{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:56:14Z","timestamp":1791222974051,"version":"4.1.0"},"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T00:00:00Z","timestamp":1791158400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Q Exchange by the Health Foundation and NHS England.","id":[{"id":"https:\/\/ror.org\/00xm3h672","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Drug-related harm is a major global public health concern, with opioids implicated in over 70% of drug-related deaths. Scotland reports the highest drug-related mortality rate in Europe, with remote and rural communities facing additional barriers to accessing harm reduction and treatment services. Assertive outreach is increasingly recognised as a key strategy to engage individuals at risk who are disconnected from traditional services. This study evaluates the use of a Trigger Checklist to identify and outreach individuals within 48 hours of referral in a rural Emergency Department (ED).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A realist evaluation explored how and why the Trigger Checklist works within the complexity of an ED setting. Guided by Pawson and Tilley\u2019s framework, the evaluation followed three stages: theory gleaning, refining, and consolidation. Initial programme theories were developed using literature and advisory group input, then refined through 13 realist interviews with ED clinicians and outreach workers (OW). Data were analysed using Context-Mechanism-Outcome (CMO) configurations and linked to middle-range theories.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Three programme theories emerged: (1) Confident decision-making, where certainty, conversational aids, ethical reasoning, and outreach worker prompts influenced checklist use; (2) Trusting relationships, shaped by OWs\u2019 approachability, situational awareness, and mutual respect; and (3) Perceived value, driven by altruism, narrative feedback, and perceived reductions in ED visits. Relational coordination theory explained how shared goals, knowledge, and respect \u2013 reinforced by timely, accurate communication \u2013 enabled coordinated action. OW presence and recovery discussions were critical to foster confident and appropriate referrals among ED clinicians.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The Trigger Checklist can support timely outreach potentially reducing drug-related harm in rural ED settings, but its success depends on relational dynamics, perceived value, and organisational integration. To avoid checklist fatigue or tokenistic use, it should be embedded with the support of OWs who foster trust. These relationships will enhance use of the checklist as a meaningful intervention within complex care systems.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0358880","type":"journal-article","created":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:29:04Z","timestamp":1791221344000},"page":"e0358880","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Implementation of the Trigger Checklist and assertive outreach to reduce drug-related harm in the Emergency Department: A realist evaluation"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2396-9992","authenticated-orcid":true,"given":"Michelle","family":"Beattie","sequence":"first","affiliation":[{"name":"University of the Highlands and Islands","place":["Inverness, Scotland"],"department":["Centre for Rural Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lesley","family":"Campbell","sequence":"additional","affiliation":[{"name":"NHS Highland","place":["Caithness, Highlands, Scotland"],"department":["Drug and Alcohol Recovery Service"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bev","family":"Fraser","sequence":"additional","affiliation":[{"name":"NHS Highland","place":["Inverness, Highlands, Scotland"],"department":["Drug and Alcohol Recovery Service"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Terje","sequence":"additional","affiliation":[{"name":"University of the Highlands and Islands","place":["Inverness, Scotland"],"department":["Centre for Rural Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,5]]},"reference":[{"key":"pone.0358880.ref001","unstructured":"World Health Organization. Opioid overdose. 2025 [cited 2025]. Available from: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/opioid-overdose"},{"issue":"3","key":"pone.0358880.ref002","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0317036","article-title":"The burden of unlawful use of opioid and associated epidemiological characteristics in Africa: A scoping review","volume":"20","author":"H Onohuean","year":"2025","journal-title":"PLoS One"},{"key":"pone.0358880.ref003","unstructured":"National Records of Scotland. Drug-related deaths in Scotland, 2024 2025. 2024. Available from: https:\/\/www.nrscotland.gov.uk\/publications\/drug-related-deaths-in-scotland-2024\/#scotland"},{"issue":"7","key":"pone.0358880.ref004","doi-asserted-by":"crossref","DOI":"10.1016\/S2468-2667(23)00082-8","article-title":"Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011: a national retrospective cohort study","volume":"8","author":"A McAuley","year":"2023","journal-title":"The Lancet Public Health"},{"key":"pone.0358880.ref005","unstructured":"Audit Scotland. Alcohol and drug services. 2024 [cited 11\/12\/25]. Available from: https:\/\/audit.scot\/uploads\/2024-10\/nr_241031_drugs_alcohol.pdf"},{"key":"pone.0358880.ref006","unstructured":"European Monitoring Centre for Drugs and Drug Addiction EMCDDA. European Drug Report 2024: Trends and Developments. 2024 [cited 11\/12\/25]. Available from: https:\/\/www.euda.europa.eu\/publications\/european-drug-report\/2024_en"},{"key":"pone.0358880.ref007","volume-title":"The Canadian Drugs Substances Strategy: The Government of Canada\u2019s Approach to Substance Use Related Harms and the Overdose Crisis","author":"Government of Canada","year":"2023"},{"key":"pone.0358880.ref008","unstructured":"UK Government. All Our Health: About the Programme. Office for Health Improvement and Disparities. 2024. Available from: https:\/\/www.gov.uk\/government\/publications\/all-our-health-about-the-framework\/all-our-health-about-the-framework"},{"key":"pone.0358880.ref009","unstructured":"Scottish Government. Medication Assisted Treatment (MAT) standards: access, choice, support. 2021 [cited 2023]. Available from: https:\/\/www.gov.scot\/publications\/medication-assisted-treatment-mat-standards-scotland-access-choice-support\/"},{"key":"pone.0358880.ref010","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-031-11269-0","volume-title":"The desistance journey: Into recovery and out of chaos","author":"G Cambridge","year":"2022"},{"issue":"2","key":"pone.0358880.ref011","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0245346","article-title":"People who use drugs in rehabilitation, from chaos to discipline: Advantages and pitfalls: A qualitative study","volume":"16","author":"N Mahboub","year":"2021","journal-title":"PLoS One"},{"issue":"23","key":"pone.0358880.ref012","doi-asserted-by":"crossref","first-page":"15978","DOI":"10.3390\/ijerph192315978","article-title":"Substance Use Stigma and Community Drug Checking: A Qualitative Study Examining Barriers and Possible Responses","volume":"19","author":"S Davis","year":"2022","journal-title":"Int J Environ Res Public Health"},{"issue":"2","key":"pone.0358880.ref013","doi-asserted-by":"crossref","first-page":"239","DOI":"10.61942\/msj.v2i2.168","article-title":"The Impact of Drug Abuse on Families and Society (Literature Review)","volume":"2","author":"L Manurung","year":"2024","journal-title":"MSJ"},{"issue":"1","key":"pone.0358880.ref014","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1186\/s12954-024-00988-x","article-title":"The relationship between felt stigma and non-fatal overdose among rural people who use drugs","volume":"21","author":"AL Sibley","year":"2024","journal-title":"Harm Reduct J"},{"key":"pone.0358880.ref015","doi-asserted-by":"crossref","first-page":"1407522","DOI":"10.3389\/fpubh.2024.1407522","article-title":"Mobile addiction treatment and harm reduction services as tools to address health inequities: a community case study of the Brockton Neighborhood Health Center mobile unit","volume":"12","author":"A Pinkhover","year":"2024","journal-title":"Front Public Health"},{"issue":"1","key":"pone.0358880.ref016","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1186\/s12954-024-01076-w","article-title":"A qualitative exploration of harm reduction in practice by street-based peer outreach workers","volume":"21","author":"J Owczarzak","year":"2024","journal-title":"Harm Reduct J"},{"issue":"14","key":"pone.0358880.ref017","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/WVVL4786","article-title":"A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study","volume":"26","author":"T Parkes","year":"2022","journal-title":"Health Technol Assess"},{"issue":"4","key":"pone.0358880.ref018","doi-asserted-by":"crossref","DOI":"10.1136\/bmjoq-2025-003524","article-title":"Reducing drug-related harm by triggering proactive outreach","volume":"14","author":"L Campbell","year":"2025","journal-title":"BMJ Open Qual"},{"issue":"3","key":"pone.0358880.ref019","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1080\/10826084.2017.1341921","article-title":"Are people who inject drugs frequent users of emergency department services? A cohort study (2008-2013)","volume":"53","author":"D Nambiar","year":"2018","journal-title":"Subst Use Misuse"},{"key":"pone.0358880.ref020","volume-title":"Reaistic evaluation","author":"RATN Pawson","year":"1997"},{"issue":"5","key":"pone.0358880.ref021","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1080\/13645579.2021.1918484","article-title":"Understanding \u2018context\u2019 in realist evaluation and synthesis","volume":"25","author":"J Greenhalgh","year":"2021","journal-title":"International Journal of Social Research Methodology"},{"issue":"3","key":"pone.0358880.ref022","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1177\/1356389016638615","article-title":"The craft of interviewing in realist evaluation","volume":"22","author":"A Manzano","year":"2016","journal-title":"Evaluation"},{"key":"pone.0358880.ref023","unstructured":"Scottish Government. National Drugs Mission Plan: 2022-2026. 2022. Available from: https:\/\/www.gov.scot\/publications\/national-drugs-mission-plan-2022-2026\/pages\/3\/"},{"issue":"7","key":"pone.0358880.ref024","doi-asserted-by":"crossref","first-page":"1747","DOI":"10.1111\/add.15336","article-title":"Association between poverty exposure during childhood and adolescence, and drug use disorders and drug-related crimes later in life","volume":"116","author":"H Manhica","year":"2021","journal-title":"Addiction"},{"key":"pone.0358880.ref025","volume-title":"Caithness Partnership Profile: Adult Health and Wellbeing","author":"NHS Highland","year":"2023"},{"issue":"11","key":"pone.0358880.ref026","doi-asserted-by":"crossref","first-page":"1408","DOI":"10.1287\/mnsc.48.11.1408.268","article-title":"Coordinating Mechanisms in Care Provider Groups: Relational Coordination as a Mediator and Input Uncertainty as a Moderator of Performance Effects","volume":"48","author":"J Hoffer Gittell","year":"2002","journal-title":"Management Science"},{"key":"pone.0358880.ref027","unstructured":"UK Government. The Caldicott Principles. 2010 [cited 2025 December 15]. Available from: https:\/\/www.gov.uk\/government\/publications\/the-caldicott-principles"},{"key":"pone.0358880.ref028","volume-title":"Visual Management in Healthcare: A Systematic Literature Review of Main Practices and Applications","author":"CM Zani","year":"2020"},{"key":"pone.0358880.ref029","doi-asserted-by":"crossref","first-page":"1504532","DOI":"10.3389\/fmed.2024.1504532","article-title":"A guide to prompt design: foundations and applications for healthcare simulationists","volume":"11","author":"S Maaz","year":"2025","journal-title":"Front Med (Lausanne)"},{"key":"pone.0358880.ref030","unstructured":"Zwaan L, Staal J. Evidence on use of clinical reasoning checklists for diagnostic error reduction. Agency for Healthcare Research and Quality. 2020 [cited 2025 December 11]. Available from: https:\/\/www.ahrq.gov\/sites\/default\/files\/wysiwyg\/patient-safety\/reports\/issue-briefs\/diagnostic-error-reduction.pdf"},{"issue":"2","key":"pone.0358880.ref031","first-page":"1","article-title":"Evidence-based practice and health informatics: enhancing care quality","volume":"11","author":"J Wan","year":"2024","journal-title":"J Evid Based Med Healthc"},{"issue":"1","key":"pone.0358880.ref032","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/s12875-024-02267-x","article-title":"The influence of fears of perceived legal consequences on general practitioners\u2019 practice in relation to defensive medicine - a cross-sectional survey in Germany","volume":"25","author":"K Goetz","year":"2024","journal-title":"BMC Prim Care"},{"issue":"3","key":"pone.0358880.ref033","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1111\/jep.13799","article-title":"Factors influencing defensive medicine-based decision-making in primary care: A scoping review","volume":"29","author":"CJ Strobel","year":"2023","journal-title":"J Eval Clin Pract"},{"issue":"1","key":"pone.0358880.ref034","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1186\/s12910-024-01135-8","article-title":"Exploring barriers and ethical challenges to medical data sharing: perspectives from Chinese researchers","volume":"25","author":"X Li","year":"2024","journal-title":"BMC Med Ethics"},{"issue":"1","key":"pone.0358880.ref035","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1186\/s12913-024-10705-w","article-title":"Technology, data, people, and partnerships in addressing unmet social needs within Medicaid Managed Care","volume":"24","author":"R Hogg-Graham","year":"2024","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pone.0358880.ref036","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1186\/s12913-025-12283-x","article-title":"The impact of digital transformational leadership on digital intensity among primary healthcare entities: a moderated mediation model","volume":"25","author":"M Kludacz-Alessandri","year":"2025","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pone.0358880.ref037","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1186\/s12913-021-06630-x","article-title":"When trust, confidence, and faith collide: refining a realist theory of how and why inter-organisational collaborations in healthcare work","volume":"21","author":"JA Aunger","year":"2021","journal-title":"BMC Health Serv Res"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0358880","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:29:11Z","timestamp":1791221351000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0358880"}},"subtitle":[],"editor":[{"given":"Maria J","family":"Berghs","sequence":"first","affiliation":[{"name":"University of Cambridge","place":["UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,10,5]]},"references-count":37,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,10,5]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0358880","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,5]]}}}