UT Medical institutes new protocols for patients with IV drug use-associated infections

Patients who come to the University of Tennessee Medical Center with infections associated with IV drug use will now be asked to agree to a comprehensive plan of care that includes addiction treatment after their infection is treated. 

UT Medical Center today announced new protocols for those patients - "clear rules," said senior vice president and chief medical officer Dr. Jerry Epps. Unless they're critically ill, before being admitted, patients must sign a form agreeing to all components of the medical center’s newly developed IV Drug Use Associated Infection Plan of Care, which it's piloting.  

Epps said that plan establishes a framework that initially focuses on treating the infection - and preventing patients from accessing illicit drugs from family and friends while hospitalized - but later provides access to treating the addiction.

Dr. Jerry Epps

UT Medical Center officials are working with other agencies in the region to identify, whenever possible, specialized inpatient addiction treatment facilities where patients can transfer when they're discharged from the hospital, he said.

“While we may have a very small number of patients who fall into this category at any given time, we recognize we have the opportunity to help one individual at a time impacted by the opioid epidemic plaguing our state and our country,” Epps said. “To provide that assistance, we’re implementing measures to put opioid dependent individuals on the path to recovery, while also providing the optimal care environment for our physicians and team members to begin that treatment. We anticipate that some will question the measures, but must emphasize that their purpose is, first and foremost, for the benefit of the patients.”

The University of Tennessee Medical Center is pictured  Aug. 5, 2016.  (PAUL EFIRD/NEWS SENTINEL)

The plan also includes "other aspects related to their disease management," Epps said. "Like any plan of care for any disease or medical condition, patients who do not want to comply with the plan of care can leave against medical advice and seek their healthcare at another facility if they choose to do so." 

UT Medical Center, along with other area hospitals, has seen a number of patients coming in with endocarditis,  in which a bacterial infection introduced through the bloodstream attaches to heart tissue and destroys it. Left untreated, it's fatal. Treatment includes replacing the heart valve -- a complicated and expensive surgery.

As drug-related heart infections climb, doctors weigh ethics of operating — or not

UT Medical Center and other hospitals were seeing a growing number of young, otherwise healthy patients get heart valve replacements - and then return with the new valve infected. 

Doctors, including Epps, on a task force with the Knoxville Academy of Medicine have been debating the ethics of refusing to do the surgery unless the patient agrees to rehab, since the chance for reinfection - and death - are so high among those who misuse the drugs. 

Last year, America produced 14 billion opioid pills (40 for every U.S. citizen), mostly paid for by the American public in the form of tax dollars or increasing health insurance premiums.

The task force even looked at partnering with a local addiction treatment facility to create a medical unit where patients could recover from surgery and get addiction treatment at the same time, but that hasn't yet occurred, though it would be ideal, Epps said. As it is, "the problem that we really have is the lack of addiction treatment resources in the nation, but particularly in East Tennessee," he said. "We can do everything to treat their medical condition, but then we're limited on the number of addiction resources treatments" locally -- particularly long-term and/or residential treatment.

A more widespread problem than endocarditis is the rising number of patients coming in with soft tissue or bone infections resulting from injecting IV drugs. Left untreated, these infections can spread, causing more serious, even fatal, problems.

Under normal circumstances, patients with those types of infections are hospitalized for a week to 10 days, getting a course of IV antibiotics, and then discharged with a port in place so that they can return daily for the next five or six weeks to a hospital or infusion center for a 30-minute outpatient antibiotic infusion.

But doctors are hesitant to discharge patients known to misuse IV drugs with a "ready-made path to inject illicit drugs," Epps said. Even though Tennessee now has a law to prevent doctors from being sued if those patients overdose and die, he said, doctors recognize that patients aren't likely to be compliant returning for outpatient treatment.

So those patients are kept as inpatients through their whole course of antibiotics -- six weeks or longer, vastly increasing the cost of their care. Epps said a little less than 40 percent of that patient population is uninsured, though some may eventually quality for TennCare; another 30 percent to 39 percent are TennCare or Medicaid, and the remainder have Medicare, commercial insurance or some combination.

The task force estimates drug-related infections cost Knoxville-area hospitals around $750,000 annually in uncompensated care -- and some doctors say that number might be conservative.

Epps said as the region's trauma center and teaching hospital, "we felt like we had to step forward and take a lead in that area. ... We're really hoping our pilot will lead to a community standard."

Though neither is yet requiring patients to sign a care plan, both Tennova Healthcare and Covenant Health hospital systems are represented on the task force and are part of the conversation on developing standard protocols in the Knoxville area, their representatives said.

If all hospitals begin to require addiction treatment as a condition of surgery, patients who opt not to get the surgery, the task force said, could get palliative care - treatment that would make them comfortable but not prevent the heart valve infection from eventually killing them.

"We don’t know exactly what will happen with this patient population," Epps said. "We certainly hope they’ll agree to the plan of care."