Our standards require – and essentially every organization we survey has this in place – a policy on impaired heath care professionals. But how effective is your policy? Do you educate your staff on the signs to look for which may be early indicators of alcohol or drug (prescription and/or illegal) abuse or dependence? A recent article in Medscape cited several papers indicating that 15.3 percent of physicians surveyed met diagnostic criteria for alcohol abuse or dependence. Additionally, another article was cited which noted that female surgeons had almost twice the rate of abuse or dependence than their male colleagues.
In April 2009, Modern Medicine published an article online titled, “Drug addiction among nurses: Confronting a quiet epidemic,” which quoted the American Nurses Association stating that approximately 10 percent of nurses in the USA are drug depen-dent. This calculates out to ap-proximately 300,000 nurses. The general population as a whole is estimated to have a drug depen-dence rate of as high as 10 percent. However, physicians and nurses are more likely than the general population to abuse and/or be-come dependent on legally con-trolled substances and other prescription medications.
With numbers like those noted above, chances are you will at some point encounter a profes-sional at your center who is in some stage of substance depen-dence. When a provider shows up with slurred speech or unusual motor activity, you would obvi-ously look into this immediately. But does your staff know what to look for in the early stages?
In ASCs, the ﬁrst clues often come from unusual patterns of drug administration, poor or missing documentation of administration of controlled substances; undocument-ed “waste;” “lost” ampoules or vials of controlled substances; empty syringes with very ﬁne needles are discovered in lockers; and requests such as, “just get me the medication and syringe and I will administer it myself so I can see how it is working and titrate the dose.” There are many opportunities in the workplace and the list above is not meant to cover all the subtle signs of drug diversion.
Certain medications, especially those that come in ampoules, have a small amount of over-fill which is easy to access. Fentanyl is an excellent example and may be the most abused drug in the ASC setting. A busy anesthesia provider could draw up small amounts of over-fill, or even a little more from many ampoules in any one day, still giving the patients all or most of what they were supposed to receive without drawing suspicion because the patients are not in pain.
Is your staff taught that addiction is a treatable disorder with best results when the treatment starts early? Do you educate them on what to look for in fellow staff members? Health care providers are often very good at hiding their abuse. Subtle signs such as unusual episodes of impatient behavior, mood swings, sleepiness, irritabil-ity, shifting blame or responsibility to another to divert attention from themselves: all these are often early signs that deserve closer attention, indicating that you need to look more closely at their activities.
These symptoms are not defini-tive proof. But they should not be ignored. Impaired performance or unusual behavior does not always mean drug abuse or dependence. But whatever the cause, close follow-up observation is vital and active investigation of atypical performance or behavior should be done. At the start of employ-ment, part of the orientation should be to review with them the corporate impairment polices and their staff responsibilities under those policies. Periodic perfor-mance appraisals must take into consideration current behavior and actions. As I mentioned, however, impairment can result from other situations so your policies should leave the door open for this possibility.
Based on my experiences over the years, emotional distress and sleep deprivation should be included. The latter is often noted in anesthesia providers who come to the ASC after a night on call for a “short” or “easy” day and, as a consequence, might sometimes be guilty of dosing off during a case. Emotional distress can be short term and situational or part of a more serious problem. Whatever the cause, don’t ignore the signs. Early intervention can help prevent problems from becom-ing more serious.
In this day and age of workplace stress, ready availability of phar-maceuticals, and people tending to not want to get involved, you need to educate your staff on how to recognize the telltale signs of substance abuse – information that goes above and beyond the regular training they receive during orientation as new employ-ees. Impaired providers are more than likely good people going through difficult times. Helping them will help you and your patients.
About the Author
Dr. Jack Egnatinsky is an anesthesiologist with extensive experience in the ambulatory surgery arena, both HOPD and ASC. He is a Past President of the Board of FASA, a predecessor to the ASC Association, and Past President of AAAHC.
He is also the Board Chair of the Accreditation Association for Hospital and Health Systems (AAHHS) and is a representative of Acreditas Global, the international arm of AAAHC.
He remains extremely active as a Medical Director for AAAHC, in addition to being a well-travelled AAAHC accreditation surveyor, both in the USA and internationally.