Table 4 Implementation facilitation roles and activities

External facilitators (EF)

Study investigator content experts (McCormack, Hawk) facilitate activities (as described below) designed to promote implementation of the clinical protocol for OUD tailored to the clinic-specific needs

Local champions (LC)

LCs were ED clinical staff who help promote ED-initiated BUP with referral for treatment. LCs will serve the primary liaison between the ED and the EFs. LCs will lead implementation efforts on the ground, identify site-specific needs, and work with department and hospital leaderships to draft policies and secure approvals

ED staff and providers

All ED staff and providers were invited to participate in the Learning Collaborative, receive training/education, and provide feedback on the implementation of clinical protocol

Formative evaluation

Using mixed-methods, the research team identify evidence, context, and facilitation-related factors impacting the provision of ED-initiated BUP with referral for treatment in the community and use these data to refine and evaluate the effectiveness of the IF

Advising on ED-initiated BUP Clinical Protocol Development

Serving in an advisory and consultant capacity, EFs work with the clinical sites to develop a clinical protocol for nonmedical opioid use screening and ED-initiated BUP with facilitated referral tailored for their site. EFs will provide ongoing consultation to help monitor, support, and refine implementation

Assistance with facilitated referrals

EFs will work with LCs to identify community OUD treatment providers and create site-specific referral lists of medication treatment providers and other supportive resources for patients with OUD. EFs will also assist with identifying a practical approach to facilitating referrals

Stakeholder engagement

Stakeholder engagement took place in the form of in-person meetings at the administrative, provider, community and patient levels. Efforts at increasing engagement were informed by the focus groups and qualitative interviews and supported by the efforts of the LCs

Tailor program to site

The IF strategy were tailored to the local site as informed by the formative evaluation, involvement of the LCs, and with feedback from all ED staff and providers

Provider education and academic detailing

All ED providers were offered educational sessions on OUD and BUP training, specifically tailored to each provider’s tasks. We will address practical issues such as efficient use of the EMR for prompts, provide tools and web-based resources, and share patient monitoring strategies

Performance monitoring and feedback

We worked with ED leaders and other members of the ED staff to incorporate clinician performance related to BUP-initiation and facilitated referral into the department’s standard quality improvement and feedback practices. Sites were provided aggregate feedback on screening for nonmedical opioid use, adherence to clinical actions, eligible patients receiving BUP in the ED and referred patients’ enrollment in ongoing treatment

Learning collaborative

A Learning Collaborative was formed by inviting each of the site’s LCs and other ED stakeholders to participate in weekly conference calls to promote shared learning regarding issues promoting and hindering implementation of addiction treatment. Topics will include DATA 2000 “x-waiver” requirements, strategies for launching a new clinical initiative, existing models of ED-BUP, and BUP education, among others