Diversion in U.S. Hospitals: A pharmacist perspective on the issues and challenges

David Swenson, RPh, Vice President of Medical Affairs at BD, reflects on conversations with customers to provide some perspective on an underreported aspect of the opioid crises – healthcare professional drug diversion.
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David Swenson

David Swenson, RPh, Vice President of Medical Affairs at BD, reflects on conversations with customers to provide some perspective on an underreported aspect of the opioid crises – healthcare professional drug diversion - which is growing importance to hospitals across the United States.

When hospital managers talk about drug diversion, how is it that you can hear such a wide-ranging spectrum of responses – ranging from “this is a serious problem” to “we don’t see a lot of issues with diversion in our facility”?

While the opioid crisis has grown to epidemic proportions across the country, with well over 100 deaths occurring daily, the related problem of theft of hospital narcotics for abuse by caregivers – commonly known as drug diversion - has received much less attention, even within healthcare. We find that many health facilities are aware of the diversion problem and are deploying resources toward detection and prevention, while others have yet to fully appreciate the drug diversion issue. In fact, we continue to hear a wide range of responses to diversion from our customers. At the recent International Health Facility Diversion Association (IHFDA) Meeting held this past September in Dallas, we saw an auditorium full of hospital leaders taking the diversion problem very seriously. They are investing significant resources in multidisciplinary teams and various diversion tools. On the other hand, as we are out talking to customers, we hear some customers say that “they don’t have a significant diversion problem.” In talking with both groups, we’ve seen a pattern emerge. Those facilities that seriously look – and put effort into surveillance – find diversion issues. Without an ongoing detection and surveillance program, what may very well be a significant diversion problem can evolve for years undetected. What tends to jar these facilities into reality is some type of major diversion incident. We see this happening more and more.

So, what does BD’s internal experts and the experts at IHFDA suggest? Are detection systems enough?

First, it’s important to understand the role of the health system Information Technology department plays in diversion detection. The controlled substances chain of custody - starting with wholesaler ordering, through pharmacy storage and perpetual inventory management all the way to nurse access to the automated dispensing cabinet followed by administration – generates data. The analysis of this data, leveraging sophisticated analytics, forms the backbone of diversion detection. Machine Learning algorithms and other sophisticated methods are now capable of providing key insights enabling compromised caregivers to be identified early and assist them in getting help.

That said, while detection systems are a key component of an acute-care facility diversion program, they are not enough by themselves. From experience we know that a successful diversion detection and prevention program takes a team approach. It’s critical that the team include representatives from key areas, from Nursing, Human Resources, Security, Employee Assistance, and be sponsored by a key member of the hospital’s Senior Leadership. The team should define an operating structure, with guidelines and procedures that set up the ongoing routines and processes. Once training on surveillance, observations and detection processes are complete, a structured method of assessing diversion related information and events needs to be in place. Pharmacy, of course, should take a leadership position on the team, by appointing an experienced professional to serve as a key component of the interdisciplinary team. At the IHFDA meeting, we heard about a best practice for diversion teams called “huddles.” Huddle meetings use what’s called an “SBAR” approach: 1. Situation, 2. Background, 3. Assessment and 4. Recommendation. Huddle output can lead to a caregiver being assessed as fit to return to duty or referred for further assessment and investigation.

Additionally, what can be particularly helpful to the interdisciplinary team is the ability to leverage technology in their collaboration. For example, some of the more sophisticated analytics systems incorporate workflow systems. These systems keep the teams organized and aligned, by allowing diversion detection information to be shared efficiently and confidentially among the appropriate team members

What are the trends you see? What’s likely to change in how health facilities view drug diversion as you look out two to three years?

There have been multiple high-profile actions by the FDA in recent years, the first big one – Massachusetts General hospital’s $2.3M DEA fine in September of 2016 was a wake-up call – many facilities saw what happened there, and many realized that the degree of diligence around controlled drug procedures and accounting was not what it should be. The pattern of DEA actions has accelerated since then. Effingham Health System in Georgia was fined $4.1M this past May, and then most recently University Michigan with a $4.3M fine. These actions are painting a clear picture that not only is the DEA serious about clamping down on hospital processes and procedures, but importantly, there’s now a growing awareness that diversion is a pervasive problem – no health facility is immune. Even today, we still do not have accurate statistics on the size of the diversion problem. One of the most important tasks for those of us in the medical device industry is to use whatever means we can do get some type of objective measure on the size of this problem. That remains a challenge.

What is your advice for hospitals and health systems?

If you are not seeing diversion in your facility, it’s likely because you are not looking. A variety of guidance and tools are available. Becton Dickinson for example, has a diversion assessment tool available for all hospitals, which can be a good starting point. Find out where you are, and then use tools like the ASHP Controlled Substances Diversion prevention guidelines to set up the needed policies, procedures and multidisciplinary teams.

Lastly, regarding tools, there is a renaissance of sorts going on right now around diversion analytics tools. I’d suggest health systems take a close look at them, as the build the interdisciplinary teams and procedures.