Epidemiological Trends

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Patient Safety Monitor Journal | 3October 2019

Q : There have been cases where someone fired for diverting drugs is hired at a dif- ferent facility and does the same thing. Once you fire someone for drug diversion, what can be done so that other facilities that might hire the person are made aware of it? Can you re- veal that info?

New: Itinerant diverters continue to be a major issue in the U.S. The best way to protect patients and institu- tions downstream is to undertake robust reporting, and that means to law enforcement, DEA, and any relevant professional board.

Q : What are some resources for hospitals to do a drug diversion background check on a potential employee?

New: Generally, federal regulations prohibit employing someone with a criminal history involving certain drugs. 21 CFR § 1301.76(a) states a registrant must not employ in a position which allows access to controlled substances any person who has been convicted of a

felony relating to controlled substances, or who, at any

time, has had an application for DEA registration

denied, revoked, or surrendered for cause. For this

reason, doing a criminal background check is vital.

The DEA encourages facilities to make inquiries into

past experiences that might flag the possibility that the

candidate could be involved in a drug security breach.

Specifically, DEA states that aside from criminal convic-

tions, unauthorized use of controlled substances is a

proper subject for inquiry. The DEA guidance can be

found here: https://www.deadiversion.usdoj.gov/pubs/

docs/clarify21cfr130190-52213.pdf#search=preemploy

ment%20screening.

Q : Is there a way to ensure that pre-pulled drugs aren’t diverted? New: Typically drugs shouldn’t be pre-pulled, but if this

must occur, the facility should provide a secure locking

location for temporary storage of the medication.

by John Palmer

As it turns out, training works when a hospital con- ducts active shooter drills.

There’s been a lot of talk in emergency preparation circles about the need for hospitals to establish a plan of action in the event of an active shooter incident in the facility. For several years, regulatory agencies including CMS, The Joint Commission, and NFPA have been working on establishing standards—albeit with vague, nonspecific instructions—that would help healthcare facilities train better through drills and other safeguards.

After a gunman open fired at a Walmart in El Paso, Texas, on August 5, the emergency department at Del Sol

Emergency preparation

An El Paso hospital trained for a mass shooting Then they got the real thing

Medical Center—about three miles away—was immedi- ately flooded with patients. The shooting left 22 dead and 26 injured, and was the culmination of two mass shoot- ings in the U.S. in a 24-hour period. A day earlier, another gunman opened fire in a nightclub district of Dayton, Ohio, killing nine and injuring 17 others.

Like several other hospitals that have faced the same scenarios in recent years—facilities in Orlando, Aurora, and Las Vegas, to name a few—the hospital staff responded as best they could in the face of unimaginable stress to save lives, maintain order, and keep their own facility safe. Del Sol Medical Center officials said they were able to respond so well to the shooting because the hospital had recently run an

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4 | Patient Safety Monitor Journal October 2019

active shooter drill—one that almost exactly mimicked the real scenario they faced on August 5.

“We actually brought people into the hospital to do a dry run of a situation just like that,” Stephen Flaherty, MD, a trauma surgeon at Del Sol, said in a report with Yahoo News. “So we have been through this before, without the real patients.”

This preparation mock drill is just one example of what hospitals nationwide have begun doing to prepare for what seems to be a common occurrence these days. In fact, mass shootings are so common that regulators have gotten serious about requiring hospitals to do their own preparations, though they’ve stopped short of giving them actual guidelines.

The NFPA in May 2018 passed what is being called the world’s first-ever active shooter/hostile event standard to help hospitals prepare and respond to shooter events in their facilities. Dubbed NFPA 3000, or more technically, “Standard for an Active Shooter/Hostile Event Response” (ASHER), the program was released officially in May 2018 and is designed to help communities holisti- cally deal with the fast-growing number of mass casualty incidents that continue to occur throughout the U.S. in healthcare facilities. NFPA 3000 provides unified plan- ning, response, and recovery guidance, as well as civilian and responder safety considerations.

Orlando Regional Medical Center experienced an overwhelming influx of patients as a result of the Pulse nightclub attack that occurred in June 2016, becoming one of the deadliest mass shootings in U.S. history.

The attack at Pulse, only three blocks away from the hospital, taxed Orlando Regional in a way few facilities are prepared for. Over a two-hour span, 44 of the 53 wounded victims arrived at the hospital’s emergency department (ED); staff scrambled to accommodate the surge as victims flooded the facility’s hallways and reports emerged of another gunman at the hospital.

Following that attack, the NFPA announced in Octo- ber 2016 the intent to assemble a group of experts on active shooter/hostile incident response to develop a new standard for preventing and responding to active shooter events.

The standard’s aim is to establish preparedness, response, and recovery benchmarks with a focus on integrated protocol and civilian and responder safety. It provides guidance for organizing, managing, and sustaining an active preparedness and response program to reduce the risks, effects, and impact of hostile events.

“The unfortunate reality is that this is the world we live in, and we were prepped for this,” David Shimp, CEO of Del Sol Medical Center, told CBS affiliate KDBC-TV in El Paso.

Accreditors slow to provide guidance

While the NFPA’s guidance stops short of giving specific instructions on what to do in the event of an active shooter, it serves as a starting point for hospitals to take preparations into their own hands, and has led to the development of preparation “toolkits” in health- care organizations around the country.

Many of the toolkits being developed include guide- lines for conducting real-life mock active shooter drills, covering things from patient triage and family reunifi- cation to managing media and caring for staff.

Some of the mock drills being run also include dealing with patient arrival, which can be a major hurdle. In Orlando, patients arrived on the backs of pickup trucks and poured into the ED entrance, leading to hallways being lined with patients. The same thing happened in 2012 after the mass shooting at a movie theater in Aurora, Colorado, killing 12 people and injuring 70.

During the emergency response to the Aurora shoot- ing, ambulance crews were hampered by chaos in the parking lot that resulted in police officers taking victims to hospitals in their cruisers. In some cases, hospitals didn’t know shooting victims were on the way until the cruisers showed up at their doors.

In many current drills, hospitals are practicing such “self-evacuation” scenarios, where victims come to the hospital on their own by walking, personal vehicles, or other means that make it difficult for ED staff to prepare.

One section of the new NFPA 3000 pertains to facility preparedness and best practices for handling a hostile

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Patient Safety Monitor Journal | 5October 2019

event that may take place on-site at hospital facilities and medical campuses. A separate chapter addresses preparedness and response for out-of-hospital inci- dents for those facilities that have the capabilities to receive outside patients, such as EDs.

“While it is not expected that NFPA 3000 will be adopted by the Centers for Medicare & Medicaid Services (CMS), the standard could be adopted at local, regional, or state levels,” said Chad Beebe, deputy executive director for ASHE, in a statement at the time of the document’s passing. “Even if it is not adopted in a hospital’s jurisdiction, the standard outlines important elements that should be included in a facility’s emergency and security management programs.”

In other words, hospitals have more or less been on their own in preparing for active shooter events, while accreditors remain vague in the language of their standards.

The Joint Commission (TJC), for instance, released Sentinel Event Alert #59 in April 2018 to bring light to the problem of violence against healthcare workers such as physicians and nurses, coinciding with Work- place Violence Awareness Month.

“Leadership needs to make the safety of health care workers a top priority and encourage candor in report- ing. Health care workers are often hesitant to report violence because they think that it is part of the job or believe that patients are not responsible for their actions,” said Ana Pujols McKee, MD, executive vice president and chief medical officer for The Joint Commission, in a press release.

“When violence occurs, it should be immediately reported to leadership, internal security and, as needed, to law enforcement. Such reporting can help health care organizations analyze what happened and inform actions that need to be taken to minimize risk in the future.”

TJC literature says little about preparing for active shooters. Most information related to active shooters on the TJC website directs users to vague government

resources that still teach “run, hide, fight” and can apply to generally any workplace.

CMS has been even more vague about preparation, but the agency sure wants hospitals to know they are expected to be ready for anything.

The new emergency preparation (EP) standard adopted in 2016 went into effect in November 2017 and requires hospitals to prove they can stay operational for 96 hours in the aftermath of a major disaster. It followed the adoption of the 2012 Life Safety Code®.

The new EP requirements were proposed by the Department of Health and Human Services in Decem- ber 2013, and were passed to prevent the disruption of hospital services on a mass scale such as that experi- enced during Hurricane Katrina in New Orleans and Hurricane Sandy in New York City.

Specifically, it requires 17 types of suppliers and providers that rely on Medicare and Medicaid funding to adopt the changes, including adoption of an “all- hazards” emergency plan, similar to what TJC now requires for accreditation. Theoretically, that includes an active shooter incident.

The rule requires not only hospitals, but smaller healthcare facilities such as ambulatory surgery centers, elder care facilities, and behavioral health long-term care facilities to “adopt changes necessary to ensure the long-term safety and well-being of their patients during a crisis.”

For a sample Mass Casualty Incident Response Toolkit from the Greater New York Hospital Association, check out https://www.gnyha.org/tool/mass-casualty- incident-response-toolkit/.

Questions Comments & Ideas

Contact me at [email protected] or 800-650-6787 ext. 3430.

– Brian Ward, Associate Editor

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