title: Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment.
abstract: BACKGROUND
  The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation.
  
  
  METHODS
  After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework.
  
  
  RESULTS
  Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training.
  
  
  CONCLUSIONS
  The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.
authors.affiliation: Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA, 02118, USA. drainoni@bu.edu.|Boston University School of Medicine, Boston, MA, USA. drainoni@bu.edu.|Center for Healthcare Organization and Implementation Research, ENRM Veterans Administration Hospital, Bedford, MA, USA. drainoni@bu.edu.
authors.forename: Mari-Lynn
authors.initials: ML
authors.lastname: Drainoni
authors.affiliation: Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA, 02118, USA.|Center for Healthcare Organization and Implementation Research, ENRM Veterans Administration Hospital, Bedford, MA, USA.
authors.forename: Elisa A
authors.initials: EA
authors.lastname: Koppelman
authors.affiliation: Boston University School of Medicine, Boston, MA, USA.|Boston Medical Center, Boston, MA, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: Feldman
authors.affiliation: Boston University School of Medicine, Boston, MA, USA.|Boston Medical Center, Boston, MA, USA.
authors.forename: Alexander Y
authors.initials: AY
authors.lastname: Walley
authors.affiliation: Boston University School of Medicine, Boston, MA, USA.|Boston Medical Center, Boston, MA, USA.
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Mitchell
authors.affiliation: Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA, 02118, USA.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Ellison
authors.affiliation: Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA, 02118, USA.|Boston University School of Medicine, Boston, MA, USA.|Boston Medical Center, Boston, MA, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Bernstein
mesh_terms: D000281:Administration, Intranasal; D000328:Adult; D000368:Aged; D062787:Drug Overdose / Q000517:prevention & control*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009270:Naloxone / Q000008:administration & dosage / Q000600:supply & distribution / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000008:administration & dosage / Q000600:supply & distribution / Q000627:therapeutic use*; D010342:Patient Acceptance of Health Care; D010564:Personnel, Hospital / Q000523:psychology*
chemical_list: D009292:Narcotic Antagonists; D009270:Naloxone
keywords: Emergency department; Opioid overdose; Overdose prevention; Policy implementation