Infection Prevention and Drug Diversion (What does drug diversion have to do with Infection Prevention?) Aimee Russell, MLS(ASCP) Infection Prevention St. Luke’s Health System, Boise February 2019

Special Thank you to Susan and APIC Puget Sound for the great conference and opportunity to attend!

The Background

I don’t think we have this issue at my hospital…..?

How does this happen? Tampering and Substitution: It often starts small and then builds as the addiction deepens Common Tactics: Theft from Pyxis Use of waste Calling in prescriptions Indicating it has been administered, but diverting instead Abuse of the culture of “helpers” Tampering and Substitution: Injectable opioid is self-administered and the volume is replaced with saline, tap water or another substance

Okay, but what does that have to do with Infection Prevention?

More Cases:

Where do we even start?

“You don’t know what you don’t know” Infection Prevention needs to be part of this process! It can be very challenging to get involved because the cases are sensitive IPs level of involvement varies widely among organizations

Oh, this really does include IP. Now what? IP will be front and center if there is transmission of pathogens Evaluation of patient harm Blood Borne Pathogen testing IP may be who identifies the diversion based on surveillance activities Risk Rounding

Blood Borne Pathogen Testing Develop a process with Occupational/Employee Health BBP testing offered to those suspected of diversion Should include HIV, Hepatitis ABC, other pathogens suggested by exposure history Prioritize BBP testing over confession Testing of victims is usually driven by proven or suspected infection in the perpetrator

Surveillance Monitor patients for Blood Borne Pathogens Consider the possibility with unexpected or unusual clusters of infections Determine your criteria, threshold and who the information will be taken to

Risk Rounding This is already a part of our practice in Environment of Care Tours and daily rounding Know what to look for: - Tampered seals: caps glued or taped back on, missing tamper seals, lower than expected level of drugs - Laundry finding syringes hidden in a linen cart - Needles left in scrub pocket - Sharps container stored in ceiling tile

Immediate Steps for Tampering Preserve suspicious vials- it is evidence Photograph the scene before disturbing it, if possible Maintain chain of custody Inspect all other medications in the drawer/area Don’t assume it was done by clinical staff Call in the ‘army’

Suspicious Behaviors Sometimes there are none! Numerous job changes or work as a traveler Being in or looking in places they shouldn’t be e.g. Anesthesia carts Often high achievers and very active is work Well liked by peers and medical staff Work the night shift in critical care or other high acuity area Comes in early, stays late or volunteers for overtime or works when not scheduled

The DOH called! Review your labs for unusual clusters or BBP Case Review of Patients Pull in your drug diversion team for a huddle Don’t have one? - HR, Pharmacy, Risk, Patient Safety, Admin, Managers Communications, etc

AAAAHAHHAGGHGHGHGHG! We have an Event!!!! Set up a command center You will not be able to handle this alone! Call the state HAI Coordinator For large scale events, set up a dedicated call center and have a plan for handling volume increase for testing, notifications, follow up, etc.

What Does IP need to do? Find out what your organization is doing Ensure that Infection Prevention is in the loop! Make sure policy is in place and up to date Develop a plan for how to handle exposed patients Utilize current practices to monitor for these events

Questions?