Hospital’s drug diversion nightmare spawns multiple infections

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Cheryl Clark, for HealthLeaders Media, June 28, 2012

Update: Exeter Hospital posted an update on its website on Monday, July 2, saying that another six patients, for a total of 27 individuals—26 patients and one employee—have been infected with the same strain of hepatitis C linked to care in the hospital's cardiac catheterization lab. Testing of other patients who received care at the hospital is ongoing.

Two months ago, Exeter Hospital was just your basic community non-profit in a town of 14,000 souls not far from the prestigious Phillips Exeter Academy, near New Hampshire's coast.

Today, the 100-bed facility is beset by a mushrooming chaos of hepatitis C infected patients, multiple government investigations, at least three class action lawsuits, and a crisis of confidence. The episode has evolved into a cautionary tale of what can happen when a drug-stealing addict is one of your caregivers.

"What we're talking about here is drug diversion. That's healthcare workers doing drugs and getting so hooked on them that they are even stealing them at their worksite," New Hampshire Public Health Director Jose Montero, MD, said in an interview this week with HealthLeaders Media.

With at least one report indicating that nationally, more than 4% of healthcare workers acknowledge some form of illicit drug use, we know that often they are the very same professionals who administer controlled substances, such as anesthesiologists and nurses. "The meaning of that in healthcare quality is clearly huge, Montero says.

Healthcare providers need to learn how to prevent these episodes from harming their ability to provide reliable care, and ruining their long-standing reputations as well, he says.

For Exeter Hospital, a 116-year-old institution with 2,000 healthcare workers, he adds, "this has been a painful way to learn that lesson."

For outsiders, the spiraling saga began May 31, when hospital officials acknowledged that four patients cared for in Exeter's cardiac catheterization lab were found to be infected with a hepatitis C viral strain that could only have come from one person.

Infection control practice lapses were ruled out.

On June 13, Montero told reporters that the likely culprit is an unnamed hospital employee who diverted, for personal use, quantities of unnamed drugs intended for patients.

According to media reports, criminal charges are likely.

Lookback procedures were launched to see how many patients might have been at risk of being infected, resulting in a count of an estimated 1,200 people treated in the cath lab as far back as October 1, 2010. All were advised to undergo testing at the hospital's expense. So far, another 17 individuals have been found infected with the same strain, for a total of 21.

Samples from another nine were negative, but are undergoing further "quasi-species" testing this week at the Centers for Disease Control and Prevention in Atlanta to be certain, a CDC official confirms. In addition to the CDC, the hospital is reportedly under scrutiny by at least eight federal or state agencies—from the Federal Bureau of Investigation, the Drug Enforcement Administration, the Food and Drug Administration, the Office of Inspector General, the state Attorney General, the New Hampshire Department of Health, and state hospital licensing officials, on behalf of the Centers for Medicare & Medicaid Services. Local law enforcement agencies have been notified. And the Joint Commission is also asking questions. 

At least three class action lawsuits claiming that the hospital was negligent have been filed or are in the works.

On June 14, the hospital's president and CEO Kevin Callahan issued a public apology saying, "We disrupted peoples' lives." The facility website's home page so far has 13 updates on the investigation and status of testing exposed patients. The catheterization lab was closed for six days. The status of the suspected employee is unclear.

Complicating the situation is the fact that the employee suspect apparently was a hospital patient too, Montero says.

Montero described similar situations that the Exeter investigation may find are similar. A caregiver might take a syringe containing "a type of medication that a drug addict would like to have," and they switch it with a syringe the addict has used. Or during a procedure, the employee injects part of the content of the syringe, refills it with saline or water, and then returns it for use on the patient.

"You see these patterns of cases that are not clustered together, but are spread out over time, because they're related to when the caregiver brought in that particular syringe."

In Colorado three years ago, a hospital surgical technician was let go after she was found to have replaced fentanyl taken through syringes with saline, sometimes in syringes that had been previously used.  She was only caught after a syringe in the tech's pocket pricked a co-worker. The hospital had to track down 5,700 potential exposures. Before the case was closed, she had re-infected 36 individuals with hepatitis C.

Montero says that the incident "certainly highlights the need for more quality assurance and scrutiny in all facilities. "But at the same time, it highlights how complex the issue of drug use is, and about attitudes we have about drug use in the workplace. And how do we manage that in a society that more and more accepts some drug use at some different levels?"

Hospitals need to incorporate better ways of securing these kinds of medications, Montero says, "so only specific people can have access to them, or you should manage them in specific ways when you are in any procedure room when you are going to dispose of them."

Of course, he adds, all hospitals already do have those policies in place on paper because they have to as a condition of licensure. "But you also must have a procedure to make sure those policies are followed. It's not just what you put on paper," he says.

Montero says that in some hospitals, human resources departments require random periodic drug testing of employees, although that's not a mandate in New Hampshire.  There are downsides to that, such as fear and morale problems, as well as false positives.

Clearly, this is a problem healthcare leaders need to find ways to solve. In the April edition of the Annals of Internal Medicine, researchers from the Florida Department of Health and the Mayo Clinic in Jacksonville described another case in which five patients were infected with hepatitis C there by a radiology technician, who eventually acknowledged diverting fentanyl intended for patients in the interventional radiology area.

"The technician reported rare self-administration of fentanyl from a syringe that had been filled with fentanyl in preparation for patient care.  The technician would replace the removable needle of the prefilled syringe with a smaller-gauge needle with the original needle, replace the administered fentanyl with saline, and return the filled syringe to patient care."

The researchers concluded that healthcare systems need to implement strategies "to control narcotics in healthcare settings that cannot be circumvented."

While narcotic diversion in the operating room is fairly well understood, the researchers wrote, "relatively little is known about the epidemiology of drug diversion and the effectiveness of strategies to prevent it outside of the operating room environment."

Exeter CEO Callahan acknowledges that the incident has damaged his hospital's reputation, but in a video interview with a local TV station, he tried to reassure the public. Exeter's 2,000 providers, he said, "are doing the very best to instill trust in that care. I cannot believe that one or two criminal actions can so damage the trust of the tens of thousands of people that we've cared for every year."

Montero says that a statewide healthcare quality commission will bring the results of these investigations to all hospitals "so everybody learns from this, and we decrease the probability that it will ever happen again—because it shouldn't."

Source: HealthLeaders Media