Opportunities to improve inpatient services and reduce rates of patient-direct discharge among people who use substances

ABSTRACT

Purpose

Patients who use substances (PWUS) report experiencing stigmatizing encounters and undertreatment of pain and withdrawal symptoms that increase the likelihood of patient-direct discharge (PDD). This scoping review examines North American literature to gain insights about how institutional factors intersect with patient experiences and contribute to PDD.

Methods

A scoping review was conducted using MEDLINE, CINAHL, Scopus and EMBASE databases. Screening was completed by two reviewers. A data extraction tool developed by the research team was used to collect demographic information and explore patients’ experiences and reasons for PDD.

Results

We present four themes related to PDD: i) effective management of pain and withdrawal symptoms, ii) therapeutic alliance with healthcare providers, iii) hospital policies, protocols, and procedures, iv) recommendations. Notably, all patients in all qualitative studies reported predominant experiences of uncaring, stigmatizing interactions with healthcare providers.

Discussion

Findings suggest that transformations are required at individual and institutional levels. At an individual level, to provide equitable care to all patients, healthcare providers in all practice settings should be competent to effectively and compassionately care for PWUS. At an institutional level, policies need to be re-envisioned to support the implementation of effective practices.

Conclusion

Hospitals are faced with the challenges to ensure respectful care environments guided by harm reduction policies that will improve engagement of PWUS in services.

KEYWORDS:

• Substance use
• discharge against medical advice
• therapeutic alliance
• injection drug use
• infection
• harm reduction

Disclaimer

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Declaration of financial/other relationships

NG: Funding from the Faculty of Medicine Marvin Burke Studentship

NK Funding from the Dalhousie University Faculty of Health Research Development grant.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

HP: contributed to analysis and writing of the manuscript.

AL: contributed to the updated data collection and extraction, analysis, and writing.

NG: led initial data collection and extraction, conducted the preliminary analysis, and develop the first draft of the manuscript.

CA: supported the management of data integrity and writing.

NK: conceptualized and supervised this project. She contributed to data extraction, analysis, and writing.

Ethics statement

Ethics approval was not required for this review.

Additional information

Funding

This project is funded in part by the Dalhousie University Faculty of Health Research Development Grant and supported by a Faculty of Medicine Marvin Burke Studentship.