Substance Use Risk Assessment: Assessing the Risk of Vascular Access Device Tampering in Patients With a History of Drug Use
Abstract
Aim:
Intravenous (IV) drug use is an increasing public health concern impacting the care of hospitalized patients. Identifying patients at risk of nonprescribed use of their vascular access device (VAD) is the first step in providing safe, effective care to these patients. Currently, as indicated by literature review, hospitals do not have a process in place to screen patients for the likelihood of misuse of their VAD. In this article, we focus on developing an assessment and work toward validating the tool.
Methods:
A literature review was performed for screening tools that identify patients with history of IV drug use who may be at risk for misuse of their VAD. After identifying a gap in research, key stakeholders collaborated to identify which questions would be necessary to recognize this patient population and developed a Substance Use Risk Assessment (SURA) tool and a Substance Use Risk Reduction Program.
Results/Conclusions:
The pilot of the assessment and program found successful identification of patients at risk for VAD misuse, and interventions were put in place to decrease risk to the patient and hospital. The SURA tool has attained an acceptable level of content validity; however, reliability was not proven due to limited data availability.
Introduction
Intravenous (IV) drug use is an increasing public health concern. Globally, in 2021, an estimated 14.8 million people injected drugs.1,2 The current or recent use of IV drugs should not preclude the use of IV antibiotics in this patient population. In a hospital setting, the presence of a vascular access device (VAD) in a patient with current or recent history of IV drug use introduces the risk of the patient accessing the VAD for misuse. This poses an increased risk to the patient of obtaining a central line associated bloodstream infection (CLABSI), potential for unintentional overdose and death, and an altered clinical presentation, which may result in unnecessary testing and delay in appropriate treatment. Currently, as indicated by literature, hospitals do not have a process in place to screen patients for the likelihood of the patient to misuse their VAD.
IV drug use is an increasing public health concern, often leading to many medical conditions.3 Risk of overdose, CLABSI, and unwarranted testing due to altered clinical presentation are just some of the risks to the patient. CLABSIs are tied to several adverse outcomes, including increased morbidity and mortality, increased length of stay, and increased health care expenditures.4 Hospitals have shown IV drug use has only increased over the last decade, consistent with the opioid crisis. Bradley et al.5 revealed an estimated 3,694,500 people who injected drugs in the United States in 2018, representing 1.46% of the adult population. Hospitalized patients with a VAD in place are at risk for tampering with their VAD for recreational drug use. Currently, a tool is not in place for hospitals to screen patients for risk of misuse of their VAD.
A 128-bed hospital in a rural setting in southwestern Indiana developed a Substance Use Risk Assessment (SURA) using a multidisciplinary approach. Although not as prevalent as in the larger metropolitan areas, IV drug use is still a concern in the rural setting. This rural hospital identified a gap in care when a patient needed extended outpatient IV therapy, and discharge was pending over the weekend. The Vascular Access Specialist (VAS) discovered a history of IV drug use while reviewing the chart of a patient before placing a peripherally inserted central catheter for long-term IV access. This scenario was presented to a supportive administrative team, who allowed an empowered group of key stakeholders to address this issue. The group swiftly collaborated and strategized a plan for this patient for discharge over the weekend. The multidisciplinary team was comprised of the Patient Safety Officer (PSO), VAS, administrators, Director of Quality Services, Security, Social Work, and the attending Hospitalist. Within 24 hours, the team created a plan, and the patient was discharged for outpatient IV antibiotic treatment with long-term IV access and tamper-evident technology (TET) in place. A formal written contract was created between the patient and the care team. Education on the plan and precautions were provided to the patient care team involved in outpatient treatment. The patient received the ordered IV antibiotics successfully and without incident. This specific case identified the need for a formal process to screen all hospitalized patients for a history of IV drug use. Early identification of high-risk patients can decrease the risk to the hospital and allow for appropriate discharge planning.
Methods
Development of Tool
A literature review was performed for screening tools that identify patients with history of IV drug use who may be at risk for misuse of their VAD. A gap in research was identified for a tool that specifically looked at potential for VAD misuse. Ethical approval for the study was obtained from the institutional review board.
In 2017, a small group of key stakeholders began the process of SURA development. Initially, the group consisted of the VAS, PSO, and the Medical Unit nurse manager. Over several months, the small group created a rough draft of the tool. After exploring options, it was determined that the nursing staff would complete a concise assessment upon admission. A clinical nurse in the Medical Unit was added to provide real-time nursing feedback on the assessment. A Licensed Clinical Social Worker was later added to the group to provide behavioral health expertise and perspective.
The SURA tool is a series of questions that are completed on admission that assess the patient’s history of or current substance use within the last 2 years. The Diagnostic and Statistical Manual of Mental Disorders (DSM) was consulted to determine when a person is considered sober. The DSM stated that people who can abstain from substance use for 12 months would be considered in sustained remission.6 Using this information in designing the tool and risk levels, 2 years was the timeframe chosen to equal the lowest risk level. The tool assigns a tampering risk level score according to answer responses. A series of hypothetical patient scenarios with various drug use histories were reviewed. Analysis of the data ensured the assignment of low-, moderate-, or high-risk level scores aligned with the severity of the drug use history. Based on the tampering risk level score, a series of nursing interventions were created and implemented. Appropriate nursing interventions may include obtaining a urine drug screen, performing a high-risk search of the patient’s room and belongings, placement of TET, relocating the patient in closer proximity to the nurse’s station, or one-on-one patient care.
The SURA tool was completed and went live in the electronic health record in December of 2018. Prior to go-live, the team created a PowerPoint® presentation and education was disseminated through an online learning management system to the inpatient and outpatient areas where a patient may obtain IV access. In addition, flyers, handouts, and a TET guide were created for the specific types of TET available at that time. A 90-day pilot of SURA was completed in the inpatient and outpatient service areas with data collection. During the trial, real-time feedback from staff allowed for changes to SURA, and changes were made to the tool in February 2019. Following the trial, further modifications were made to SURA based on feedback from nursing staff. For example, a patient may be unable to answer the questions due to intubation or level of consciousness. A question, “Is the patient able to answer SURA questions?” was added, allowing the nurse to defer the question until the patient is extubated or alert. This also ensured that nursing staff consistently completed SURA and at-risk patients were not being overlooked. These modifications were completed in May of 2019. Beginning in late 2019 and early 2020, COVID-19 shifted the focus for this hospital from this patient population and SURA to the demands and stressors of the COVID-19 pandemic. The SURA team reconvened to work on validation of the tool in 2023. The tool remains in use at the present day (see the Figure).
Citation: Journal of the Association for Vascular Access 30, 1; 10.2309/JAVA-D-24-00008
Content Validity
The content validity of the SURA tool was established by using the content validity index (CVI) calculation.7 A panel of 6 experts with either a master’s degree or doctorate and expertise in medicine, nursing, psychology, and drug addiction was invited to independently evaluate the SURA tool using an electronic version of a 4-part Likert scale electronically through SurveyMonkey®. The panel independently examined each of the 9 SURA items for relevance and clarity. They also evaluated if the SURA tool items effectively measured the domain they were intended to assess. Acceptable CVI values with 6 content experts must be at least 0.83. The SURA tool attained an acceptable level of content validity with a CVI of 1.0, as explained below.7
Upon completing their review of the 9 items of SURA, the content experts provided a score on each of the items based on the degree of relevance scale as follows:
1 = The item is not relevant to the measured domain.
2 = The item is somewhat relevant to the measured domain.
3 = The item is quite relevant to the measure domain.
4 = The item is highly relevant to the measured domain.
Afterward, before calculating the CVI, the relevance rating was recoded as 1 for responses on the relevance scale with a rating of 3 or 4, or 0 for any responses on the relevance scale with a rating of 1 or 2, as shown in Table 1.
The universal agreement (UA) score of 1 was assigned to the item that attained 100% experts in agreement. The I-CVI score, the content experts in agreement divided by the number of experts, was then calculated. Based on the I-CVI scores, the S-CVI/Ave was calculated. The S-CVI/Ave is the average of I-CVI scores across all items. Finally, the S-CVI/UA, the average of all UA scores, was calculated as presented in Table 2.
Based on the calculations above, it can be concluded that the I-CVI, S-CVI/Ave, and S-CVI/UA meet the acceptable level. Therefore, the SURA tool has attained an acceptable level of content validity.7
Data Analysis
Cronbach’s α coefficient was the statistical procedure used to calculate the internal consistency of the SURA tool. This statistical procedure indicated the average correlation among all the items that make up the SURA tool. Cronbach’s α coefficients can range from 0.00 to 1.00, with higher values indicating greater reliability.8,9 Among 566 patient records, only 12 of them were used in finding Cronbach’s α, regarding 3 items Q2a, Q3, and Q3a. A Cronbach’s α of 0.569 was provided by SPSS.10 Furthermore, pairwise covariances were found to be very small. In summation, a small Cronbach’s α suggests the existence of weak internal consistency among these 3 items. The authors acknowledge the weak internal consistency of the SURA tool due to the small sample number, n = 12. It is anticipated that the SURA tool will be shared and used by other organizations, leading to larger sample sizes which will strengthen internal consistency.
Results
In October of 2021, 566 patients were screened using SURA, and these data were used in determination of Cronbach’s α. Implementation of SURA and the TET contract helped to identify a patient at risk who was receiving outpatient antibiotics. When the patient failed to present for IV therapy, staff attempted to contact the patient. When unable to reach the patient, local police were notified for a welfare check. The patient was brought back in to have the VAD removed. Education at the time of VAD placement for a patient deemed at risk included education that the VAD would be removed if patient failed to comply with the reasonable expectations established for the plan of care. The ordering provider was notified, and an alternative treatment was outlined for the patient. Another successful example is a patient deemed high risk, and TET was then applied. TET disruption was questioned but unable to be positively confirmed, and the patient denied having tampered with the device. TET was replaced, and the patient was moved closer to the nurse station, where he or she could be more closely monitored. Another success story of SURA came from a patient who was screened, and TET was applied. The patient later had signs of impairment, but TET remained intact. A urine drug screen identified the presence of a controlled substance when the initial drug screen had not. It was later determined that the patient’s visitors had presented the patient with the contraband. Policy was then changed to include screening of patient belongings, and visitor belongings remained locked outside of the room prior to entering the patient room. Increased awareness of staff of the potential risks of misuse is a success of SURA and the risk reduction program.
Discussion
Screening for a history of IV drug use of every patient upon admission to inpatient and outpatient departments allowed for early identification of at-risk patients. Open communication with the patients about their drug use helped in offering appropriate substance use treatment options, establishing clear expectations of the purpose and function of the VAD, and delineating consequences if the VAD has been tampered with by the patient. Intentional conversations by nurses and providers with the patients who inject drugs could have an impact on the number of patients who leave against medical advice (AMA) and establish an environment of trust where patients feel heard. This hospital found that open communication with this patient population has fostered relationships and initiated a dialog that may not have occurred otherwise. SURA offered nurses a formal way to initiate hard conversations. Staff were surprised to find that patients were candid about their drug histories when presented with the questions. Vallersnes et al.11 found that self-discharge was more frequent among patients using alcohol or illicit drugs, and patients who leave AMA have triple the risk of readmission within 30 days. Identifying and establishing formal processes assist in reducing risk to patients and health care facilities. Risk can include accidental or intentional overdose during hospitalization by patients who often go to great extents to procure illegal contraband inside the hospital through third-party visitors.3 Development of a CLABSI increases the risk of morbidity and mortality for the patient, increases length of stay and health care costs, and is reportable to the National Health and Safety Network.
Limitations
The SURA tool is limited by the willingness of the patient to answer the assessment openly and honestly. A lack of TET options is another weakness once a patient is identified as at risk of tampering with their VAD. While the focus of this article is on the development of the assessment tool, it is important to note that TET options and availability have changed since SURA was developed. Cost of manufactured TET products may limit their use; however, a TET sticker covering all access ports of the IV line is a cost-effective method that is an improvement over no intervention at all. Other limitations in the study include a lack of generalizability to nonrural patient populations. Challenges from the addition of SURA involved individualizing the nursing interventions to the risk assessment score. Patients are unique, and each patient scenario varies. Staff education using patient examples helped to overcome this challenge as staff became more comfortable with the tool and the nursing interventions that comprised each level. The authors acknowledge the weak internal consistency of the SURA tool due to the small sample number. The group desires to disseminate SURA to be used by other organizations that are willing to share data and assist in strengthening internal consistency and SURA tool validation.
Conclusion
Development of SURA has allowed for early identification, communication, and collaboration between all patient care team members. Patient safety is the highest priority, and using SURA has enhanced patient and hospital safety in this high-risk patient population. SURA has helped strengthen the patient and care team relationship by providing a validated tool for initiating the conversation about drug use. The patient is included in the plan of care during the completion of SURA on admission, education of expectations and consequences of VAD misuse, and development of a discharge plan.
If your organization would like to use SURA and help establish reliability, please contact MHSURRP@mhhcc.org.
Disclosure
The authors have no conflict of interest to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Memorial Hospital Substance Use Risk Assessment.
Contributor Notes