Dr. Silverman is the Chief of Infectious Diseases at London Health Sciences Centre (LHSC) and St. Joseph’s Health Care in London, Ontario. He is concerned about the increasing prevalence of people who inject drugs (PWID) in London, and the risk to PWID of bacterial infections due to contamination (e.g., improperly or unsterilized injection equipment, skin not being sterilized before injection). Of primary concern is the risk of infective endocarditis (IE), an infection in a patient’s heart. Treatment for IE entails antibiotics administered through the intravenous (IV) route. IE is generally treated through home care; in London, the South West Community Care Access Centre (CCAC) is responsible for delivering home care. To treat IE at home, a patient would need a peripherally inserted central catheter (a PICC-line) and assistance from a CCAC nurse to administer the antibiotics. This option, however, is not viable for some patients, including those who fall under the category of PWID or who may not have a fixed address. In the case of PWID, the PICC-line, in effect, becomes a “highway” for injecting other drugs; in instances where a patient may not have secure housing or be homeless, the CCAC nurse may not be able to track down the individual. When a patient in one of these situations is being treated for IE, it puts the care team in a difficult position. The alternatives to home care are hospital admittance or no treatment at all, neither of which are ideal solutions. Dr. Silverman is currently in this position, as he must decide on a treatment plan for Mr. W., a patient who has IE, has struggled with drug addiction (the likely cause of his IE), and who does not have stable housing. In making his decision, Dr. Silverman has included on Mr. W.’s care team two other physicians from LHSC, a representative from the CCAC, and the managing director of London CAReS, a community-based housing-first organization. The care team must determine the best treatment plan for Mr. W.
- Identify the role of key stakeholders in health care decision-making.
- Discuss and identify barriers for vulnerable populations (e.g., PWID, homeless individuals) to accessing health services.
- Understand the concept and importance of inter-professional collaboration for health care delivery.
- Identify the key stakeholders and effectively engage with them to determine different barriers to delivering home care to vulnerable populations.
- Discuss and identify how competing priorities (e.g., safety of nurses, efficacy of treatment, financial impact) influence health care treatment decisions.
- Understand the role of community organizations in the prevention, treatment, and management of health care issues.
Case Study Questions
- What is the main problem or issue discussed in the case?
- What role do family meetings have in health care delivery?
- Who is on the care team and what are their roles? Are there any notable absences on the care team? Who else should be on it?
- What are some factors or reasons that make treating PWID for IE especially difficult?
- What is the role of collaboration or inter-professional collaboration in health care delivery? Do you think it is important? Why?
- Who is responsible for ensuring a positive outcome for patients receiving home care?
- What are some key challenges or barriers to incorporating community organizations in treatment decisions?
- What are some of the factors that might be contributing to the increasing problem of drug addiction, and specifically the injection of drugs, in London? Who should be involved in helping to identify solutions?
- What are the legal and ethical obligations of the care team? What about the CCAC nurse? The community organization?
- How important is it to consider the financial impact of different treatment options?
people who inject drugs, endocarditis, homelessness, home care, treatment, health care delivery
Sibbald, S.L., Shelley, J.J. (2017). Policy Meets Practice – People Who Inject Drugs (PWID). in: John-Baptiste, A. & McKinley, G. [eds] Western Public Health Casebook 2017. London, ON: Public Health Casebook Publishing.