Diversion Mitigation Starts Before an Order is Ever Written with Joni Street RPh, BCPS, Pharmacy Supervisor, Diversion Officer
Joni works for a Common Spirit facility and her team has done some great work with Enhanced Recovery After Surgery (ERAS) protocols. A lot more is involved than just the medications administered. She shares the journey and lessons learned with us. Join us to get some ideas on additional diversion mitigation.
Transcript
Terri
My guest today is Joni Street. Thank you, everyone, for joining us. Joni is a pharmacist and the diversion officer at a Common Spirit facility in Omaha. Welcome, Joni.
Joni
Thank you, Terri.
Terri
Absolutely. Oh, great. Let’s start with you telling us a little bit about your pharmacy journey. How did you get where you are today?
Joni
Oh, goodness. Okay. So I decided to go to pharmacy school, kind of because my big brother is a pharmacist. I think that’s kind of how I got into this. And then I actually started in retail for a little bit, and then I came and started working overnights in a hospital, and I became very autonomous on overnights and always kind of liked problem solving. And so eventually after I was kind of ready to be off of overnights, I ended up working in the or satellite pharmacy for a number of years and worked very closely with our anesthesia friends was down in the depths with all of our narcotics that we see all the time and was frequently trying to help solve discrepancy issues or identify if there was something going on. Not to lay anything on our anesthesia friends, but as we know, we got to keep a close eye on things and be there to help them out.
Joni
So I kind of started there, and then I took a supervisory position, and because I kind of had an interest in this, I started doing some of our diversion monitoring and just kind of had a knack for it.
Terri
Okay. And it kind of rolled from there. Yeah, that sounds, in some ways a little bit similar, especially the pharmacy school. I wasn’t planning on going to pharmacy school, and I kind of changed my mind and started to panic in my sophomore year, and my roommate at the time was a pharmacist, and she’s like, well, why don’t you go to pharmacy school? And I’m like, what do they do? And that’s how that started, which is unusual. I don’t know. I suspect you’re a little bit like me, where most of my decisions are very well thought out. I don’t really do a whole lot of okay. And that one was okay. That actually worked out very well.
Joni
Good.
Terri
All right. Well, we often focus on diversion monitoring when we’re talking about this subject. Right. How do we monitor? How do we find those healthcare professionals that are working impaired or diverting from the workplace? We do have discussions on Mitigation, such as making sure we have policies and procedures in place so that we can define those parameters and hold people accountable, or getting automated dispensing machines to make things a little bit easier to track or to make sure our witnesses are really witnessing right. To prevent that. But I think we sometimes forget that mitigation can start much earlier, and that is what Joni and I are going to talk about today. Joni’s hospital has done a lot of work surrounding minimizing the amount of opioid, prescriptions opioids that are prescribed within the hospital setting. And that is really important because every controlled substance order on a patient profile allows somebody access.
Terri
Right. So, Joni, tell us about some of the work that you have done in this area with your facility.
Joni
Okay, I would say probably the biggest thing that we talked about, that we’ve talked about before, is the Enhanced Recovery After Surgery protocol. We do an eras protocol. We’ve put that into place, and we’ve gotten that pretty widely used on most of our cases. And so just to give you a little bit more background on that, the eras protocol is very all encompassing. It’s from having a visit before surgery. Letting the patient know what the expectations are, what kind of surgery you’re having and what to expect as far as pain and recovery go. Making sure that if they have obstructive sleep apnea, they’re actually on a CPAP. If they have diabetes are your sugars under control or at least under control? As much as possible. Different things like that. And then just to carb loading before the surgery, making sure that they take enough fluids on board, but not too much fluids and not too much salt so that they’re not fluid overloaded.
Joni
And it basically takes the patient from pre op. And then we go into that intraoperatively and doing more pain blocks with local anesthetics instead of just pouring in more opioids. For example, we really have used a multimodal pain approach that kind of acts from various different sites. So you might have non steroidal anti inflammatories that you’re giving you might give Tylenol scheduled, but it’s important to do it scheduled so that you continue to stay on top of things. I have been a pharmacist for long enough that I remember when we called pain the fifth vital sign, and it was important to stay on top of the pain. Well, we know that we don’t want to do that by just pouring opioids and pouring more and more opioids onto the patient. But we do want to make sure that if we can try hitting that pain from various angles, that’s going to help as much as possible.
Joni
So, like I said, there’s neuropathic pain. We do gabapentin for some of our patients. We do celebrexper or celicoxib for the non steroidals acetaminophen, et cetera. So doing a multimodal pain approach is very helpful. We also utilize a lot of IV lidocaine and IV ketamine as well, low dose ketamine, and that has been very helpful. Also, magnesium is part of that protocol as well. And so using that in conjunction with trying to do more pain blocks instead of more regional anesthesia, instead of necessarily just going full blown, here’s a bunch of fentanyl, for example. That’s something that we’ve really been involved with doing. And then once the patient gets out of surgery, we really worked with our post op order sets. For example, we used to have a ton of opioids on the Pacu order sets or the recovery Room order sets. And we really minimized the amount of opioid and made sure that we’re trying other things before we automatically jump to the fentanyl or the Dilauded injectables and that kind of thing.
Joni
So that’s been where a lot of our focus has been. And then obviously, once we get into the post op period, once the patient gets up to the floor, we also want to look at the order sets for those post surgical patients to make sure that we don’t go right from, okay, were doing a great job in recovery. Now they’re up on the floor and they can get whatever they want. That was actually a learning that we had. We had a residency, a pharmacy resident do a project on it and found that the amount of opioids that were giving in recovery room was remarkably lower. But then once the patients went to the floor, it was kind of back to the same old status quo. So continuing those non steroidals the Tylenol ordered around the clock dexamethorphin is another one that we use quite frequently.
Joni
Using those medications as well before just automatically jumping to the opioid has been really helpful. And then different things like Ptot, we want early mobility. It makes a big difference in getting the patient out of here, making sure that they’re not doing all we can to prevent post op nausea and vomiting. If they get up and get moving, or if they’re not having nausea and vomiting, they’re a lot more likely to get up and get moving. If they’re getting up and get moving, then their gut’s going. Their gut’s going. They’re less likely to get an Ilius, et cetera. I mean, it just goes all down the line. So similar with the fluid overload and making sure their blood sugars are controlled, they’re going to heal better if their sugars are under control. So kind of looking at the whole patient and trying to make sure that we’re doing all we can to get everything in line, essentially.
Terri
Yeah, no, that makes sense. I mean, there is so much more to just going into surgery for whatever it is that you need and then you’re out. But there’s so much to it that yeah, like you said, everything. If they have nausea and vomiting, they don’t want to get up. If they don’t get up, they don’t heal well, their pain lasts longer, all kinds of stuff.
Joni
Yeah. And it’s so much like Normothermia, that’s another thing that we’ve really learned about how important it is to make sure that patient’s temperature stays high enough so that if it doesn’t get too low, then you’re going to do a lot better. You’re less likely to get a surgical side infection, et cetera. So there’s a ton of different research that has gone into the Eras protocols.
Terri
Yeah, some of that stuff I’d never even you mentioned carb load and fluids and now this, thermal. Yeah, I don’t know anything about any of that, but a whole lot that goes into it, right? My anesthesia friends got out of the recording.
Joni
Yes. My anesthesia friends have been very good, actually, about educating a variety of people because a lot of times all of us kind of get into our set ways and we have the way we’ve always done things. And so we kind of started like one by one, specialty by specialty, saying, okay, hey guys, how about we start on all of our colon cases? We start using this fancy new eras. Actually, it’s kind of funny because I can’t see the Taylor Swift Tour, which is the eras tour without thinking it’s the eras tour because I have had eras on my brain for so many years, so it’s kind of funny.
Terri
You know, that happens to me too, actually. I was in spend time in California and there’s a city called Ocean Beach, and I don’t know what sign I saw some festival or something and I’m like, an OBstetric festival. It’s like, oh, ocean beach. But how we put it in our this is our zone, right? Yes. Yeah. Okay, so I was going to ask you about that. It’s like, how did you have to work pretty hard to get people on board? So we’ll start with anesthesia because there’s the nursing component of it too. Was it their idea or did you have a champion that kind of started this?
Joni
We did. We had some anesthesia champions that really came in and said, you guys, we’re missing the boat on this. This is something that we need to be doing. And they worked really hard to get buy in and it wasn’t easy. I mean, even from us. We never ran ketamine drips before in the pharmacy. And then we’ve got these anesthesia providers coming to the or pharmacy saying, I want a ketamine drip because I want to run it for a while. And what are you doing with that? I’m used to using ketamine.
Terri
Show me the literature.
Joni
Yes, I’m used to using ketamine for like an out-of-control patient that we need to throw a dart at them and try to get them to calm down so that we can get them back into the room or whatever. So it’s just like relearning some of this stuff. I’m not going to say it was easy, but we had some really good anesthesia champions that came in and then they were willing to really a lot of times with providers, they accept recommendations better from other providers. So really it was our anesthesia team going to each of the surgery teams and saying, this is what we think we can do. Give us a try. Let’s try it, let’s try it and see what happens. And then they’re always surprised at the results, and once they start seeing the reduction, it’s kind of crazy. I mean, one of the ways that was really easy to see it was when we put it into the OB, we started using eras with our deliveries and it was huge.
Joni
How much less Opioids we’re actually using in our postpartum during delivery and postpartum as well.
Terri
Right, okay. So speaking of postpartum, now we’re on to the nurses, as you said, once they got out of recovery and they went up to the floor and then the orders were there and they started using it because that’s what I tend to see. If you’ve got a non steroidal on the profile versus an Opioid, most of the time that nurse is going for the Opioid. So how did you work with your nursing staff to get them on board and buy in?
Joni
For the most part, and this was very challenging, and I’m not going to say that it isn’t a fight that we still have. We had to take the orders off of the order sets. Essentially, if it’s there, unfortunately that’s going to be the one that is almost always chosen if you give a choice, especially because we want our patients to get some sleep in the hospital and it’s hard. And so a lot of times there’s some of that anxiety and sedation that comes with those Opioids that have that additional benefit and it’s hard to not lean on that side of things. So for the most part, we really had to clean up some of our orders so that it wasn’t there as an option and they have to call and get an Opioid ordered or it’s specific parameters that it has to be this before you give the Opioid to the patient.
Terri
Right, okay, that makes sense.
Joni
Yeah. So that’s been the biggest I would say that’s getting the providers on board. I actually am at an academic center, so we have a lot of learners here and so there’s a lot of opportunity to call someone to get an order. So we still have issues where we do know that it works in medicine, too. If mom won’t let me, then I’ll ask dad type scenarios. So we have those here as well. So we’re in a constant reeducation process and trying to make sure that people understand the reason why we’re doing this.
Terri
Right. When you get your next set of residents, do you have any education that is kind of focused around this so that they all know when they get that call in the middle of the night?
Joni
Yes. Our anesthesia champions are good about going and meeting. They actually end up doing it about twice a year, actually.
Terri
Okay, good. That makes sense. And then how do you handle because I’ve seen on profiles where there might be tylenol around the clock and that’s what they’re trying to do is to minimize the opioids. And then you see the note patient refused and then you see that they have the Norco or the percocet. So is this part of the discussion with the patients? And do they sign something or repeat back what they’re hearing to agree to?
Joni
They don’t sign anything, but it is a part of the education process as well. We did specifically do some pamphlets for our Ed, for example, because that’s another opportunity where we frequently have people that may be looking for a quick fix. Maybe because they just got hurt or maybe because they’re seeking out narcotics or whatever coming into the Ed. And because that was a very easy point for people to come in and say, I just want to get a dose of Demerol or whatever, and then I’ll be on my way. We actually made up some pamphlets explaining that this is the reason why we’re not just going to give this to you. And it talks about the different types of pain, different things. There’s a lot of things you can do for pain besides just giving a pain medication. And as much as I’m a pharmacist and I know we’ve got some really good things, I also know there’s a lot of other things that our physical therapy colleagues can assist with.
Joni
Meditation, breathing, all that kind of stuff can really help. But we’ve got to try it and we’ve got to talk about it. And if we don’t talk about it, then it gets missed. It’s very easy to miss. So educating those specific patients, saying, just because you came in here doesn’t mean we don’t want to take care of you, we want to take care of you, but we’re not just going to automatically write a prescription for you. So a lot of that same conversation is you might not feel like you want to take the Tylenol right now, but this is the reason why we’re doing it. We’re trying to stay on top of it. We’re trying to hit it from different angles and that’s to help us avoid some of the opioids and that kind of thing, right?
Terri
Yeah. And there again, we rely on our nursing colleagues who are at the bedside when this comes up. So we really have to get nursing buy in with all of this because if they don’t believe it, then the patient will easily be like, okay, fine, let me call I’ll get you something else. So we really rely on them.
Joni
And honestly, Terri, the other thing is sometimes we do need to use those opioids. I mean, we have to keep that in mind as well. This class of drugs is very effective for a reason and there are definitely times where it’s appropriate to use them. We just went overboard in the mid ninety s and were giving them to everybody for anything and really went over the top. I kind of like to refer to some of my friends that have gone on mission trips and they’ll go to Haiti and do surgery on these patients and they don’t get anything. Or if they mean? I’ve donated, like, Tylenol and Ibuprofen, and if they get a Tylenol, they’re just like, oh my gosh, this is amazing. So sometimes it’s resetting our expectations. I know. I’m sure you’ve probably had this in one of your many other podcasts talking about what a large percentage of the narcotics in the world that we actually utilize in the United States.
Joni
And it’s insane. So sometimes we need to think about resetting the expectation, but also realizing that we do have some of these medications and they are appropriate to be used in certain circumstances as well. So not to automatically ignore that either.
Terri
Right? Yeah. Well said. Well said. Yes. Okay, great. Well, thank you for the great work that you’re doing because it does start all the way at the beginning. And not only that, it’s minimizing the use, which is maybe impacting somebody that might have been exposed to an opioid for the first time and ended up in trouble. Right. We’re not only minimizing diversion because our professionals have less access to it, less reason to get into it, but we may be helping somebody who is at risk and then doesn’t develop a substance use disorder because they were exposed to it. But also, these protocols are, I imagine, giving better outcomes in general, quicker turnaround times, better recovery, all of that type of stuff. So it’s beneficial for multiple reasons, not just dating diversion.
Joni
Definitely. Yes, definitely. Kind of the whole package.
Terri
Absolutely. And that’s what we should be doing is be looking to improve that whole piece of it. So it’s great. It’s just one piece. The other thing you and I talked about is socializing and networking and how important that is. And that’s how you and I met. We met at a conference where were networking and we shared with each other a couple of stories. And my story, after I heard yours, that I shared with you, was that I was at a retirement type of a social party at the hospital, and I got to talking to somebody in another area med staff, I believe. And come to find out, were both trying to do something on the same topic, the same initiative, but we had no idea that each other was working on this. And it was definitely something that would have been better that we had collaborated on.
Terri
It was just, oh my gosh, I had no idea. And this was just a conversation outside of work right. That ended up being so valuable. And so we talked about that, and I know you encountered something similar that also kind of ties in to how we as pharmacists can beneficial on other teams when it comes to substance use disorder and diversion. So if you could share a little bit about that would be sure.
Joni
So when we met, it was actually at a Natty event. So the National Association of Drug Diversion Investigators. And I am the president for the Nebraska chapter. And so I have with my team obviously, I’ve got some great board members that assist as well, but when were setting up our state chapter for this year, were looking at who we wanted to come and speak. And I have had the pleasure of working with a physician, dr. Louis Traveson is his name, and he works at Yale actually, so he lives in Connecticut, but he is also an associate professor at Creighton University. And so I’ve had an opportunity to work with him as well. And so I asked him if he would be willing to come and speak some about substance use disorder because a lot of times when we are talking about diversion we have a lot of law enforcement friends as well and a lot of times we’re talking about more of the penalty side of things and that kind of thing.
Joni
But we also need to acknowledge the fact that substance use disorder has chemical changes in the brain. We need to do some treatment of that. So I asked him if he would be willing to come and speak, and he was kind enough to come to Omaha and speak for the conference. And as I was visiting with him a little bit after the conference, he said he was getting ready to go to a substance use disorder retreat the following day. And I said, oh, well, if you need any input for some pharmacy colleagues, just let me know. And he was like, oh, well, I would imagine there’s some pharmacy people there. And I said, well, maybe there is. I don’t know. I mean, I’m not, but if you need any pharmacy. And he’s like, Well, I think pharmacy should be there. And so I promptly got an invite to the substance use disorder retreat.
Joni
And then we have an Opioid Stewardship pharmacist as well, and she’s been really helpful as far as a lot of some of our protocols and that kind of thing that we’ve been working with also. And so the two of us got kind of got an invite last minute. But it was great because were working with the whole Behavioral Health substance use disorder retreat, the Substance Use Disorder team. And it was great because at the end of the day, we all went around the table and talked about what were most thankful for because so much good conversation came out of this. And probably at least a third of the people that were there said the interprofessional collaboration is great because we also had someone from OT there that specializes in behavioral health, and it’s just amazing how many resources are out there that you don’t even necessarily know about if they’re not in your specialty.
Joni
So it ended up being really good. We’ve had continued involvement in the Substance Use Disorder Committee. We’re getting some education together. We actually just had another meeting. This been it’s been really good, but I am a talker, as you know, Terri. So I find myself in those situations a lot, and it’s amazing how just having, oh, are you from wherever? I know so and so. And it’s amazing how many times those social sites can just get things hooked up. And it’s amazing how frequently things can happen and people can get more done when they work together.
Terri
Right, yeah. Well, that’s a clear example of you are the diversion officer, but more importantly, you are the champion. You’re the diversion prevention champion. And I say that is one of the key pieces to a solid program, because you need that person that is constantly injected into whatever conversation, or it’s on the top of mind every time something comes up, and how can we do this better or collaborate more? And so I think that’s just a perfect example of how that champion that gets involved in socializing and networking and stuff can be so you don’t even realize the value until the conversation starts.
Joni
Right, right. Exactly.
Terri
Yeah, absolutely. So on that note, if you would like to do a shout out for Natty’s annual conference that is coming up, you go right ahead, President.
Joni
Yes. So Natty’s national conference is in myrtle beach, south carolina. It’s October 24 through the 27th, and I am very excited to go again this year. We always have a really good group of speakers that come. It’s a lot of healthcare folks. It’s a lot of law enforcement folks. It’s amazing how we work together and looking at different cases from different perspectives, what you can learn from each other. It’s something that I am very passionate about. Yeah, it’s great. So I would encourage anyone that’s interested to sign up for that conference.
Terri
Yeah, well, I’ll see you there. I’ll be there.
Joni
Yes. Great.
Terri
I’m actually presenting with the team, so looking forward to that. We’re going to try to shake it up a little bit, maybe be a little yeah. All right, well, thank you very much, Joni. I’ve enjoyed our conversation, and thank you for being willing to share with all the listeners out there the type of stuff that you guys are doing.
Joni
Thanks, Terri. I appreciate it.