Overview The New Settings NH C Activities - One and … · prescription drugs in the past year (US, 2011) 11 million reporting nonmedical use of opioid analgesics No estimates

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New Hampshire Department of Health & Human Services

Katrina Hansen, MPHHealthcare‐Associated Infections (HAI) Program Manager

Bureau of Infectious Disease ControlNew Hampshire Division of Public Health Services

New Jersey Drug Diversion Conference

June 2016

The New Hampshire Experience: Drug Diversion in Healthcare SettingsThe New Hampshire Experience:

Drug Diversion in Healthcare Settings


Overview

Drug Diversion Background

NH Hepatitis C Virus Outbreak Investigation

NH Drug Diversion Prevention and Response Activities

Public health expectations for reporting in NH

Question, Answer, and Discussion


Drug Diversion Background

Picture from: http://www.newsweek.com/2015/06/26/traveler-one-junkies-harrowing-journey-across-america-344125.html


Drug DiversionAn act that removes a prescription drug from its intended path from the manufacturer to the patient

Closely related to issue of prescription opioid abuse and misuse

>14 million people reported nonmedical use of prescription drugs in the past year (US, 2011)

11 million reporting nonmedical use of opioid analgesics

No estimates of prevalence of drug diversion by US healthcare personnel

Access to narcotics, familiarity with their use

Substance abuse disorders among anesthesiology residents was ~1% in one study, with most using fentanyl and other intravenous opioids

Drug Diversion and Patient SafetyDiversion of any drug can result in patients not receiving the care they need

Poor pain control

Relief of symptoms

Diversion of any drug can result in patient harmA 2011 drug diversion incident in MN resulted in one patient death (overdose) and one amputation (pain relief)

Diversion of injectable drugs can result in bacterial infections and bloodborne pathogens

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6 outbreaks have occurred since 2004

> 100 illnesses were associated with the outbreaks

84 patients infected with hepatitis C virus

34 with gram‐negative bacteremia

Case count does not include probable or suspect cases (I.e. infections cleared and could not be typed to source)

~30,000 patients potentially exposed and targeted for notification and testing

Drug Diversion‐Associated Outbreaks


Figure from: http://www.cdc.gov/injectionsafety/drugdiversion/drug‐diversion‐2013.html


Infections were spread by tampering with injectable controlled substances

Implicated HCP included 3 technicians, 2 nurses, and one nurse anesthetist

Gaps in prevention, detection, and response to drug diversion in healthcare facilities

Appropriate response1

Consultation with public health officials when tampering with injectable medication is suspected

Prompt reporting to regulatory and enforcement agencies

Drug Diversion and Outbreaks, cont.The New Hampshire Hepatitis C (HCV) outbreak at an acute care hospital

The Full NH DHHS Outbreak Report is Available at: http://www.dhhs.nh.gov/dphs/cdcs/hepatitisc/documents/hepc-outbreak-rpt.pdf

Blood borne pathogen

Transmission: contact with contaminated blood

IV drug use

Dialysis

Blood products/transplant before 1992

Clotting factors before 1987

Tattoos

Needle stick injury

Sexual

Vertical

Hepatitis C Virus (HCV) Epidemiology

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HCV Cluster? – Initial Steps

May 15th, 2012: A NH Hospital reports 4 individuals with recently diagnosed HCV

Questions:

Are these new infections?

Do they have a common source?

Investigation steps:

Medical record review

Interview cases

Genomic sequencing

Questions:Are these new infections?

At least one with seroconversion and acute HCV infection

Do they have a common source?

Epi – common link in Cardiac Cath Lab (CCL) at Hospital

3 patients

1 HCW

Lab…….

HCV Cluster? – Initial Findings

1206010187-R1

1206050018-R1

1206010120-R1

1206080064-K1515163-1b

541356-1b

514640-1b

1206010125-R1517331-1a

1206020034-K2R519281-1a

514366-1a

1206080094-K2535110-2a

1206080132-K1-F539954-2a

1205230049-K2

1206040058-122F512652-2b

512863-2b

537798-6

535318-6

515603-4

1206080014-K1524253-3a

535886-3a

0.00.10.20.30.40.5

1205170046-R1Analysis of NS5b Region Sequences

= Common source

Nosocomial HCV Transmission

3 main mechanism:

Contaminated equipment

Lack of injection safety (syringe reuse, single dose vial for multiple patients)

Drug diversion

Goals of Public Health

Stop the transmission (find source)

First step: Close cath lab until source is contained

Diagnose all those infected and connect them to care

Notify patients and start testing

Understand how transmission happened to prevent future outbreaks

PH Activities Test all employees

Observe procedures

Mock up procedure

Real procedures

Interviews

Staff

Patients (cases)

Review

Medical records

Drug dispensing and administrating

Policies (infection control, narcotics)

Patient testing

Cath Lab investigation

Outside cath lab investigation

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PH Activities

Active Surveillance

New diagnosis of HCV

Providers

Lab results

Routine Surveillance

ED visit data

Death certificate data

Cath Lab investigation

Outside cath lab investigation

CCL Testing Summary Epi Classification

Pt indicated for testing 1214 Exposed

Total pt tested

(Unable to test)

(Need to be tested)

1074

(132)

(8)

No evidence of HCV infection 997

Evidence of past HCV infection 27 4 probable cases

5 suspect cases

15 unknown cases

3 not a case

Active unrelated HCV infection 18 Not a case

Active matching HCV infection

(Evidence of co‐infection)

32 (+1)

(3)

Confirmed case

PH Investigation FindingsNarcotic use, control and oversight

Gaps in processes & proceduresAccess

Use

Waste

Oversight

Discrepancies in med record review

Increased use of controlled substances for cases

Infected HCW

Co‐workers concerned about behavior

Only HCW present for all case procedures or hospital stays

Infected HCW:

Assigned to work based on med record:Confirmed cases: 17 of 32

Probable cases: 1 of 4

At work based on schedule/ card key for procedure/ hospital stay: Confirmed cases: 32 of 32

Probable cases: 4 of 4

Results: Confirmed Case Medication Use

More than three times higher vs. pre‐employment *┼

Two times higher than overall CCL cases during employment

* Unable to provide statistical comparison due to aggregate data┼ Excludes 2 procedures occurring before time of employment

235 mcg

2.96mg

Epidemic Curve

HCV, unrelated strain

Cleared infection

HCV, Matching strain

Infected HCW Start of Employment

Note: hospital stay overlapped

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Phylogenetic analysis with first identified

cases

Final phylogenetic analysis

PH Investigation Findings

3 main mechanism:

Contaminated equipment

Single dose vial for multiple pts

Drug diversion

Investigation expanded

Criminal Investigation

Multi-state Investigation

June‐July 03HCW graduates RT school in MI and certified as radiographer (not disclosing DUI)

2003‐2007HCW works in several MI hospitals

Nov 07“Staffing Agency A” places HCW at a hospital in NYS

March 08“Staffing Agency B” places HCW at hospital in PA

May 08Early termination: allegedly found with Fentanyl syringe + positive drug test. “Staffing Agency B” placed him again

June 08“Staffing Agency A” places HCW at Maryland hospital

Multi‐state Investigation: timeline

Timeline adapted from: http://dhmh.maryland.gov/pdf/Public%20Health%20Vulnerability%20Review.pdf

Sept 08HCW applies for radiographer license with MD. Multiple omissions in applications and license issued in Oct 08

Nov 08“Staffing Agency B” Places HCW at another MD hospital

Feb 09Early termination: falsifying time records and forging supervisor signature

March 09“Staffing Agency C” places HCW at a hospital in AZ

June 09 HCW applies to renew expired MD license. Multiple omissions and false answers. License re‐issues July 09

Multi‐state Investigation: timeline, cont.


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July 09“Staffing Agency D” places HCW at another hospital in MD

Oct – Nov 09Prior hospital offers HCW a second contract and permanent job. Later rescinds the offer in November

Jan‐March 10HCW work as permanent employee in another MD hospital. Quit w/o sufficient notice and classified “not re‐hirable”

March 10“Staffing Agency E” places HCW at another Arizona hospital

Early termination after being found unresponsive in restroom with a Fentanyl syringe

HCW admits to injecting. Claiming found syringe in lead apron

Hospital does not press criminal charges

“Staffing Agency E” reports HCW:American Reg of Rad Tech

Arizona licensing board – investigation starts immediately and HCW surrenders his license.



March‐ April 10“Staffing Agency F” places HCW at another hospital in PA

May 10“Staffing Agency D” places HCW at KS hospital6 patients at that hospital later test positive for same strain of HCV

June 10KS issues the HCW a license

Oct 10HCW works at a hospital in GA

Apr 11“Staffing Agency G” places HCW at hospital in NH where he is hired as a permanent employee on Oct 11.

May‐June 12 NH DPHS initiates investigation and notifies PH in other states



Final Multistate HCV Outbreak SummaryHCW worked in 17 facilities in 8 states

>12,000 patients possibly exposed

46 HCV‐infected patients identified as being associated with the outbreak

32 New Hampshire, 7 Maryland, 6 Kansas, 1 Pennsylvania

Infected HCW criminally charged Charges included fraudulently obtaining drugs and tampering with a consumer product

Pleaded guilty to all charges in August 2013

Sentenced to 39 years in prison in December 2013

NH and MD release public reports with numerous recommendations for prevention

Lessons LearnedMany facilities lack robust systems to identify and respond to suspected drug diversion

Lack of recognition that drug diversion introduces patient risk and understanding role of public health

Numerous information sharing gaps existRegulation needed to support information sharing across facilities about HCW suspected of drug diversion

Response can be challenging due to extensive legal involvement and multiple local and federal agencies

US Attorney, federal agencies, public health, and law enforcement conducting parallel investigations

Defining the Role of Public HealthSince 2012 outbreak, additional reports of HCW diversion of injectable drugs have been identified in NH

Including EMS providers and nurses

No patient illnesses were linked to these events

Urgent need to define role of public health in drug diversion

Key areas for Public Health involvement are:Patient risk assessment

Ensuring blood‐borne pathogen testing of diverting HCW

Facilitating communication and notification to appropriate agencies

Educating healthcare providers to prevent and identify diversion

Drug diversion has potential for public health risk and therefore is reportable to public health

Any suspect drug diversion must be reported within 24 hours

Outbreak Aftermath: Prevention and Response Activities in NH

Several statewide meetings on diversion for healthcare leadership

Educational materials provided to healthcare workers and healthcare facilities

Facilities have invited experts to assess prevention programs

Formation of several drug diversion task forcesEMS, facilities, legislative, law enforcement

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Outbreak Aftermath: Prevention and Response Activities in NH

Forming new and building existing key stakeholder relationships

Hospital association, Licensing Boards, law enforcement, Bureau of Drug and Alcohol Services, etc.

Legislative activityAdverse event reporting, Med Tech registration, drug‐free workplace, communicable disease administrative rules

Hospitals working internally on processes

Developed public health response guidelines

What have NH hospitals done?Assessed current processes and changed medication delivery systems

Evaluated current practices re: narcotics

Establish relationships (law enforcement, boards)

Educate and orient staff about behaviors of drug impaired coworkers

Implemented monitoring and audit practices that are more sensitive to detection

Revised policies re: drug testing

Evaluated hiring processes, references

Formed drug diversion teams and/or created new roles


Public Health: NH Expectations for Reporting

Drug diversion has the potential for public health risk and therefore is reportable

The two main goals:Identify

Determine the extent of public health risk

Any suspect drug diversion event must be reported within 24 hours


The NH HAI program will initiate investigation to determine if patients exposed to blood borne pathogens (Hepatitis B, Hepatitis C, HIV)

Steps:Ensure appropriate authorities notified

Test implicated HCW if not already performed (voluntarily or compel testing)

Coordinate low cost testing options if needed

If negative‐ public health investigation complete

Public Health: Expectations for Reporting, cont.


Consider patient notification and testing if the following conditions A,B, and C are all met

A) There is evidence of injection drug diversion in a healthcare facility

B) Method(s) of injection drug diversion may have put patients at risk for blood borne pathogens

C) Test results suggest alleged diverter may have been infected with a blood borne pathogen during times of employment




Guidelines include tools for healthcare facilitiesIncident Report Form

Drug Diversion Fact Sheet

Steps for healthcare facility prevention and response Adopted from national guidelines

Recommendation to involve infection control staff and other key programs/personnel

List: websites and other resources

List: contact information and agencies that need to be notified

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The Way ForwardContinue to identify and work with partners in drug diversion prevention

Apply lessons learned from drug diversion investigations to improve timeliness and quality of public health response

Investment of resources = prevention National drug diversion meeting

Developing facility tools

Health department tools


Helpful ResourcesPublic Health Vulnerability Review‐ Drug Diversion , Infection Risk, and David Kwiatkowski's Employment as a Healthcare Worker in Maryland – Maryland Department of Public Health & Mental Hygiene ‐March 2013

http://dhmh.maryland.gov/pdf/Public%20Health%20Vulnerability%20Review.pdf

AONE Guiding Principles: to protect patients from reckless behavior by registered nurses – 2011

Hepatitis Toolkit – HONOReform: http://www.honoreform.org/default.aspx

DOT drug and alcohol regs/procedures/data http://www.dot.gov/odapc

Diversion central: http://www.diversioncentral.com/

International Health Facility Diversion Association: https://ihfda.org/


Helpful ResourcesNational Association of Drug Diversion Investigators (NADDI):

http://www.naddi.org/aws/NADDI/pt/sp/home_page

MN Dept’ of Health and Hospital Association Drug Diversion Toolkit:

http://www.health.state.mn.us/patientsafety/drugdiversion/index.html

CDC and One and Only Drug Diversion information:http://www.cdc.gov/injectionsafety/drugdiversion/index.html

CDC Patient notification toolkit: http://www.cdc.gov/injectionsafety/pntoolkit/index.html

Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/

National Institute on Drug Abuse: https://www.drugabuse.gov/


AcknowledgmentsNHDPHS infectious disease team

State Police and Narcotics Investigation Unit

NH Hospital Association and Foundation for Healthy Communities

Bureau of EMS

CDC

One and Only Campaign

CSTE

Other state health departments (CO, MN, FL, MD, NJ)

HONORReform

NADDI

IHFDAKim New

Bureau of Alcohol and Drug ServicesPharmacy, Nursing, and Medical BoardsHealthcare facilities Infection Prevention Staff


Questions?

Follow us on Twitter @NHIDWatch New Hampshire Department of Health & Human Services

References:1) Kim New, JD BSN RN, Drug Diversion Presentation

2) Schaefer MK, Perz JF. Outbreaks of infections associated with drug diversion by healthcare personnel, United States. Mayo Clinic Proceedings.2014; 89 (6).

3) NHDHHS, DPHS. State of New Hampshire Hepatitis C Outbreak Investigation Exeter Hospital Public Report. Published June 2013. Accessed June 10, 2013 .http://www.dhhs.nh.gov/dphs/cdcs/hepatitisc/documents/hepc‐outbreak‐rpt.pdf

4) NADDI. Drug Diversion FAQs. Accessed June 12, 2014. http://www.naddi.org/aws/NADDI/pt/sp/resources_faqs

5) CDC. Risks of Healthcare‐associated Infections from Drug Diversion. Accessed June 13, 2014 from http://www.cdc.gov/injectionsafety/drugdiversion/index.html

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Katrina Hansen, MPHHealthcare‐Associated Infections Program Manager603‐271‐[email protected]

For More Information:

Documents

Overview The New Settings NH C Activities - One and … · prescription drugs in the past year (US, 2011) 11 million reporting nonmedical use of opioid analgesics No estimates