transferable learning)
The aim is to achieve a reduction in non-fatal overdoses and drug- related death as evidence suggests engagement with services has a protective effect for this vulnerable group. Those at risk of drug-related harm are concentrated in areas of social deprivation and this area has one of the highest rates of harm in the UK.
How will the project be delivered?
This work will build on existing relationships between the Caithness Drug and Alcohol Recovery Service, ED staff and academics from UHI. The first aim will use the Model for Improvement and the second aim will take a realist evaluation approach to interview key stakeholders to test and refine the theory of implementing the Trigger Tool and Assertive outreach within the ED. The outreach workers are established posts within the Caithness Drug and Alcohol Recovery Service. This approach will offer value for money and potential impact as it aims to
· reduce the number of non-fatal overdoses
· reduce the number of drug related deaths
· create generalisable middle range theories to inform similar projects
The realist findings will provide foundational work for further large-scale funding. The risk of person dependency will be mitigated by integrating the work with the recovery service.
How is your project going to share learning?
Drug-related harm is a problem across the UK and Ireland. This work will create valuable outputs that can be shared across the wider healthcare system i.e. the Trigger Checklist as well as learning from implementation. Importantly, middle range theories developed from this project could help inform the implementation of other trigger tools in emergency settings across the UK, Ireland and beyond. The project findings will be shared at the Community Hospitals, Evaluation and or the Improvement Research Network Specialist Interest Groups.
Learning will be shared by:
· Creating flyers for key stakeholders
· Presenting to the Highland Alcohol and Drug Partnership
· Sharing progress and outcomes with the Q community via Specialist Interest Groups.
· Publishing an academic paper
. Sharing a summary report to Q Exchange
· Presenting the work at the International Forum on Quality and Safety in 2025.
How you can contribute
- - Any feedback would be welcomed
- - Any expertise of integrating both QI and research methods simultaneously
- - Any experiential feedback in integrating any type of trigger tool within an emergency service that could help us build our initial theories for testing
- - Creative ways of stretching a budget
Plan timeline
| 31 Jul 2024 | Pre Start -contracts & ethics |
|---|---|
| 31 Aug 2024 | Initial Programme Theories |
| 31 Aug 2024 | Ongoing Team Liason |
| 1 Sep 2024 | Test & Implement Trigger Checklist |
| 30 Sep 2024 | Measure process and outcome ongoing |
| 1 Nov 2024 | Recruit Stakeholders |
| 1 Dec 2024 | Realist Interviews |
| 31 Jan 2025 | Realist Interviews |
| 31 Mar 2025 | Transcribing |
| 31 May 2025 | Draft Analysis |
| 1 Jun 2025 | Finalise analysis |
| 1 Jul 2025 | Dissemination of Findings |
Comments
Tracy Sutherland 6 Jun 2024
This sounds like a well needed project/tool. A widely available tool for use not just in A&E but throughout community . I know from experience just how much this is required to be able to highlight to the relevant services about a vulnerable patient. My team of generalist community nurses have felt alone when it comes to supporting people at potential harm who don't necessarily engage with the appropriate services potentially because we aren't saying the right things that trigger to appropriate services the right level of need
Michelle Beattie 6 Jun 2024
Thank you Tracy. You are right we definitely need this or something like it to identify our most vulnerable right across the system. I'm hopeful that the learning and middle range theories we get from this project will aid implementation in other contexts as well.
Michelle
Anthony Fryer 29 May 2024
Liking the look of this a lot. Not sure if I'm missing this, but how are you involving those who have lived experience of this area in the development of your service? In my experience of working with a lived experience group who support those with multiple social disadvantage (https://expertcitizens.org.uk/), they would offer invaluable insights into how such a system would work in practice.
One other thing. About the realist evaluation, I like the approach (we are doing something similar in the patient involvement space), but you might consider generating a logic model too (more people will understand it), and perhaps consider a systems thinking perspective to get a wider view on the knock on effects (or at least think about balancing measures).
Michelle Beattie 29 May 2024
Thank you Anthony - some very useful suggestions. The team have worked with service users to create the tool and service. However, due to the amount of funding here and the fact that there remains a need to implement within the local Emergency Dept we are focusing on that for this particular project. We are hopeful that this may lead to further funding to carry out a realist evaluation with service users.
The initial project had balancing measures and these were the number of service users opting out after being outreached and staff and user experience. I like your idea of using the logic model and this is something we will look to integrate into the project.
Thank you
Michelle
Dr Rebecca Hunter 23 May 2024
This is a really important piece of work, and I think your decision to use a realist approach is well considered. When it comes to the complexities of drug and alcohol recovery, realist evaluation is a powerful tool to understand not just if a trigger checklist works but also how and why it makes a difference. I am confident that the learnings from this project have the potential to be highly transferable to other recovery services, making the impact even broader. Please let me know if there is anything I can do to help from a realist methods perspective.
Michelle Beattie 23 May 2024
Hell Becky
Many thanks for your comment - its great to hear you think the methodology will be useful here. I will definitely be in touch to sound you out with my initial rough programme theories!
Michelle
Mariyana 4 Mar 2024
Great to see a realist methods being used with QI and with this project Michelle. You might want to speak to Nicola Clibbens at Northumbria University to exchange ideas.
Michelle Beattie 4 Mar 2024
Thank you. I'll drop Nicola an email. Thanks for the connection
Sarah Yardley 1 Mar 2024
Hi Michelle, just catching up on emails and saw your request re realist methods. You might find this of interest: https://bmjopen.bmj.com/content/12/1/e048045
I've done quite a bit with (adapted) realist methods... feel free to get in touch if interested. https://profiles.ucl.ac.uk/52841-sarah-yardley
All the best, Sarah
Michelle Beattie 1 Mar 2024
That's very helpful Sarah. Thank you. I'll read the paper and be in touch.
Michelle
Clare Carolan 28 Feb 2024
Hi Michelle,
Much needed project. Given geographical context of Caithness (i.e. serves rural population) will you solely focus on ED in Rural DGH or widen out to Scottish Ambulance Service. Just thinking about roll out of initiatives of 'Call before Convey' and perhaps use of trigger tool by SAS team for those not conveyed to the physical ED? Wonder if including SAS as key stakeholders might be an important part of understanding system boundaries? Think it's interesting to consider whether you are conceptualising 'ED care' as a place or a system - significant relevance in terms of remote and rural populations and hence why learning from Alaska/Norway etc as mentioned above might have relevance for your population in Caithness.
Clare
Michelle Beattie 29 Feb 2024
Thanks Clare. That's very helpful. The trigger tool is already being used with other emergency services i.e. police custody etc and yes, there are plans to implement with the ambulance service. However, we know there are particular challenges getting the tool to work in ED and I was hoping , from this project, that any transferable learning from middle range theories would help us to implement in other areas as well as in the ED. I am keen that this work would be a springboard to do a larger scale study which would include the other emergency services. Definitely useful to hear from other remote and rural areas with these challenges.
David Elder 28 Feb 2024
This looks like a great project. It would be particularly interesting if there is scope to share any learning about how this trigger tool sits alongside others in the ED like the frailty one mentioned. It would be useful to demonstrate how multiple tools are implemented and received by staff within the same department.
Michelle Beattie 29 Feb 2024
Thanks David. Another useful reminder for us to think about the other trigger tools. There is some thinking that the use of multiple trigger tools reduces their potential impact. A bit like multiple bundles being reduced by too many checklists etc. We will definitely explore this.
Esther Dickinson 28 Feb 2024
Great project with so much potential . If you need any NHSH QI support let us know
Michelle Beattie 28 Feb 2024
Thanks Esther. Will give you a shout as needed.
Elaine Mead 27 Feb 2024
This looks like a great idea to attempt to address the wicked and tragic problem of drug-related deaths in the Highlands. I wonder if there might be something to learn in the adoption of the trigger tool from other populations, like the Sami in Northern Norway and Finland or the Nuka team in Alaska, where this has also been a significant cause for concern particularly amongst the young male population. Good luck with your proposal.
Michelle Beattie 28 Feb 2024
Thank you Elaine. Oh would definitely be useful to learn any lessons. I'll look them up but if you have any contacts please email me.
Nicola Gray 27 Feb 2024
Great project idea! There is a real need to have evidence informed health service approaches to reduce the harms associated with substance use, particularly for marginalised groups. It aligns well with the work of our substance use research group @School of Health Sciences, University of Dundee. We would be happy to share learning.
Michelle Beattie 27 Feb 2024
Oh that would be brilliant Nicola. I'll drop you an email to connect to the substance use research group
Margot Cohen 26 Feb 2024
Great project for both those needing the right support at the right time and reducing the burden on less appropriate services.
Michelle Beattie 26 Feb 2024
Thanks Margot- they are a 'hard to reach' or 'easy to ignore' group. Yet, the high drug related death rate is hard to contemplate. I am hopeful this project will reach out and 'pull' them into services as opposed to them having to reach out.
Michelle Beattie 22 Feb 2024
Thanks Laura. I would definitely be interested in the experiences of those trying to implement a trigger tool in the ED. I'll drop you an email as this feedback will inform my development of initial theories, which would then be tested and adapted by the participants in this project.
Laura Keel 22 Feb 2024
This is an incredibly worthwhile project and an increasingly wicked problem which requires this kind of proactive engagement and testing. Although not the same - there is currently a working group at Raigmore looking at the creation & implementation of a frailty trigger tool in ED. Perhaps some shared learning could be gleaned.
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