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Post by katevaughn on Feb 27, 2018 10:56:45 GMT -5
This month's journal club is presented by Laurie Meginnis. She chose an excellent article that highlights opioid abuse among anesthesia providers. This topic can be sensitive but is an incredibly important one to review to be able to identify risk factors and prevention strategies to help keep ourselves and our colleagues safe. Laurie has chosen some questions to engage discussion. Enjoy! Here is a link to the article. Questions for discussion engagement: 1. Unfortunately, the impaired provider is frequently not discovered until overdose occurs. What methods would you suggest would be helpful in identifying anesthesia providers that are abusing drugs? 2. Do you think you would be able to tell if a colleague is abusing the drugs we use everyday? Would you report your suspicions? 3. With the high incidence of relapse, do you believe that providers that have previously been caught abusing should be allowed back to administer anesthesia?
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Post by Angie Brooks on Feb 27, 2018 16:52:24 GMT -5
1. Unfortunately, the impaired provider is frequently not discovered until overdose occurs. What methods would you suggest would be helpful in identifying anesthesia providers that are abusing drugs? It is important to watch for inconsistencies such as increasing amounts of opioids being taken from pyxis or increasing amounts of pain from patients under the providers care. Also looking at changing trends in work schedules such as working off shifts or picking up many shifts. This has been been highlighted in other articles on this topic. Random testing of waste medications is also an indicator. Wasting with another provider that hasn't watched the provider the entire case is completely useless to prevent diversion.
2. Do you think you would be able to tell if a colleague is abusing the drugs we use everyday? Would you report your suspicions? This is a difficult question. Many people with addictions become very good at hiding their addiction. As the article stated, it is often discovered when it is too late. If I had suspicions that were warranted, I would definitely alert the department head. They would be putting patients as well as themselves in a dangerous situation.
3. With the high incidence of relapse, do you believe that providers that have previously been caught abusing should be allowed back to administer anesthesia? I do believe that people are able to overcome an addiction. In our situation (continually being tempted with triggers) it is much more difficult than the rest of the population with similar issues. I believe that there would have to be a much longer period away from clinical practice along with many checks and balances. This would have to take place for an extended period of time.
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Post by Jessica Switzman on Feb 27, 2018 17:33:30 GMT -5
I like the signs and symptoms the article listed but I don't think it is always so easy to tell that someone is using. I think random testing of wasted narcotics can help. We need to educate SRNAs about this hazard in Anesthesia and help people develop healthy coping mechanisms so one doesn't use drugs.
I would report a colleague if suspected because I would want to get them the help they need. AANA has a 24 hr help line for CRNAs who are in need of where to go if they are using or for colleagues who suspect someone but don't know what to do.
I do believe people can over come addiction or with support control themselves. I would hope and welcome a CRNA back to work but it would be case dependant; not everyone is able to return to providing Anesthesia. I think one year away from anesthesia with extensive treatment for addiction and involvement in a 12 step program is necessary.
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Post by LarSharVeA Bennett on Feb 28, 2018 13:42:59 GMT -5
The key to discovering diverting providers is vigilance. Even so, heightened vigilance is impeded in that there is no communal nurse's station where behavior can be observed frequently.
As a nurse, I have reported a colleague for diverting; but in the same environment, I have confused personality traits with addiction. It was later discovered that the latter was using as well.
I think return to the workplace should be handled on a case by case basis, however, the article presents cons to returning that should be strongly considered. The risk of relapse, loss of life, the constant triggers, patient safety, and infinite supply of opioids are all variables that make return a greater threat to patient and provider.
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Post by dahliarouchon on Feb 28, 2018 15:33:56 GMT -5
What methods would I suggest to be helpful in identifying anesthesia providers abusing drugs? An observance of the provider's level of fatigue could be a clue. Being seen asleep and disoriented when awakened despite not being in an unstimulating environment can raise a flag. Making frequent and simple mistakes between patients, often, i.e. charting on a wrong patient, not having recall on conversations on a regular basis all are causes of concern. Being supportive to this provider by offering breaks and monitoring them for appropriate levels of rest is important. If it appears beyond safe for the provider to continue care, I think it would be critical for the safety of the patient and importantly for the safety of the impaired provider, to be privately taken aside to discuss the cause of the behavioral change. I think I may be able to recognize if a person was abusing drugs from the level of distraction they may exhibit and if there was unwarranted irritability/disorientation shown to others. I would report my observations discreetly to an immediate supervisor in hopes the individual would be approached privately and in a sensitive and kind manner. Providers caught and proven to be abusing drugs may be able to return to work after 1 year and following the recommendations mentioned. I believe I would encourage non OR exposure, i.e. in a preoperative screening clinic, or suggest other administrative or educational settings.
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Post by mdougla5 on Mar 8, 2018 13:17:52 GMT -5
1. Unfortunately, the impaired provider is frequently not discovered until overdose occurs. What methods would you suggest would be helpful in identifying anesthesia providers that are abusing drugs? Being that we do not work directly with one another (in different OR rooms), I think that it is difficult to identify impairment in a colleague using subjective signs and symptoms. And, "impairment" can be confused with other personality behaviors stemming from life events outside of work (ex. fatigue and illness). Therefore, I would advocate for an objective measures, such as random testing of wasted narcotics. 2. Do you think you would be able to tell if a colleague is abusing the drugs we use everyday? Would you report your suspicions? I think that it would be difficult to identify a colleague abusing drugs that we use daily. If I felt that someone was acting different from their baseline, I would first inquire directly with the individual if they were ok. I would hate to have a rumor-mill created in our department toward an individual based solely on an assumption.
3. With the high incidence of relapse, do you believe that providers that have previously been caught abusing should be allowed back to administer anesthesia? Having been a drug dependence counselor, I know that those in recovery are encouraged to change "people, places, and things" that were present during their active addiction. Because of this, I feel that it would be difficult for a provider to return to an environment where they had easy access to the drugs in which they were abusing. However, as stated in the article, "opioid-addicted" healthcare providers in recovery are protected by the Americans with Disabilities Act. Therefore, they cannot be discriminated against. This protection also extends to those with an alcohol-abuse problem because using alcohol is not a "crime."
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Post by BrittneyKeating on Mar 10, 2018 9:39:31 GMT -5
1. The article lists patterns of behavior and consequences associated with substance abuse and dependency, which I agree can be helpful in identifying an anesthesia provider who is abusing drugs, or support suspicions. However, I would argue that noticing these patterns of behavior among anesthesia colleagues is not enough to identify someone who is abusing substances. As previous posts have mentioned, we work in a very isolated environment. There are many days that I do not see all of my anesthesia colleagues assigned to my same clinical area, and there may be weeks or even months that pass before I see some colleagues simply due to the large size of our clinical environment. For this reason, it is very challenging to notice changes in patterns of behavior amongst anesthesia colleagues, more so than working on a single nursing unit or clinic/office environment. I would argue that more hospitals employ an objective means of identifying diversion by random sampling of controlled substances returned to pharmacy, as the article mentions Mayo Clinic in Rochester, Minnesota has done. Currently at JHH, anesthesia providers empty syringes or mini-bags of the controlled substance into the trash upon wasting. I have worked at other institutions that require a witnessed "waste" of the controlled substance entered into the pyxis, but the actual syringe or mini-bag must be marked with a patient label, and put in the controlled substance bin for pharmacy to collect and verify. This would be one means of allowing pharmacy to randomly perform quantitative assays of controlled substances.
2. Given our isolated work environment, I am not very confident that I would be able to tell if a colleague was abusing the drugs that we use everyday. It is very challenging to notice changes in patterns of behavior or impairment due to abuse of controlled substances versus individual personality traits or changes in personality due to significant personal life events, especially when we work with our colleagues very little on a one-to-one basis. If I was suspicious of a colleague who was abusing drugs, I would report my suspicion to my manager directly, as the imposed risk to the provider and his/her patient is just too high to disregard such a suspicion. I am hopeful that the person who I would make this report to would approach the provider in a private, and gentle manner so that the provider can get the help that he/she needs.
3. I do not think there should be a "strike-one, you're out" policy for returning to the workplace. However, our clinical environment is very unique in that as anesthesia providers we order, acquire, and administer controlled substance on a daily basis without supervision or another human checkpoint, making it very easy for relapse to occur. For this reason, I would argue for strict drug test monitoring for many years following their re-entry into practice. Additionally, I think recovering providers should be encouraged to enter areas of practice where controlled substances are not handled on a daily basis such as a pre-evaluation clinic or administrative role, as Dahlia mentioned previously.
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Post by Jocelyn Datud on Mar 12, 2018 13:55:19 GMT -5
1. As mentioned in the article, there are several factors that can predispose a person to chemical dependence. As for anesthesia providers, our occupation in itself is the biggest triggering factor- stress, access and attitude. Some methods that can be done are constant assessment and evaluation of these triggering factors by regularly assessing stress level of the providers (ex- well- being index survey); random urine toxicology test; regular review of narcotics utilized by each provider for a case; and constant reminder/education about the incidence, triggers, symptoms, and risks of opioid abuse and resources available.
2. It will be challenging to tell if somebody is abusing drugs. However, I think, providers who belong to a smaller group are able to notice behavioral changes immediately. If there is a suspicion about it, I will follow the chain of command and will make sure to follow up if the issue is being addressed especially this involves the safety of the patient and the provider.
3. I agree with the other members who don't believe in the strike-one, you are out policy. The statistics for relapse had been high among anesthesia providers hence, the treatment/therapy should be modified accordingly. Just like what others suggested, during the first year, the providers should be assigned to work in an environment where they won't have open access to narcotics.
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Post by amandaeggert on Mar 12, 2018 15:46:36 GMT -5
1. Unfortunately, the impaired provider is frequently not discovered until overdose occurs. What methods would you suggest would be helpful in identifying anesthesia providers that are abusing drugs? I think that random drug testing when wasting narcotics would be the only way for sure to know when narcotics are being diverted. Other signs to look for, as the article states, are recurrent patients in pain after surgery or multiple discrepancies by the same provider.
2. Do you think you would be able to tell if a colleague is abusing the drugs we use everyday? Would you report your suspicions? There can be a variety of reasons why a coworker might exhibit changes in work habits, shifts, or personal mood. Personal circumstances outside of work can have an effect on each person differently. However, if I really had a suspicion about someone was abusing drugs, I would report it to my supervisor for their safety and for the safety of their patients.
3. With the high incidence of relapse, do you believe that providers that have previously been caught abusing should be allowed back to administer anesthesia? As the article states these providers are protected under the Americans with Disabilities Act as long as they are not currently using. I feel like a long break from the clinical setting would be necessary. Strict monitoring and drug testing would be necessary upon return to work.
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Post by emedina1 on Mar 26, 2018 20:47:59 GMT -5
What m
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Post by emedina1 on Mar 26, 2018 20:51:35 GMT -5
1 .methods I would use: I would be more vigilant on providers who do not want to take a break or do not want to be relieved on certain cases. Be more careful in identifying providers who constantly can to reconcile their narcotics. High incidence of relepse-- I would give these providers a second chance. They should undergo a regular urine test scheduled or random.
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Post by chrisdiem on Mar 29, 2018 20:48:55 GMT -5
1.Unfortunately, the impaired provider is frequently not discovered until overdose occurs. What methods would you suggest would be helpful in identifying anesthesia providers that are abusing drugs? — I believe that the stated method of increasing vigilance is the most realistic. Looking for the listed personality characteristics or behaviors that are common among impaired providers is something that everyone can easily do. As an individual you may not always pick up on these small changes because as mentioned, in this institution, we sometimes don’t see another CRNA for weeks or even months at a time. However, as a department along with the attending who works more closely with each CRNA I feel these people can be identified. The random screening of wasted drugs and random drug screening are theoretically great ideas and I think that would definitely assist in identifying these individuals. However, these come at an added expense and we all know how things go when it comes to added expenses in healthcare. No institution, especially Hopkins enjoys or is looking for added expenses.
2. Do you think you would be able to tell if a colleague is abusing the drugs we use everyday? Would you report your suspicions —As previously stated I feel as though it may be difficult to accurately identify an individual who is abusing drugs because addicts become very good at deceiving those around them. Additionally, many of the behaviors or characteristics listed in the article can be explained by other possibly external factors and or differing personality traits. That being said, if I ever had strong suspicions that one of my colleagues was abusing drugs I would report those suspicions to an immediate supervisor or manager so that they could be followed up on in an appropriate manner. In the long run it is potentially saving patients as well as the provider themselves who could could overdose.
3. With the high incidence of relapse, do you believe that providers that have previously been caught abusing should be allowed back to administer anesthesia? — I believe that providers should be able to return to administering anesthesia on an individual basis. I think that the Individual must complete a certified treatment program as well as be away from anesthesia practice for at least a year. In addition, I think that it is warranted to follow these individuals closely when reentering the workforce. This could include random drug screening as well as regular meetings with management to discuss how things are going. As the article stated there is data to support that providers can successfully return to providing anesthesia and I agree.
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Post by lmeginnis on Mar 29, 2018 21:12:52 GMT -5
We are very isolated at work and we don't see the same CRNA's everyday. I think it would be difficult to identify someone impaired unless we are very familiar with them or they are exhibiting obvious signs. I believe that we are obligated to inform someone of our concerns. Although I believe it would be very difficult to come back, I think that with strict protocols, we should give the opportunity.
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Post by darolyn on Mar 29, 2018 22:01:42 GMT -5
I agree that it is hard to identify a colleague who is using in the early stages of abuse. Probably drug testing would be the best way to identify anesthesia providers who are abusing. I can say that I thought a colleague was using something based on his behavior but I could not say it with certainty. Making such an accusation which may prove to be false leads to constant questioning of professional integrity/reputation. What I am saying is we have to be careful with the potential of making false accusations. Should an anesthesia provider who had previously been caught abusing,, resume their professional duties? that is hard to say. Maybe if there is a monitoring protocol in place which includes some type of support to lessen the probability of relapse, then I say yes.
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nanci
Junior Member
Posts: 57
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Post by nanci on Mar 30, 2018 8:44:41 GMT -5
1) Random drug testing and/or more focused drug testing if a provider is impaired or noticeably repeated changes in behavior. I agree that life stressors and work stressors can really impair behavior, without the added diversion of narcotics/medications- so important for those of us who know a provider better to speak with them and speak up when seeing something different that is concerning. As we don't work with each other and see each other in passing (if at all) it is very difficult to tell. Acuse, Blame, Criticize is NOT going to help anyone and should be avoided.
2) I am not sure I would be able to identify a colleague using/abusing. I would report it if I saw it happening. Honestly if I suspected I might hesitate reporting until after discussing with that person or repeated behavior happening that really raised my suspicions high. I wouldn't want to be the one to ruin someone's reputation if the allegation was false.
3) After time away reintroduction into the work place could be possible but that would have to be determined with the person, the employer, the situations are so different for everyone but I believe it to be possible. It would be difficult but possible and I would hope that there would be measures in place for the provider's protection, frequent testing, and support available for them. I agree with the article that it is possible and would like to think that chance would be given. But yes, the circumstances and time away for treatment would have to come first to even give that provider a good chance at success.
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