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Alex Yampolsky – Stopping Drug Diversion at Your ASC
88 Plays7 months ago
Alex Yampolsky is the CEO of MedServe, and he will join us this week to share insights into how you can stop drug diversion at your ASC. Drug diversion is not a topic we’ve covered yet, and I think the work Alex and his team are doing is super important. I’m excited for everyone to hear our conversation and hopefully implement some of Alex’s advice. We cover the most vulnerable areas in an ASC, tools that ASCs are using to help, some red flags to look for, and how to build a culture where staff feel comfortable addressing their concerns with leadership.
After my conversation with Alex, we’ll switch to our Data & Insights segment. Today, we’ll break down the average OR and Recovery Times per specialty. Every minute in the OR and Recovery Area counts, so while patient safety is the number one priority, it’s essential to look at the industry averages to see if you have the opportunity to increase efficiency.
Resources Mentioned:
HST’s State of the Industry Report
Aromatherapy's Role in Decreasing Postoperative Nausea and Vomiting
Brought to you by HST Pathways.
Recommended
Transcript
Podcast Introduction and Focus
00:00:01
Speaker
Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guests, and then we'll close the episode by recapping the latest news impacting surgery centers.
Episode Overview with Alex Janpolsky
00:00:17
Speaker
We're excited to share with you what we have, so let's get started and see what the industry's been up to.
00:00:28
Speaker
Hi, everyone. Here's who you can expect on today's episode.
Understanding Drug Diversion in ASCs
00:00:32
Speaker
Alex Janpolsky is the CEO of MedServe, and he joins us this week to share insights into how you can stop drug diversion at your ASC. This is not a topic we've really covered at all yet, and I think the work that Alex and his team are doing is super important. So I'm excited for everyone to hear our conversation and hopefully implement some of Alex's advice.
00:00:55
Speaker
We cover the most vulnerable areas in a surgery center, tools that ASCs are using to help, some red flags to look for, and how to build a culture where staff feel comfortable addressing potential concerns with leadership. And after my conversation with Alex, we will switch to our data and insight segment.
Data Insights: OR and Recovery Times
00:01:16
Speaker
And today we'll break down the average OR and recovery times per specialty.
00:01:23
Speaker
As you know, every minute in the OR and recovery area counts. So while patient safety is of course the number one priority, it's important to look at the industry averages to see if you have the opportunity to increase efficiency. Hope everyone enjoys the episode and here's what's going on this week in Surgery Centers. Alex, welcome to the show. Glad to be here. Can you share a little bit about yourself, please?
00:01:53
Speaker
Sure. Alex Imposky. I'm a pharmacist. I'm the CEO of MetServe and MetServe is the only digital narcotic cabinet and management system built specifically for surgery centers. And I live and breathe drug diversion prevention. I love it. We've got to get some merch. Maybe we've got a link to the, to your merch in the episode notes eventually. I know. We should start selling the shirts. Everybody I talk to, they're like, Oh, I like it. Can I have one of those shirts? Cause it also has a fancy, like all of these like fancy art work on it. Love it. That people get a kick out of.
00:02:22
Speaker
Perfect. Cool. So this is not a topic that we've covered yet, but I think that the work that you're doing is super important. So I'm excited to have you on so we can all learn a little bit more about how we can stop drug diversion from taking place at surgery centers.
Challenges and Detection of Drug Diversion
00:02:38
Speaker
So from your perspective, how prevalent is drug diversion in an ASC setting?
00:02:46
Speaker
It's a tough one to answer. So when we look at statistics, so I know Becker said something out where it's assumed that about 95% of drug diversion goes undetected. And a lot of drug diversion also goes unreported because who wants that bad PR of their nurse or their anesthesiology stealing from their center. We don't hear a lot about a lot of cases, a lot of cases we just never find out about, but yet there's something in the news every single day. I don't know. Most people probably aren't like me and don't have a
00:03:15
Speaker
Google Alert set up for one drug diversion in news articles, but I see something new every week. Whether it's a nurse at a hospital swapping out fentanyl with saline and then patients dying or a nurse at a fertility center stealing hundreds of vials of fentanyl or it happens all the time, but we only hear about a fraction of what's actually going on.
00:03:34
Speaker
Yeah, I'm sure every nurse, anyone who's been in the industry for a while has their own stories, whether they've, situations that they've been aware of, whether they've come out publicly or not. So I'm sure everyone listening can relate to this in some sort of way. In a surgery center setting, what are the most vulnerable areas that you typically see? So it's actually shocking to me when I first found this out.
00:04:05
Speaker
You know, coming from a health system, we expect technology. We expect there to be electronic medical records. We expect there to be medication dispensing cabinets. And when we step foot in most surgery centers, it's like we've traveled back in time.
00:04:18
Speaker
I'm sure your listeners and you know this, probably about 98% of surgery centers still keep their narcotics locked in a regular double locked cabinet with a paper log. They may have a camera nearby. They may have another lock on the door, but the reality is that is the most vulnerable area. People can access it after hours. Nobody knows when it's been opened. Nobody knows what's gotten in or out of it.
00:04:39
Speaker
And it's an honor system. There's a paper log where you record your activity. And for us, we see that as one of the biggest areas of mass diversion, where hundreds of vials can go missing over time. My current diversion usually happens at a wasting level. So if you, let's say, used a fentanyl vial, but then you use all of it for a patient and you have some left,
00:04:58
Speaker
That get, that's where abusive a lot of times happens as well, that half a syringe you can, or half a vial, you can figure out a way to use it and divert it and not actually properly document the waste. That's a small scale, large scale as the cabinet. Got it. So most vulnerable area would just be the lack of documentation, required documentation. And I think it's the lack of oversight, I'd say it's, there's an ability to access the entire narcotic stock without any oversight.
00:05:27
Speaker
And I think that's the biggest issue. Sure. Anybody ever known that you've been in there. Yeah. Wow. Okay. So considering 98% of ASCs, that's their process. What tips do you have for preventing drug diversion? I guess if that is their process, but then also just in general, what tips do
Preventing Drug Diversion: Tools and Strategies
00:05:47
Speaker
you have? What tools could they be using? Yeah. Well, we see really helpful. So of course there's technology solutions out there. And I think like until.
00:05:55
Speaker
You know, our company MetServe, we play in this space. This is exactly what we do. And until last, there really hasn't been a solution that was priced and built for surgery centers. So that's why so many were stuck. They couldn't afford the technology. So if you can afford a technology and that is very affordable now, but if you still can't do that.
00:06:12
Speaker
having two people as much as possible, having redundancies in the process and figuring out a way to have key control and cabinet control so that you know when somebody has been in there there's oversight. It's hard to do because so many centers are short staffed or
00:06:27
Speaker
just step just right and that's hard people do struggle with it but the best thing you can do is have somebody else looking over someone's shoulder when they're interacting with narcotics and there's different places where this happens a drug order comes in from a distributor from the manufacturer and it sits somewhere in the center then it gets stocked into the cabinet then it gets removed from the cabinet for anesthesia or for patient use then it gets expired or wasted and there's these different touch points
00:06:51
Speaker
that we talk to many customers about, and they know many in the industry who specialize in this, also talk about and how to prevent it. But there's those specific touch points where drugs are accessed, where you really should have two people, and it's not the same two people. Interesting. Okay. Kind of gives you those, that checks and balances. So maybe one person orders, but then somebody else documents. Is that... Yeah.
00:07:17
Speaker
what you're thinking. Okay. Yeah. Yeah. And then actually I personally was involved with a case of what it wasn't in a surgery center, but we had a pharmacist that I worked with who was a mentor of mine when I was a student who we ended up catching years later stealing 120,000 Vicodins and thousands of oxycodone, thousands of Valium. And the way that he got around it was he had, he ordered medications out of the normal process. Then they were received by him, stocked by him and then removed by him.
00:07:44
Speaker
And they never made it into the inventory of the pharmacy. So yes, definitely having different people do different things. And what we see a lot of times, too, in surgery centers, there's the pharmacy nurse. There's that one person that takes care of the pharmacy needs because it's a skill set that's learned for most nurses. It's not something we do. We see them do in hospitals a lot. And they become the one point of contact, the one point of control and oversight. And then that's a problem.
00:08:11
Speaker
Yeah, I can see that thinking about tools aside from having, you know, a cabinet that is built for this, let's say they, they can't afford it or for whatever reason, don't have the cabinet. You had mentioned cameras.
00:08:23
Speaker
before, so like video surveillance, what else? Yeah. So some other tools is, yes, having that eye above, right? So that at least when somebody goes into the cabinet, they know that they're under a supervision. The other thing that we see a lot of places now is batch scanning at the door. At least we know if somebody access the supply room or pharmacy room or medication room, whatever facilities call it, we know that there's a record of them going in. And if somebody goes in after hours, hopefully someone's looking at it to understand that, Hey, why is this person going in after hours and spending time in this room?
00:08:54
Speaker
Those are some tools that we see quite a bit of. I think they've been helpful, at the very least, to deter the person and scare them that somebody else is looking over their shoulder. Yeah, absolutely. What about prefilled syringes? Have you seen that help at all? Yeah. We have anything you can do to minimize the waste. If you can have prefilled syringes, temper evident caps, anything along the lines to help limit the waste, limit those potential areas of abuse,
00:09:22
Speaker
Unfortunately with shortages, a lot of times we saw centers ending up having to buy larger quantities. So they'll buy five milliliter vial instead of a two milliliter vial, which they normally would buy. And then there's quite a bit of waste leftover. And again, those are big areas where they can get diverted because initially it just, when somebody does it once and don't get caught, they realize they're not being watched. And then it just escalates. And that's when they end up going from taking a little bit and using that once to stealing hundreds of vials.
Behavioral Red Flags of Drug Theft
00:09:52
Speaker
Sure. So what would be kind of some red flags associated with a staff member who might be doing something they shouldn't be and stealing drugs? Well, so from what we've seen and I've seen throughout my career is unfortunately it ends up being a lot of times the person you suspect the least. It's the person that puts in the most work. It's the person that
00:10:17
Speaker
takes on the majority of the responsibility. And it's really sad because it's someone that you trust. But that aside, the things that happen that we call them red flags in behavior, obviously outside of being impaired at work, which happens, and there have been cases that I've heard about anesthesiologists being impaired at work because they're abusing the wasted narcotics, changes in behavior. So somebody who's been punctual,
00:10:41
Speaker
All of a sudden starts missing work, showing up late. Somebody all of a sudden volunteering to help in the supply room or in the medication room and take control over it. Even though we want people to take, to take on more and to take ownership of things. A lot of times that is actually a red flag because the person that's closest to it is the person that has the most access. And they have sometimes a reason for why they want to do that.
00:11:02
Speaker
The other thing is, and this is very basic, and I can't even believe that I have to say this, but when vial caps come off really easily, that's not normal. They should be a click. There should be a pop. We know what it should be like normally. When patients complain that their pain isn't well controlled, yes, some people maybe don't respond to a pain medication like somebody else does. But when this happens over and over, we can see a trend.
00:11:25
Speaker
And there've been many cases documented where there've been complaints and nobody paid attention. So we need to be on the lookout for it and having a great, you know, I'm a pharmacist by training. That's not, that's not what we do now, but having a great consultant pharmacist work with the center, they can educate the staff on the things to look out for, like those red flag behaviors, like the policies and procedures, like what to do when there's a shortage or when there's a discrepancy in the inventory counts. A lot of these things could be, you can build systems around it.
00:11:52
Speaker
Yeah, that's actually a great segue. So with the policies and procedures, is it typical to have something in there about if a staff member unfortunately becomes suspicious of another staff member? How do you build a culture where they're comfortable or someone's comfortable reporting that or knows what to do next? Training. Training and talking about it. That's really the best way to do it and not blowing people off.
00:12:20
Speaker
We've had cases where somebody's been like, yeah, you know, this person's been acting goofy, but I didn't even bring it up because in the past when they brought up my concerns, they've been just kind of tossed to the side. Like, I didn't even bother. We've definitely heard things like that and that's terrible. And, but yeah, it all goes back to the culture of the center and the type of team, teamwork that you have and openness and communication and training. People need to know to look out for these things, what to look out for and that they know, and they know who to report to.
00:12:45
Speaker
Sure. And I've heard you mention in the past mock investigations. So how do those typically go down? And I'm sure that would help to build that culture and that transparency. Yeah. So here's what happens in some centers. It's end of the day, most of the people are already gone. The people involved are definitely gone. Or
00:13:07
Speaker
could be gone and you find the discrepancy and you just have to just people stay after work. You're trying to not let anybody leave without until you figure it out and you're scrambling. You don't know where to look. You don't know which pages. So those things can go much smoother. You have to practice. And I suggest that people do these fun. It's, it could be like a fun team building activities. Hey, let's play pretend we're short to fentanyl. How do we, who do we look at? What do we look at and how do we get
00:13:36
Speaker
to the answer really quick because usually it's not stolen. Usually it's just not recorded properly. Somebody didn't add correctly or subtract correctly. It's a goofy mistake usually, but sometimes it's not. And having these mock investigations, having different people involved could be fun for the center, but it also can get the center more prepared. You know, we do drills. We do fire drills. We do, we can do a diversion drill as well.
00:13:57
Speaker
Yeah, I think that's great advice. Yeah, really interesting. I would love to hear from surgery centers who have done a mock investigation or something similar like that, just to hear how it was received by the staff and how it went. I think that'd be really interesting to hear some firsthand perspective.
Case Study: Yale Fertility Clinic Lawsuit
00:14:13
Speaker
All right, so I do really want to talk about the lawsuit that's going on right now with Yale's reproductive... Is it their infertility clinic, I think? Yeah. There's a class action lawsuit. Please share what's going on there and the latest. Yeah. If any of the listeners haven't heard about this, it's really a terrible case. And I guess drug diversion in general is terrible on so many different fronts. We tend to think about it from impact
00:14:43
Speaker
to the employee, maybe impact to the culture of the center, maybe DEA fines and the regulatory things. Sometimes we think about the patient side of it. And what happened with, in this case, it turned into a murder mystery podcast almost. That was super popular last year. And it really, I think, shined the light on the patient harm here. So what ended up happening is there was a center where a nurse was diverting fentanyl, replacing it with saline, patients going through egg retrievals.
00:15:13
Speaker
basically didn't have any pain medicine on board. No matter how much extra medicine they got, there was no pain relief. And there were many layers here from the nurse to the culture of the facility.
00:15:27
Speaker
to doctors blowing patients off and thinking like, oh, it's something about you. It's not us because I just gave you some fentanyl or whatever the medication was. But at the core, kind of, when we look under the hood, what actually ended up happening that led to this. And this went on for a very long time. I can't remember how long the nurse admitted to doing it for, but there were patient reports of same situations years before. Wow. This was a nurse who was the main nurse at the center. So patients referred to her, they had her as
00:15:55
Speaker
Donna REI, like when they called the clinic, they were calling her. She handled refills. She handled a lot of stuff. She was the go-to for these people. She was the source, the person that they trusted. And what ended up happening, she was having family issues, abusive husband, and going through a messy divorce, and a whole lot of stuff that she didn't really bring to work, except that she couldn't handle it. And she started diverting. And from what we've learned is she was initially started diverting right in the center.
00:16:22
Speaker
and using it on the job. And eventually, when she went on for so long, she started just taking files home, using them at home, replacing them with sailing, sometimes returning them, sometimes not because nobody kept track. And when we look deeper, why did nobody keep track? Well, there was a new administrator that started, trusted the team, trusted the original process.
00:16:44
Speaker
Trusted Donna to continue to manage the pharmacy aspect of it. Donna was the person ordering, keeping up the logs, basically keeping track of all that paperwork. And if she never raised a flag, there was no flag raised. The other thing was that this particular center was just skeleton crew, understaffed. And the other thing was when they interviewed some nurses that worked there and the nurses said they were shocked when they stepped foot in the center. It's like they went back in time. There was no automation for medications.
00:17:11
Speaker
They're used to having a pixus or an Ami cell in the hospital, but there was no automation in the center. It was manual paper log, double locked cabinet. So all of those things kind of combined ended up leading to this case where so many women ended up going through egg retrieval procedures with no pain medicine on board, suffering like tremendous pain and the pain that they like, they kind of had to proceed with. They couldn't just, there was so much prep work, so much emotional investment and financial and time.
00:17:38
Speaker
And this is the time to do it. This is the window and I have to suffer through it. And there was so much post-traumatic, so much trauma after the fact that a lot of women were left very scarred by this. And yeah, it's a terrible case.
00:17:52
Speaker
It's such, it's so layered because any drug diversion is horrible, but especially at an infertility clinic to your point, it's like, there's already been so much emotional pain, so much physical pain leading up to this, so much sacrifice leading up to this point to then that have been your experience, especially knowing that it could have been caught a while back if maybe people were paying closer attention or maybe they just had, you know, more staff. So being from Connecticut.
00:18:19
Speaker
I'm very familiar with this case, but it's interesting because if we go back to the red flags that you mentioned earlier in the episode, it sounds like they were all prevalent where, or like the person, nobody suspected, you know, just happening over time, patient complaints, like there were patterns leading up to this, to the point you made earlier. And what was the final straw? Like how did it all kind of come to a head? And theesthesiologist noticed that the cap came off too easily on fentanyl vial and that triggered an investigation.
00:18:49
Speaker
and reported it and that triggered an investigation. But to your point, had somebody else, there were red flags. There were patients complaining of pain during, after, and some people have to come back time after time to do this because the first attempt may be unsuccessful.
00:19:07
Speaker
Had this been, had flags been raised earlier, it would have triggered an investigation earlier. But yeah, so in this easiologists popped the fentanyl cap came off too easily reported it triggered an investigation. And then Donna knew that was it. And over the weekend, I believe she brought in 175 vials and dumped them into their sharps container. Like she was ready to get caught at that point.
00:19:29
Speaker
Yeah, jeez. Is it completely over? Are they in court going through settlements now? I think it's going to be going on for a while. Okay. The case itself is that the charges have been the legal aspect of it with Donna.
00:19:45
Speaker
That's been dealt with and that's over now, but the lawsuits, that's going to probably continue. Yeah, geez. Well, I hate to end on a heavy note, but I think that it's an unfortunate but realistic case of how easily this could happen and how prevalent it is. And you might not think it's happening at your surgery center. No one wants to think that it is, but it very well could be. But I think you've given a ton of great advice and just reminders for everyone listening of how they could kind of do their part.
00:20:16
Speaker
So we do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers? So I'm going to do two. I'm going to say look into technology, of course, but secondly, do these mock investigations and see where you have areas where you have a hard time pinpointing who the offender is. And those are the areas you should focus in on having extra oversight in.
00:20:44
Speaker
Perfect. Thanks, Alex. We appreciate you coming on. Thanks for having me.
State-of-the-Industry Report on OR Times
00:20:51
Speaker
Welcome to Data and Insights, where we turn data into dialogue and numbers into narratives. So HSC Pathways released a state-of-the-industry report late last year highlighting best practices, key process steps, and KPIs for every step of the patient journey and for nearly every recurring administrative duty.
00:21:11
Speaker
Most importantly, using our own unique dataset from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers. Two quick disclaimers, we only pulled data from clients who gave us permission and we omitted any extreme outliers. So today we'll be looking at two very important metrics, OR duration per specialty and recovery times per specialty.
00:21:37
Speaker
So let's start with OR duration. After analyzing data from over 450 ASCs across the country, we determined that on average, the top three longest OR times are plastics with 164 minutes, dental with 67 minutes, and ortho with almost 62 minutes.
00:21:59
Speaker
Our data analysts derived this metric by first categorizing each primary CPT code into one of the top 12 specialties. They then subtracted the procedure end time with the procedure start time and average that number by specialty. Why does this data point matter? The time spent in the OR directly influences operational costs. Monitoring average OR duration helps manage costs by identifying areas where efficiency can be improved.
00:22:28
Speaker
This ensures that operating rooms, equipment, and staff are all being used effectively. So if you're not seeing the success that you'd like to, or maybe when you're looking at your month over month trends, you're seeing upticks in certain areas where you would like it to stay stagnant, you must try to identify patterns. So factors could include the surgeon assigned to the case, patient characteristics, complexities of the case, even days of the week. You never know.
00:22:55
Speaker
And every minute matters in the OR. So the more efficient you can be while maintaining the highest levels of patient safety, of course, the better. The second data point I'd like to dive into is average recovery times. So using the same data set, we determined that on average, a cardio case will take 83 minutes in recovery. Plastic cases will take 82 minutes. They were super close. And ortho cases will take 62 minutes.
00:23:25
Speaker
And our data analysts derived this metric by following a very similar process as for OR times, but instead looking at recovery end time and recovery start time.
00:23:35
Speaker
So why does this data point matter? The time patients spend in the recovery room is critical for their safety and comfort post-surgery, but it's also critical for your bottom line. By ensuring that patients are moved efficiently through the recovery area, it will guarantee that your nursing staff and other resources are utilized efficiently and that you're not hemorrhaging money for no reason.
00:23:59
Speaker
Of course, patient safety is the number one priority, but if your recovery times are way above average, there might be an opportunity to, let's say, adjust your anesthesia and medication combo, or maybe you just need to lead into some extra staff training.
00:24:14
Speaker
And interestingly enough, the National Library of Medicine also released a paper last year or so sharing the results from a study they did that tested the benefits of something called post-ease, which is a custom essential oil aromatherapy blend that's known for decreasing that post-op nausea and vomiting. So depending on what your analysis shows, there might be a simple fix or at least things that you could try to get those recovery times down.
00:24:42
Speaker
And I will leave you with this. When looking at both OR and recovery times per specialty, both data points share four of the same five specialties for the highest averages. And those are cardio, plastic, ortho, and podiatry. If your ASC covers any of these specialties, you'll absolutely want to make sure you're closely monitoring both of these metrics and moving patients through as efficiently and safely as possible.
00:25:09
Speaker
If you're interested in more data points and use cases, subscribe to the podcast so that you don't miss any upcoming segments, or you can head to our website to check out the full State of the Industry report to get your hands on even more data. And that officially wraps up this week's podcast. Thank you, as always, for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you're listening from. I hope you have a great day, and we will see you again next week.