Epps said he first learned last year about the severe problems UTMC staffers were having with patients being treated for infections associated with drug use when he was developing a new clinical protocol for standardizing pain treatment.
He found out about the large amount of drugs and paraphernalia being confiscated by security, the verbal abuse staff endured, the drug deals taking place, and the lack of consistency in the plan of care for these patients. Some nurses were making moral judgments about those patients that were affecting their care. He feared nurses were feeling overwhelmed and would start leaving.
After multiple meetings with physicians, nurses, other clinical staff, security and administrators, Epps crafted a plan of care for patients to sign, modeled on a patient contract used by Providence Regional. The goal was to have everyone present a united front, so patients couldn't play individual doctors and nurses against each other.
That care plan has been modified over time, for instance allowing patients to earn back certain privileges—such as being allowed to have a cellphone and leaving the hospital floor for an outdoor break—based on good behavior. The policy has been extended to drug-addicted patients who are admitted for reasons other than infections.
“It's one of the best things we've done for our team members to help them become more empathetic,” said Janell Cecil, UTMC's chief nursing officer. “They aren't being berated and abused, and that has changed the attitude of everyone involved.”
“Nurses were ready to quit over this,” said Laura Harper, a UTMC nurse manager. “This plan of care has rejuvenated them. Now they don't mind taking care of these patients.”
But Epps acknowledges that major challenges remain, particularly getting patients into addiction treatment after discharge. That's a big problem in Tennessee, which hasn't expanded Medicaid to low-income adults, making it harder to find a payment source for an extended course of residential medication-assisted treatment.
That contributed to UTMC's 18% readmission rate for patients with drug-use associated infections since the new rules were implemented. One patient returned nine times. “The lack of addiction treatment resources is the most disheartening thing for our team members,” Epps said. “Only 10% of our patients are getting addiction treatment. That's appalling.”
Some patients respond angrily when asked to sign the written plan of care, he said. They often leave as soon as they find out they can't have visitors. Or they may stay only two or three days until their abscess is drained and they feel better, even though most patients need three to six weeks of IV antibiotic treatment to cure their infections.
“After the way I was treated tonight at UT, I will be contacting a medical malpractice attorney,” one patient wrote in an online review of her experience. “I am sick of being judged because of my history & will not stand for it any longer! … I will speak out for myself & all recovering addicts.”
Epps said he understands that people feel it's harsh. “But we don't force patients to participate in this plan of care,” he said. “They are fully involved, they have autonomy, and they can refuse it.”
Arthur Caplan, director of medical ethics at the NYU School of Medicine, said he could accept short-term restrictions on the autonomy of addicted patients if that increases success in treating this difficult population. Yet he doesn't see it as an ethical way to treat patients outside of mental health settings.
Still, he views such a restrictive policy, which he hasn't seen at any other acute-care institution, as a research program that should be evaluated based on treatment effectiveness. UTMC's 42% rate of patients leaving against medical advice seems high to him. “If you come up with a very tough treatment policy, and only about half the people sign it or complete it, my hunch is it won't take us to where we need to go with that population,” he said.
Martin Green, immediate past president of the International Association for Healthcare Security and Safety, said he's seen similar approaches in mental health facilities but never in an acute-care hospital.
“I'm not saying it's the wrong thing to do, but it's a new one on me,” he said. “The patient is in a hospital, not a jail. It may be a violation of that person's human rights.”
But success with these patients is iffy no matter what approach providers take.
UTMC's Cecil cited as a success story a patient who received antibiotic treatment for a drug-use associated infection under the new conduct rules, got clean after leaving the hospital, and returned several times to visit and thank the nurses. “That makes it all worthwhile,” she said.
Asked whether this patient would agree to an interview, a hospital spokeswoman checked. “I have sad news to report,” she replied the next day. “We learned that he overdosed and passed away this spring.”
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