PainMedicine News –
An updated set of American Society of Health System Pharmacists (ASHP) Guidelines on Preventing Diversion of Controlled Substances, planned for 2021-2022, will help hospitals implement best practices using newer technologies.
Since 2017, when the first ASHP guidelines and 100-point hospital self-assessment test were issued, diverse technologies have reached the market, including:
- analytical and artificial intelligence platforms that detect and track anomalous behaviors;
- radiofrequency identification (RFID) labels from manufacturers that track medications from the source until administration to patients; and
- waste tracking systems.
The updated guidelines from ASHP aim to address “1,000 points across a hospital where diversion could happen, from procurement to preparation and dispensing, to prescribing, administration and waste removal,” Chen said. “Every time you implement a process or tech-driven solution, someone figures out a potential way around it.”
Massachusetts General Hospital (MGH), in Boston, and Children’s Mercy Hospital, in Kansas City, Mo., are two institutions on the leading edge of such anti-diversion efforts.
At Massachusetts General, the added difficulties of caring for COVID-19 patients drove “higher diversion surveillance efforts overall,” said Christopher Fortier, PharmD, the chief pharmacy officer. Those efforts included an inventory audit following the hospital’s springtime surge “to ensure we accounted for the increased amounts of controlled substances we had to purchase” for the care of the sickest COVID-19 patients, he noted. The hospital’s annual mid-year audit focused on fentanyl, hydromorphone, lorazepam, methadone, midazolam, morphine and oxycodone.
Although many factors may contribute to diversion, Fortier cited a few likely culprits. During the first COVID-19 surge last year, MGH had to make rapid adjustments to workflow and other key operations. For example, “we converted general care units to ICUs, and needed nurses and physicians who don’t normally work in the ICU to staff those areas,” he said. Such changes could contribute to breakdowns in the normal checks against diversion, he noted.
Coupled with the added stress on health care practitioners, Fortier noted, these factors could explain why institutions have seen more discrepancies and overrides for controlled substances.
The response at MGH, where 4,000 nurses administer more than 2 million controlled-substance doses annually, was to “purchase the next generation of [a] controlled substance surveillance system that uses machine learning algorithms. We’ll implement it probably in early 2021. Pharmacy will take the lead on managing it, working very closely with nursing and anesthesia,” Fortier said.
“Technology like this is so new that the jury is still somewhat out—though I do know I want a machine learning system to help me identify a diverting worker in possibly a much shorter time frame, and I don’t want to weed through thousands of transactions each day. I want to see the exceptions pulled out of the system each day that show discrepancies and warrant further investigation. Machine learning brings in advanced algorithms to find those exceptions and saves an immense amount of time looking for the needle in the haystack.”
Fortier noted that soon after he came on board at the facility, he was tasked with “cleaning up” after the hospital paid the Drug Enforcement Administration a $2.3 million fine to resolve drug diversion allegations in September 2015. The health system agreed to implement a comprehensive corrective action plan lasting until September 2018. He noted that his institution’s multifaceted, evolving program is based on a culture he implemented “where people know this is serious, that we report appropriately, look out for peers, and put patients and care quality first so they’re never affected by diversion, as far as we know.”
Hospital leadership’s interest in the program and in its multidisciplinary collaboration components “remains high,” Fortier added. “We’re always working to get better.”
The anti-diversion program includes the following:
- An interdisciplinary team of pharmacy, anesthesia and nursing leaders, police and security, human resources, compliance, legal, occupational health and employee assistance. “If someone is diverting and cooperates with the investigation, we want to help them,” Fortier said.
- 1.5 FTEs who review drug surveillance data from technology and nursing leaders’ reports of anomalous behaviors (reported daily.)
- There also are 170 automated dispensing cabinets (ADCs) with all drugs in individual pockets and blind counts, in which nurses don’t know how many are in each pocket—all integrated with the pharmacy management and electronic health record systems. In addition, 90 anesthesia workstations document controlled substances waste within the pre-op, operative and post-op areas.
- Drug testing of every newly hired employee is conducted.
Brian C. O’Neal, PharmD, helped draft ASHP’s initial guidelines to curb drug diversion, and he brought many of those best practices to Children’s Mercy Hospital, in Kansas City, Mo., where he serves as the senior director of pharmacy and biomedical engineering. Central elements of his program include:
An interdisciplinary controlled substance oversight council. This group reviews details of any diversion incidents to improve the system. It also also establishes policies related to controlled substance handling and accountability.
An internally developed controlled substance handling dashboard. This workflow software feature shows the numbers of discrepancies, overrides, transactions and events that might indicate poor practice and vulnerability. The software feature also confirms adherence to policies.
Overhead cameras. These are placed by all ADCs that hold controlled substances. The hospital system has 85 Cerner ADCs, which integrate with the Cerner pharmacy management system and Cerner electronic health records. “When you get an inventory discrepancy at an ADC, you don’t know for sure if the prior person caused it, or if the person who found it caused it,” O’Neal said. “Did one person access the return bin but not put anything in? Cameras put us at that location to help resolve discrepancies.”
A satellite pharmacy within one of its two operating rooms. This setup tightens up waste procedures, so that “all controlled substances are returned to the OR pharmacy, where the anesthesia provider turns them in and watches with the pharmacist as they reconcile what was given out to them minus what came back,” O’Neal said. “We’re doing periodic sampling, but we’re working to transition to test everything that comes back after every OR procedure. Having a high-end refractometer or other analytic technology is also important.”
He added that Children’s Mercy is evaluating the potential addition of ADCs outside of each group of three to four rooms within the pediatric ICU. “We currently have three medication rooms with ADCs in our PICU. We discovered, though, that the distance from bedside to medication rooms, coupled with the highly acute nature of some of our patients, can lead to some highly undesirable handling practices [such as person-to-person handoffs and failure to waste in a timely fashion]. Although there is certainly cost associated with adding ADCs, we’re looking at whether these [units] would offer our nurses an additional tool to manage controlled substances in a compliant fashion, while being able to respond to the urgent needs of our patients.”
Although O’Neal said he is implementing an advanced analytics diversion detection software system, he still feels “there’s not yet strong data behind AI to prove that these new software packages have cracked the code on diversion. These systems have a lot of data, but it will likely take an end user to come up with a road map they can present or allow the vendor to share with other users. We have the tools, but aren’t quite sure of what to do with all of these data just yet.”
Closing the Loop
Michael Campbell, PharmD, MBA, the director of pharmacy services at Pomona Valley Hospital Medical Center (PVHMC), in California, underscored the link between the stressors of the pandemic and drug diversion. Pharmacy workflow modifications made during a pandemic, he noted, such as those aimed at reducing virus spread, conserving personal protective equipment and limiting employee exposure to infection, can increase the risk for diverting behavior.
Campbell added that using software-guided solutions makes sense. The technology, he noted, “requires users to complete steps to close controlled substances transactions.” The software also flags staff “who may need follow-up training in our controlled substance management processes.”Healthcare Diversion New Technology New Trends