On June 4, the Franklin Lakes, N.J.-based BD (Becton, Dickinson) released a whitepaper entitled “Health Care’s Hidden Epidemic: A Call to Action on Hospital Drug Diversion.” The report was authored by a team of BD researchers.
As the report’s introduction noted, “The opioid epidemic has reached unprecedented depths – Americans are now more likely to die from opioid overdoses than car accidents, according to a 2019 analysis by the National Safety Council. Healthcare workers are not immune to the crisis,” the report noted. “Hospital drug diversion, when a health care worker diverts opiates and other controlled substances away from patients for personal use or sale, remains a significant, and largely underdiscussed, challenge. Left undetected, diversion can imperil patient safety, harm diverters and generate significant risks for hospitals.”
Further, the report noted, “Because hospital drug diversion has been understudied, the BD Institute for Medication Management Excellence commissioned a new national survey of more than 650 hospital executives and providers to better understand diversion perceptions, behaviors and solutions.”
Among the key results researchers found, based on a survey of hospital leaders:
> Healthcare executives and providers recognize diversion is a problem, with one caveat: four out of five believe it’s not an issue in their own hospital.
> The survey data supports anecdotal observations that health care providers are often stressed beyond their ability to cope.
> Health care providers acknowledge preventing diversion is challenging, but only 25% believe their tools are very effective.
> Surveyed executives and providers believe more accurate data, as well as machine learning and advanced analytics, would improve their ability to detect drug diversion.
Ranjeet Banerjee, worldwide president, medication management solutions, at BD, one of the report’s authors, says, of the report, “With what we do in medication management, we are looking for what some of the biggest challenges our customer leaders have. And as part of that process, we’ve been digging in deep and talking directly with customers, and one of the issues that bubbled up to the top was diversion, the illegal use of opioids and painkillers meant for patients but that are being diverted by people in healthcare. And we tried to understand why this problem exists; and when we started studying this problem, it became clear that it’s a pretty significant issue, and it’s not just a compliance issue, it’s also a patient safety issue. Often, if a caregiver uses it on her/himself, you could be dealing with an impaired clinician. Also, it could involve a situation such as a syringe being reused.”
Meanwhile, when asked what the overall solution to medication diversion is, Banerjee says, “The solution really hinges on the ability to track opioids in a systematic manner. If we can do that in an automated fashion—today, people are trying to do it manually. So you find out how much of an opioid was dispensed, how much was administered, did it go to the right patient? How much time was wasted?” Automating the process will increasingly be a part of the solution, he emphasizes.
As the BD report noted of the survey on which its findings were based, “The survey also confirms anecdotal observations that health care providers are often stressed beyond their ability to cope, making them vulnerable to substance use disorder. Many are high achievers who suffer from long hours, emotional strain and heavy patient volume.”
Some more specifics: “The survey showed 78 percent of providers know a peer who may be stressed “to the breaking point.” And while the vast majority of participants acknowledge they have resources to help manage stress, fewer than half have accessed that support.” What’s more, the report notes, “This stressful work environment may put hospital staff at great risk, particularly nurses, pharmacists and anesthesiologists with access to drugs. Many respondents also feel inadequate detection tools are a major barrier.” In addition, the report noted, “They cite the need for better information resources, including more accurate data to reduce false positives, as well as machine learning and advanced analytics capabilities. In the end,” the report noted, “most hospital professionals in the survey said they are confident that, with adequate resources and attention, they can enhance diversion detection efforts in their facilities.” And it cited a statistic from the Drug Diversion Digest that stated that “nearly 19 million pills were diverted in the first six months of 2018.” What’s more, the report notes that, “In April 2019, 60 health care professionals in multiple states were indicted for a diversion scheme.”
Asked whether she perceives the drug diversion situation in U.S. patient care organizations as a crisis, Katelyn Hipwell, PharmD, pharmacy clinical operations manager at the University of Virginia Health System, in Charlottesville, Va., says, “Yes, I think it’s pretty accurate to call it a crisis; we’re trying to figure out what term is best, but I think that ‘crisis’ or ‘epidemic’ are appropriate words for it. And just figuring out where to start is a problem.”
What are the key dangers involved? “The situations involved exist everywhere where clinicians are providing care,” Hipwell says. “We clinicians have sworn an oath to take care of patients and to do no harm—but who’s providing care when those individuals are sick or in need? Our highest priority at UVA is to protect patients, obviously, but then also employees. And providing help for them is so important.” As to how the problem plays out on a day-to-day basis, she says, “We are a tertiary, academic medical center, we have 612 licensed beds, and we’re growing and expanding. So you have all that influx of patients. And we have about 8,000 clinicians—physicians, nurses, pharmacists, of all kinds. But you’ve got all of those individuals. We use automated dispensing cabinets, so when the medication leaves the pharmacy, it goes into a machine, and is tracked. But that doesn’t mean that when that nurse takes that medication out of that cabinet, that something might not happen. The hardest thing to catch is what we call ‘skimming.’ You’re giving 5 milligrams of oxycodone to a patient, but maybe they give a substitute to the patient.” That’s how challenging it is to track misconduct, she says. UVA Health has partnered with BD to use its Health Site Diversion Analytics solution to address the issue.
“What they’re really looking for is, how can an organization detect when there’s a problem?” Hipwell says. “In any organization, if an opioid is being prescribed, dispensed, and administered, the reconciliation of data becomes very important. And let me put this into a context. In a typical 300-bed hospital, there could be several thousand medications being dispensed and administered every day. And that’s where the power of data comes in. Per why data, the more that organizations can mine that data in a simple, automated way, the easier it is to find patterns and signals; that’s the power of the data.”
BD’s Banerjee emphasizes that there are four elements involved in addressing the issue. The first three are the classic ones referenced in numerous contexts in healthcare: people, process, and technology. “And,” he says, “the fourth element is leadership. If I look at what the future might look like, this has to be something where the leadership of the hospital agree that they’ll own this and find effective solutions. That’s what happened with medication errors 20 years ago. Twenty years ago, new data about medication errors helped people to become aware of the problem. So rather than placing blame, you need to take the approach of finding system failures.”
Meanwhile, Banerjee continues, “Second, you need to make sure the organization leverages the right technology to reduce the workload and to capture the data and convert the data into actionable insights. The third is around process. On the process side, a lot of organizations are engaging in diversion management processes, and formalizing roles, and coming up with specific processes. And 60 percent of providers have taken diversion courses or learned about it, but 40 percent still have done no formal learning. So training, developing processes, is important. And the last element is culture. Openly talking about it. And rather finding people to blame, it’s identifying failed processes. It is that theme. It is the cultural element.”
What will the landscape around this issue look like five years from now? “I think there will be a stratification of the hospital base; there will be some leaders who will truly have transformed this and come close to solving these issues, because they’ve taken the right steps,” Banerjee says. “There will probably be a big group in the middle who’ve made a lot of progress, but will still have a ways to go.”
And, he continues, “The main difference between the two groups is around leadership. The organizations that are making this a c-suite topic, I feel will lead the way in finding comprehensive solutions, as they reduce the impact of diversion on patient safety, but also find other benefits, for example, around clinician burnout, because of the workload around solving this issue.”
Meanwhile, at UVA Health, Hipwell reports that, in terms of addressing the issue, “It helps automate everything we were having to do in all of our disparate systems—EHR [electronic health record], automated dispensing cabinets, and in the pharmacies, we have an electronically controlled vault, an automated dispensing cabinet specifically for controlled substances. It’s pretty locked down,” she adds.
What needs to happen in the next few years? “I think any manager or anybody who’s been involved with controlled substances oversight, we’re trying to make progress,” Hipwell says. “And these results in the survey weren’t shocking. Everyone knows there’s an issue. Everyone tends to not believe it’s in their organization, of course. So seeing these results is confirming everything I’ve been feeling in my career so far.”
How can leaders help to impress their colleagues on the need to move forward with determination? “You have to make the case for the fact that there is a real problem,” Hipwell says. “And organizations that have experienced diversion are more likely to move forward to put good systems into place and provide education.” Meanwhile, she advises, “Once a diversion is known, it ramps up the efforts, and then people tend to relax too much. And remember, the turnover rates are very high, particularly at academic medical centers, where people are coming and learning and not always staying a long time.” So vigilance and forward-looking efforts will be important for the foreseeable future.