June 25, 2012

Could The Exeter Hep C Outbreak Have Been Prevented?

By  Michael D. Shaw

You can bet that this question is foremost in the minds of hospital administrators—and not only those at Exeter Hospital. As of this writing, the number of victims has increased to 20, and the boundary date for testing has been pushed back to October 1, 2010. At least 1,175 patients have been identified as being candidates for testing, and more than half of them have already been tested.

To make matters worse, either the hospital or the state of New Hampshire—or both—were responsible for mishandling blood samples that were drawn on June 7 and 8, and were picked up on June 9 by the state’s courier for testing. The state insists that the samples were not received within the 72-hour window, after which they expire. Thus, many people will have to be re-tested, and a number of them are not at all comfortable about returning to the “scene of the crime” to have this done, as one observer put it. Provisions will be made for alternative testing locations.

In a prepared statement, the hospital noted that “[It] is committed to determining, together with the state, why these samples were not processed within the required 72-hour time frame, even though they were picked up from Exeter Hospital on Saturday by the state’s courier.” Cold comfort indeed to those affected, and hopefully not indicative of an odd and supercilious lack of focus on the matters at hand.

While it has not been conclusively proven, many officials believe that the outbreak was caused by what is euphemistically referred to as “drug diversion.” In July, 2003, the Colorado Board of Nursing published a resource manual entitled “The Impaired Nurse.” In this work, drug diversion is defined as occurring “[W]hen a controlled substance or a drug having a similar effect is not used as prescribed. Drug diversion includes obtaining a controlled substance or drug having similar effects from wastage.”

In the Exeter case, the likely scenario involves a hep C-infected employee using a syringe to withdraw a drug from a multi-dose vial, and making up the loss in volume by using the same syringe (now infected with the hep C virus) to inject a volume of saline back into the vial.

Many recommendations to prevent diversion were made in the Colorado manual including:

• Prohibit nurses from sharing or revealing their controlled substance access codes
• Regularly monitor how drugs are administered, wasted, and documented
• Regularly inspect controlled substance packaging and appearance for drug substitution
• Learn common behaviors displayed by nurses with chemical dependency problems
• Audit automated drug dispenser reports on a routine basis

Ironically, six years after that manual appeared, a Colorado surgery technician was sentenced to 30 years in prison for infecting 39 patients with hepatitis C, in a classic drug diversion case.

Findings summarized in a recent article in the Annals of Internal Medicine state that “More than 4% of health care workers have acknowledged illicit drug use, and prevalence of abuse has been reported to be higher in subsections of the health care workforce directly involved in administering controlled substances to patients, such as anesthesiologists and nurses.”

In a world where some of us are terribly concerned over drug abuse by athletes, random drug testing of health care workers would seem like a no-brainer. While this is opposed by groups representing the workers, it is also regarded as a sort of “third rail” by regulatory agencies, although the situation may change after Exeter.

What about bringing in the tools of strategic planing to help prevent such infection control breaches? I recently spoke with Scott Regan, Founder & Chief Execution Officer, of AchieveIt—a company that bills itself as “your virtual strategic planning and quality improvement consultant.” AchieveIt is deeply involved in cloud-based strategic planning and quality management software solutions. The company started off in the health care industry, and recently branched out into other fields.

Scott commented that quality improvement, as often practiced in health care settings, consists of a quick project, but it is usually not followed-up. Thus, controls are not being put in place to ensure that what was fixed becomes hard-wired into the system. He also mentioned a new product, ImproveIt.

Scott told me that ImproveIt is built around leading quality improvement methodologies—including Lean, Six Sigma, and PDSA—allowing organizations to achieve breakthrough levels of quality improvement. He stressed the importance of identifying the root cause of why some adverse event occurred. In addition, he stated that hospitals must do a better job of defining the customer value proposition—a key component of strategic planning—regarding its employees.

After all, these breaches will virtually always be related to employee misconduct of some sort. Given the shortage of health care employees, hospitals need to have a relevant strategy in place to attract the best people. “How can you have a strategy without really knowing what it is that you stand for as an employer, beyond being a ‘great place to work’?” Scott asks.

Lest we forget, there is also a customer value proposition for the patients, which must have at its core “First do no harm.”