The growing perils of painkillers
The growing perils of painkillers
How the opioid crisis is affecting hospital safety and security
Healthcare organizations justifiably worry about increasing threats such as the Zika virus, active shooter incidents, and medical errors contributing to patient deaths. But perhaps their greatest topical fear should be the snowballing opioid epidemic and the consequences it can wreak upon medical facilities.
Consider that 78 Americans are killed daily from opioid overdoses and that overdose fatalities involving prescribed opioids have quadrupled since 1999, with over 165,000 people dying in the U.S. between 1999 and 2014, according to the CDC. Additionally, per the CDC, more than 1,000 people are treated each day in EDs for misusing prescription opioids, the most common being methadone, as well as the painkillers oxycodone and hydrocodone.
Aside from the devastating toll it takes on human lives, opioid abuse imposes an estimated $55 billion in societal costs every year, with $25 billion of that price tag going to aggregate healthcare costs in the United States, based on a 2015 report by Matrix Global Advisors.
Opioid patients and perpetrators can significantly jeopardize safety and security within a healthcare facility. But by recognizing the threats, assessing the areas of vulnerability, and following smart strategies, organizations can better safeguard their occupants.
The potential for aggression
Some hospital safety experts say patients under the influence of opioids put staff, fellow patients, and visitors at risk due to the risk of aggressive behaviors, especially acute drug poisoning admissions.
"Opioid use by patients coming to the ED remains among the most common reasons we call for security assistance in order to help manage violent patients," says Jeff Puttkammer, MEd, CPP, vice president of Healthcare Security for HSS, a Denver-based security provider for over 170 hospitals in 23 states across the country. "We often see numerous incidents occur where complete patient information is not immediately available, so Narcan [a drug used to reverse the effects of an opioid overdose] is not immediately administered and the staff is left to attempt to calm or restrain a patient. Often, other drugs like Ativan, Haldol, or Zyprexa are given to these aggressive patients and may not be as effective on them due to the potential opioid use."
Others say that hospitals need to prepare for individuals in the throes of an opiate addiction that have the potential to exhibit aberrant behaviors?from anger and confusion to violence?and create an escalating event. Sometimes these patients arrive voluntarily seeking treatment, but often they are rushed to the ED after an overdose or other medical emergency.
"You have to prepare for dealing with these folks as patients," says Steven MacArthur, senior consultant and safety expert for The Greeley Company in Danvers, Massachusetts.
Kristine Sanger, MT (ASCP), HCPCP, associate executive director of the Association of Healthcare Emergency Preparedness Professionals in Omaha, Nebraska, thinks staff safety is the biggest area of concern.
"The potential of someone high on narcotics for committing a violent crime in search of drugs is very high. Personnel in hospitals should be well trained on how to respond to this type of threat. Processes and plans should be in place, and they should be practiced frequently to ensure that all staff is comfortable with the plan and prepared for the threat," says Sanger.
Other related hazards
Puttkammer says opioid-influenced patients also present an infection control risk due to the fact that they may bring in and use their own needles from the outside, share needles with other drug users while inside the facility, or pilfer needles and supplies from the hospital, creating the potential for sharps injuries.
In fact, on the day he was interviewed for this article, Puttkammer says one of his officers was stuck with a dirty heroin needle while searching a visitor's bag at the entry point within a Colorado hospital. Without the search protocol in place, "this visitor would have been allowed to enter a patient care room and use the needle and the drugs in this bag at will," adds Puttkammer.
Increased theft and diversion of opioids are other concerns that healthcare organizations need to address. See p. 4 for an example of a drug diversion prevention checklist you can use on your security rounds.
"The opioid crisis has made hospitals and especially clinics a larger target for theft," says Matt Shaw, CHSP, director of public safety for Methodist Health System, a network of medical centers located in Nebraska and southwest Iowa. He adds that several hospitals in the network have observed a significant increase in internal and external drug theft. "Hospitals and clinics are open environments with minimal measures to restrict movement throughout the facilities?this is the ongoing battle between providing security and meeting the fire code."
Beyond the ED
Mark Rosenberg, DO, MBA, FACEP, chairperson of the emergency medicine department and medical director of population health for St. Joseph's Regional Medical Center in Paterson, New Jersey, says it should not be a surprise that some patients in the ED try to use drugs.
"Emergency department violence has increased nationwide and may be, at least in part, related to drugs and mental illness," he says.
MacArthur says the pharmacy, lab, and exterior grounds and parking lots are also particularly at risk, as well as physician offices and other off-site care locations.
"[Addicts] who are desperate are not necessarily going to be particularly discerning when it comes to identifying potential targets," he says. "Pretty much any portal to a hospital would have to be considered a potential vulnerability."
At Massachusetts General Hospital (MGH) in Boston, an epidemic-level of opioid abuse in the state has forced the facility to tackle abuse inside its own walls.
According to a report from WCVB-TV, hospital staff have been reporting heroin users shooting up in MGH bathrooms, walkways, and parking garages to more quickly get medical help in case they overdose. One tactic the TV station mentions involves users tying bathroom emergency pull cords to themselves so an alarm will sound if they collapse.
Although MGH claims drug abuse numbers are low on its premises, staff have noticed an increase in the last 18 months, the report says, and the hospital is now equipping security guards with the overdose-reversing drug Narcan. According to the report, Boston Medical Center is the only other facility in the area that follows the same protocol.
Puttkammer says common medical floors and wings are also risky areas. "There, we often see the use of IV ports placed by medical staff being used by patients for their drug addictions," he says. "We've observed more than a handful of times at a Colorado hospital where a patient either elopes with an IV port in place to use for later drug use or a patient shoots up while still in the hospital using an empty IV saline flush."
Addicts are resourceful, notes Puttkammer. "We even have patients who become MacGyver-like in their efforts to procure a needle or flush for later use?going so far as to fish dirty needles out of sharps bins using medical tape wrapped, sticky side out, around pens or markers with a length left at the end as a makeshift fishing line," he adds.
Peter Charvat, MD, an ED physician at St. Cloud (Minnesota) Hospital, agrees that it can be difficult to medically manage opioid patients while also maintaining a secure environment.
"You have to attend to the patient's medical needs as well as keep them and everyone else around them safe," he says, noting that St. Cloud Hospital has beefed up security around this issue by implementing a six-bed, sub-block secured unit for high-risk patients separate from the ED. The hospital also installed a metal detector in the waiting room that all patients have to pass through, hired off-duty police officers to supplement in-house security, equipped security officers with Tasers, and enlisted patient care assistants who carefully watch video-monitored high-risk areas.
"We see patients often come in with complaints of pain like backaches and the expectation that they'll be prescribed narcotics," Charvat says. "They may get confrontational and aggressive, which puts us in a tough position because pain can often be hard to diagnose."
He notes that "others are admitted as overdose patients who come out of it often in an aggressive or violent delirium state," and that "many [staff] think the answer is to put [patients] into restraints right away, but we're using more chemical means to calm patients down from these behaviors so that we can better treat them."
St. Joseph's Regional Medical Center is being touted as the first hospital in the U.S. to implement a program that will attempt to manage patients' pain in the ED without the use of opioid painkillers, according to a March 28 report from WPIX-TV in New York. The St. Joseph's ED, one of the busiest in the nation, has already treated more than 250 patients with alternative medicine or treatments instead of opioids. Although opioids will still be used to treat chronic pain, they will no longer be the first line of treatment.
"Our job here together is to look at the whole equation and understand how we can stop people from going from a prescription to an addiction," Rosenberg said in the report.
At the hospitals for which his team provides security, Puttkammer says security personnel often are called upon to assist in augmenting the patient care team by supplying one-on-one security assists to respond to a combative patient.
"This can require unique training and understanding on the part of the security officer in verbal de-escalation skills as well as recognition of the manifestation of an overdose," he says. "These one-on-one assists can last several days or weeks, which can create staffing and scheduling challenges as well as the need to divert security resources from other areas of the hospital."
Action?not just words
Ensuring the security and safety of opioid patients and the people around them without hampering the effective management of their medical needs isn't easy. To help, experts recommend these approaches:
- Ensure that hospital staff is appropriately trained in intervention techniques. "I advocate TEAM [Techniques for Effective Aggression Management] training or a similar de-escalation training program for all staff, regardless of discipline or function, as this issue affects the entire hospital," says Puttkammer, who adds that healthcare organizations need to be more proactive on this issue. "You don't want an officer or staffer who is not familiar with these specific issues potentially endangering themselves or others because they are ill-equipped to handle these patients."
Shaw recommends that security officers be trained in physical intervention processes such as pressure point control tactics and use of force protocols, and all employees should learn verbal intervention tactics "and defensive techniques such as blocking and kicks, releasing grabs, pulled hair, and bites."
- Harden the perimeter of care. "Implement access controls, require compliance with identification policies, and keep as few entry points open as possible," MacArthur says.
- Institute better opioid screening protocols for incoming patients. "If you can determine ahead of time that a given patient is an opioid user and may be suffering from withdrawal symptoms, you can better manage those symptoms and have fewer incidences of anger and frustration," says Tyler Oesterle, MD, MPH, medical director of the addiction treatment program at St. Cloud Hospital Recovery Plus.
- Designate a "safe room." Some experts recommend creating a special intake/holding area to treat high-risk patients?far removed from low-risk patients.
- Better prepare the work environment for opioid patients. "The security team, in conjunction with the patient care team, can begin to prepare patients' rooms by removing items which could present a danger to the patient or staff," Puttkammer says.
- Minimize security staff multitasking. "Security officers are not infrequently asked to do other tasks outside of their 'regular' duties, such as watching patients and tending to vehicle service calls like dead batteries and flat tires," says MacArthur. "These can divert resources away from their being able to make rounds."
- Employ a strict visitation policy for all high-risk patients. "Have all visitors for that patient sign a form that states what they can and cannot bring into the room with them. This should not be deviated from?make it your standard 'universal security precaution' for these patients," says Puttkammer.
Diversion risk rounds checklist
The group doing rounds should be small. Rounds consist primarily of observation. Staff should be asked the questions below periodically in each unit, but these questions aren't required on each set of rounds.
Determine where controlled substances are stored, transported, and used in each area and assess for security and handling practices:
How do controlled substances arrive in this location?
Is the transport method into the unit and after removal from the drug cabinet secure?
Where are controlled substances stored?
Is storage secure?
What is the process for removal of controlled substances?
Are institutional policies and procedures for medication handling being followed?
What is the process for returning unused controlled substances?
What is the process for wasting controlled substances (i.e., done at the time of removal or as soon thereafter as possible, with a witness)?
Are sharps and medication disposal containers visualized for integrity, and the presence of unspent syringes or vials and pills? (DO NOT REACH INTO SHARPS CONTAINERS!)
Per regulatory authorities, are all sharps containers secured so that unauthorized individuals can't easily remove them?
How are PCAs and controlled medication drips handled?
If required, are weekly drug cabinet inventories being done and documented?
Potential questions for staff:
How are patient medications from home inventoried/stored?
How are discrepancies resolved?
Do staff know what diversion is and how to report it?
Do staff know signs of diversion/impairment?
What are the biggest controlled substance security risks staff feel are present in their area (i.e., if I wanted to divert drugs, how would I go about doing it)?
In procedural areas:
Are controlled substances removed from the cabinet early and placed in a location where they will be available during a case?
If medication is removed early, is it labeled by patient, initialed by the staff member, and kept secure at all times during the procedure?
Are there handoffs of controlled substances?
How does wastage occur?
Is waste tested by refractometry, and if so, is this being done according to policy?
Is there ongoing auditing done of drug transactions in this area, and if so, by whom and how often?