Overview The New Settings NH C Activities - One and … · prescription drugs in the past year (US,...
Transcript of Overview The New Settings NH C Activities - One and … · prescription drugs in the past year (US,...
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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
New Hampshire Department of Health & Human Services
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
New Hampshire Department of Health & Human Services
Drug Diversion Background
Picture from: http://www.newsweek.com/2015/06/26/traveler-one-junkies-harrowing-journey-across-america-344125.html
New Hampshire Department of Health & Human Services
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
New Hampshire Department of Health & Human Services
Figure from: http://www.cdc.gov/injectionsafety/drugdiversion/drug‐diversion‐2013.html
New Hampshire Department of Health & Human Services
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.
Timeline adapted from: http://dhmh.maryland.gov/pdf/Public%20Health%20Vulnerability%20Review.pdf
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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.
Multi‐state Investigation: timeline, cont.
Timeline adapted from: http://dhmh.maryland.gov/pdf/Public%20Health%20Vulnerability%20Review.pdf
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
Multi‐state Investigation: timeline, cont.
Timeline adapted from: http://dhmh.maryland.gov/pdf/Public%20Health%20Vulnerability%20Review.pdf
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
New Hampshire Department of Health & Human Services
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
New Hampshire Department of Health & Human Services
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.
New Hampshire Department of Health & Human Services
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
Public Health: Expectations for Reporting, cont.
New Hampshire Department of Health & Human Services
Public Health: Expectations for Reporting, cont.
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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New Hampshire Department of Health & Human Services
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
New Hampshire Department of Health & Human Services
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/
New Hampshire Department of Health & Human Services
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/
New Hampshire Department of Health & Human Services
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
New Hampshire Department of Health & Human Services
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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New Hampshire Department of Health & Human Services
Katrina Hansen, MPHHealthcare‐Associated Infections Program Manager603‐271‐[email protected]
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