Do Pediatric Hospitals Have Unique Diversion Challenges? With Lacey Rodgers, PharmD, MHA, BCSCP Diversion Officer at St. Louis Children’s Hospital
Pediatric hospitals have their own unique set of challenges. Lacey and I discuss drug diversion challenges that may not be unique to, but certainly more prevalent in, a pediatric setting. We also highlight what we feel is the number one diversion mitigation strategy that will go a long way in a pediatric setting.
Transcript:
Terri
My guest today is Dr. Lacey Rogers, the diversion officer at St. Louis Children’s Hospital. Welcome to the Diversion Insights podcast, Lacey. Thanks for being here.
Lacey
Thanks for having me, Terry. Really excited.
Terri
Absolutely. I’m looking forward to our conversation today. Working at a children’s hospital, I’m going to talk with Lacey today about maybe some of their own unique set of challenges that they have. Well, maybe not unique, but certain known vulnerabilities might be a little bit more prevalent, and that’s what we’re going to talk about today. So, Lacey, to get us started, what would you say is probably the number one diversion issue that may be more of an issue in a pediatric hospital than it is in an adult hospital?
Lacey
Yeah, absolutely. So I would say in pediatrics, one of our most unique challenges and most unique vulnerabilities for diversion would be waste. So in adult settings, there’s a lot more use of a full package to administer a dose. And in pediatrics, very rarely is the commercial presentation the correct weight adjusted dose for our patient. So we have waste in our system. Now, sometimes that’s at the point of care with the nurses, sometimes that’s in the pharmacy department in preparation. But regardless of where it happens, the volumes of waste that we deal with in pediatrics tend to be substantially higher than what we see in our adult populations as just a part of the normal practice.
Terri
Yeah, waste is, I think, a very large gap that we still haven’t quite figured out. And you’re right, in your pediatric populations, there are a lot more. I was going to give you a hard time and say, what, you don’t draw individual doses for every single one of your kiddos, but you brought up a good point, and then it would be in the pharmacy. Right? Because if you can’t save it and use it for the next one, then you’ve got your waste there. So either way, you’re going to end up with that waste. So I won’t give you a hard time on that. Yeah. Wouldn’t it be nice if we had the staffing and the time, and we could respond fast enough to our nurses that need the meds and do individualized dosing?
Lacey
I would love it.
Terri
Exactly. It’s that happy medium we try to find. Right. Well, what about assaying waste then? If that is a big hole in where diversion might take place, what do you think about assaying the waste? Or how could that work? Or do you have that in your institution?
Lacey
Yeah, so waste assays are a great option for testing waste to validate that it is what you expect it to be. Right now, the technologies that exist that I’m aware of for waste assay, obviously there’s the good old refractometry, and that one does have its own barriers and challenges, particularly when it comes to low concentrations of substances like fentanyl. And low concentrations are part of our game in pediatrics. So we do compound down to pretty dilute substances. There are some limitations there when we refract those. There are some other commercial options available. I know I’ve seen some that use UV vis spectroscopy and some Ramen spectroscopy. Those have greater potential for IV substances at low concentrations. And I think both could be really big assets to a program where you’ve got a lot of IV based.
One of the big limitations in the technology as it exists today are our oral substances. So a good example would be something like oral morphine. The commercial presentation is a ten milligram cup of commercial oral liquid. And when we’re dealing with doses like a half a milligram, 1 bulk of the substance is wasted. The, say, nine milligrams that we want to validate is in fact, morphine with oral substances. We don’t have a great technology that exists today that would allow a validation of that substance. That’s usually because there’s a lot of excipients present in our oral presentations to make them palatable. But because of that stuff gets in the way for any type of refractometry or spectroscopy that we would do with, say, our IV substances. So I would love to have a solution that could validate that. My oral substance, waste is what it purports to be. Unfortunately, that part of the market just hasn’t quite gotten there yet.
Terri
Interesting. Yeah, I never thought about that when I’ve talked to them. You’re right. The discussion is all about injectables. Never even thought about the oral piece of it, which is going to be big in your world too, then. Okay. All right, so waste is a challenge. Are there any others in terms of a pediatric hospital?
Lacey
Yeah, I think we have lots of them.
Terri
All right. Number two.
Lacey
Number two. So our patients themselves are different. And when I think about our population compared to an adult population, my kiddos are not accurate historians. So where in an adult setting it might be easy to do a quick patient interview when you’ve got somebody on PRN pain meds, in my setting, that is much more challenging. You can’t really ask a three year old very clear questions about the number of doses of pain medication they’ve received in the last 24 hours, where you may be able to ask that. In an adult setting, we also almost always have somebody else in the room with the patient. So just like most listeners are not going to be super comfortable dropping their three year old off at the hospital and coming back for them later, we generally have family present at bedside throughout the stay with varying levels of direct involvement in their child’s patient care.
So we may have a child who will not take their oral meds from a nurse, and so that nurse may hand it off to a parent to administer under direct observation. That’s not something that we see a lot in adult population, and it is something that can present a gap or challenge if it’s not done really well and done correctly in an observed fashion. So that’s another one that I think comes up a lot. If I were going to pick number three in Lacey’s list, is probably our difference in drugs. We deal with a lot more stimulant in Pete’s, which is just a different drug that offers a different avenue of abuse. Besides just our typical opioids that we frequently think about, benzos that we think about, our stimulant population is much higher. So for clinicians who are abusing a substance, the substance that we deal with in larger quantities, that can lead to some interesting and different types of substance use than what we may see in our adult settings.
Terri
Yeah, that’s interesting. The signs may look a lot different for that too, then. Okay. All right. Now going back to the you’re right, poor historians, and on a few podcasts, we’ve been encouraging people incorporate your patient interviews not just when you think you have a problem, but on a regular basis, right. To try to anticipate, because we’re always surprised when there is a situation. You do patient interviews and every once in a while you get a patient like “oh yeah, it never works when she’s my nurse”. Like “oh, could you not have said something right to us before?” So you learn these things. But you’re right, you can’t do that for most of your patient population. When it comes to somebody at the bedside, I suspect when you said I forget exactly how you said it, but it’s got to be done just right. If you hand it to the parent or whoever’s at the bedside, your nurse should be observing that administration. Righ? But I suspect it’s probably very easy to say, “oh good, you do it. I’m going to go do this other thing.” Right? So you never actually see it administered. Now, that wouldn’t be our healthcare professional. That is perhaps diverting, but we all know there are parents that struggle as well. So that could be your challenge. And I don’t know if you have you seen stuff like that or how do you handle that or what kinds of things have you seen with those types of handoffs.
Lacey
So the things that we see so I have been fortunate enough not to have a direct case of diversion that I’ve investigated involving that type of a transaction. Now, the types of interaction, though, that we see that we do have to look into is when something is handed off and then is dropped or not administered and found later at the bedside. So we handed it off, the parent was going to give it, the nurse left the room, which would not be kind of our standard procedure, but our nurses are super busy people with lots and lots on their plates. So I get when the shortcuts happen and then later somebody says, hey, there’s this tablet sitting on the counter or this syringe of liquid or whatever the substance was, and it didn’t end up in the patient and it was out of the custody for a while.
Those are big risk gaps in our process, and they’re things that we have to look into and investigate. It’s not entirely dissimilar than when we hand a patient a cup and say, “here, take this”, and then they don’t. But it ends up kind of loose in the system, so it’s not too dissimilar from an adult process. But adding that extra element of somebody else in the room that definitely could be struggling with substance use is one of our constant challenges.
Terri
Right? Well, certainly the “oops, I dropped it”, or “oops, I squirted it out”, or then it’s like, well, did you really? But I guess it goes kind of the same. If it doesn’t happen all the time and there’s not all these kinds of excuses, then it probably is legitimate versus why does this parent always have trouble? So I think a lot of it comes back to that education piece. Right? I mean, just like, we don’t want to believe that our peers would do something like that in terms of taking the controlled substance for themselves. We don’t want to believe that parents would take that from their child either. But it’s that trust but verify that we all need to be aware of and just well, it happens with this parent. So let me keep an eye on that. Or maybe not leave the room anymore and follow our own policies, right?
Lacey
Yes.
Terri
Okay. All right. So we’ve got waste, we’ve got poor historians, we’ve got people in the room, and then we’ve got more use of Stimulants than opioids. So we do need to be aware of what those other signs are for. So when you educate your staff to look for those types of signs, how does that differ? Or does it from opioids or benzos?
Lacey
So it really does differ some in what we expect to see when somebody is under the influence as well as what we expect to see when someone withdraws. So what we do when we do our education is we don’t give you just one profile of things to look for. We say, here are some broad swaths of what we would expect. And what we’re really looking for are those changes. Is somebody behaving different than how you’ve seen them behave before different than how they were at the start of their shift? Anything that to you seems different than what you would expect, as well as saying we’re looking at similar stuff to what you would be looking at in your patient population. If you’re looking for withdrawal symptoms in your patient, it’s not that much different than it is in the colleagues sitting next to you. It’s being cognizant that could be going on with anybody that you’re going to encounter at any time.
Terri
Yeah, that all makes sense. And you’re right, it’s those broad things. But you also mentioned are they behaving differently at the end of the shift than they were at the beginning of the shift. I’ve heard more and I focus too on changes in behavior in general, like what were they like a month ago versus now, but the beginning of a shift and an end of a shift, that is a big thing too, especially if they’re trying to hold on until they get off that shift. Right, and we know that does happen as well because they don’t want to take something while they’re at work. All right, so that’s good. So, any more that you have?
Lacey
So, I would say the next one that I would list is probably not as much a clinical practice setting as some of the tools that we have at our disposal. So we talked about the patient interview. My patient interview as a tool is just a little bit different and often not as good an option when we start to talk about software and surveillance tools. One thing that’s notable in pediatrics is that a lot of the auditing tools are really helpful. So when our records don’t reconcile, it’s helpful to be able to identify and see those. But a lot of the AI and the machine learning algorithms have a bit of a skew and an optimization for adults. And part of that is just the data set. The bulk of users of those are going to be adult institutions and so any kind of machine learning algorithm is going to be skewed a bit to the adult so it can overlook some of those items that are more significant in the pediatric population.
Obviously, one of the big inputs there is the one I talked about at the start, which can’t say enough is waste. So understanding the role that waste diversion may play in pediatrics compared to adults is just not something that all of the software solutions are able to detect and present to us in really meaningful ways. And how that impacts user scores is a bit unusual. So that’s one that I would say it’s not that the software doesn’t have value, a lot of them have a ton of value and I think that they can really be used in our settings successfully. It’s keeping in mind that it may not be as straightforward to interpret the data that you’re going to get out of a software solution in a Peas hospital setting as it would be in a comparable sized adult hospital setting.
Terri
Yeah, because in an adult setting, even when it does come to waste, if that is the method of which somebody is doing their diversion we’re looking for, do they have more waste than others? Right. Do they put themselves in a position to get their hands on the waste, oh, I don’t need this now and let me waste it. But your volumes in your pediatric setting, I suspect that all they have to do is do what they’re normally supposed to do and just not put the waste in the bin.
Lacey
Correct.
Terri
And that would be enough. They don’t have to set themselves up for not following orders or oops patient decided not to need it. They just literally need to go about their day and so they wouldn’t look any different than their peers in the data.
Lacey
It is very hard to pick them up as different from their peers. And so that’s probably one of our biggest challenges and biggest limitations to the utilization of software. The example I give is, like I said, I think we talked about morphine briefly. So if we’re using that ten milligram cup to give a half milligram dose every 3 hours and we schedule it because somebody’s on a wean, we’re going to give four milligrams in the day and we’re going to waste 76 milligrams if you use that commercial presentation. So that looks like a ton of waste. But every nurse on every shift taking care of that patient is going to do that. And so then it starts to appear normal to the software. And if one of those nurses is somehow diluting subbing or otherwise pulling that 76 milligrams out of the system, that’s enough to maintain a healthy habit without truly doing anything that the software is going to grab as inappropriate.
Terri
Sure. Okay, so based on that, then what do you say is the number one thing a pediatric hospital needs to have in place to combat drug diversion?
Lacey
So if I were going to pie in the sky, the biggest thing that I would say is the same thing that we need at any hospital. And it’s having a culture that supports prevention of drug diversion and identification and investigation of diversion. So that’s the number one is if we have a culture where the expectation is that the process is done this way every time, nobody is going to deviate from that. And if they are, it’s going to be reported and investigated, that’s great. That would solve a ton of our problems. My 76 milligrams of morphine wouldn’t have a way to get out of the system if everybody everywhere is following the correct process and procedure every time.
So working on that culture would be my number one, knowing that we’re not going to be able to build perfect processes that people are going to follow every single time. And, that likely no matter how good my process, somebody who is desperate will still find ways to get out of drug out of the system. My couple of big items that I would say, one, getting your dosage form as close as possible to your average dose size on the units where you’re going to be giving it. So reducing and minimizing that waste as much as we possibly can. I know it’s not completely possible to eliminate and like I mentioned earlier, it’s going to shift some of it to pharmacy. But there are ways around it. There are ways we can compound down to smaller concentrations and smaller sizes so that instead of having access to 76 milligrams of waste, we might have access to five milligrams or smaller to accomplish your same doses.
Terri
And pharmacy is smaller too, right? Usually. So as long as you’ve got people that are watching in pharmacy, you could probably do a few more things for less investment in terms of maybe cameras or just making sure everybody was watching and pool that down to a much smaller pool in the pharmacy.
Lacey
And you can also manage to compound without creating as much waste. Right? So if we compound that single unit dose cup into multiple doses, now we don’t have to waste the nine and a half milligrams out of the cup. I can make that last for the whole day. It requires extra labor and work in your pharmacy department. It requires good oversight in your pharmacy department, but it does take some of that risk straight out of the system. The other options are your more cost prohibitive options, but I think they add a ton of value. Surveillance is really helpful, and when I say that, I mean camera surveillance. So understanding what your waste process really looks like is huge and helpful. And video surveillance is probably the best way to see that in current state.
Those waste testing solutions we talked about, especially if you’re dealing with large quantities of IV waste, they are really good. I think they do add a lot of value. They help you identify issues early on for IV products. They can be used in pharmacy and outside pharmacy, so you can get coverage in all of the different areas where you may be encountering waste issues. And then the one I said at the top, I’ll repeat it again, is working on that culture and engaging kind of at every level. So at unit level, are we looking at how we waste drugs? How important is this to the staff on this unit as part of their workflow? If it’s not happening in the way we expect it to be, can they speak up and tell us that and can they tell us why? And can we start removing those barriers? Are the waste bins too far away? Is where they document, not where they actually waste? What are the ways that it could be getting out of our system so that we can work on those root causes to make sure their default process is the correct process, and that way when there’s an outlying behavior, we’re able to identify it as outlying.
Terri
Absolutely. Yeah, you bring up some good points there, too. And the culture well, first, the culture not only to follow the policies and procedures and speak up if there’s a barrier, but what is diversion and what does it look like? And I know you don’t want to believe that any of your peers have a substance use disorder. But chances are pretty good that there’s somebody there that does, right? And so recognizing that and having that culture of speak up because we do want to get them help, right, it’s not just a punitive type of a thing. And so it wraps that entire culture together of following the procedures and policies and recognizing because we care and we want to help, and then they’re more inclined to speak up. And I think that issue of listening to your staff and being aware of what their processes are and how they are physically set up because there are times where either we have set them up for failure because of some sort of equipment thing or the way the pathway to whatever you get to, but also it’s just not practical.
Sometimes in the pharmacy we’ve got these visions that will just do it. I mean, what is the problem? And there are problems and I go back to I was so fortunate to be able to work at a hospital when I was chair of their Med Safety Committee, that we had a tremendous amount of participation with front end staff and a lot of them were nurses. And I had to work on my poker face sometimes because they would just say, well, Terry, and then I’m like, you’re what? And I’d be like you’re what? And they’re like, hey, we’re just keeping it real. This is what we do. This is what we’re going to do. If you put that in place, this is how it’s really going to happen. And so you got to face those realities and look for something. Granted, there are times when you just have to say, you know what, you’re going to have to figure out a way to make this work, so let’s talk about this.
But there are other times where it’s like, okay, this is not the best idea, so let’s look at what your barriers are and to change that. And so it really does all go together. And if we could get that culture in all of our hospitals, not just our pediatric hospitals, then that would go so far for diversion mitigation right. That’s absolutely kind of what it’s all about to get them engaged. All right, so let’s talk about there’s got to be something that in a pediatric hospital they are in a better position. Let’s flip it around. Like what do they do better just naturally when it comes to diversion mitigation.
Lacey
Surely there’s something oh, yeah, I’m sure we’ve got plenty of things where peeds is kind of excellent. So I would say I have harped on the waist with my pediatric nurses and my colleagues. And so I have to give them the credit that they also do in pediatrics. There is an incredible amount of advocacy for all of the clinicians, but especially my nursing partners on behalf of their patients. It is one of the cultures where I feel like it is safest to speak up on behalf of the patient. And part of that is just the nature of caring for children. If they see something that seems odd, my nurses will say something, hey, that order seems off. That math doesn’t check out. I don’t understand why we’re doing this. Can you help me understand something? And so things where like an order might get entered as a verbal order that seems weird.
My nurses won’t let that slide pretty much ever. They would bring that kind of thing forward immediately as this looks weird. And I think that is one of the places where we shine in peeds. Family focused rounding is another one. So a lot of places and a lot of times we include the whole care team in the rounding setting. So you’ll have the parent in addition to the child with the clinician and the nurse providing care, all in this kind of collaborative space. So if something is happening, no matter who it’s happening with, was it the nurse on the prayer shift? Was it one of the people standing there? Is it the parent? That stuff can get brought forward much quicker and sooner in kind of a collaborative setting, which I love in pediatrics, there’s a ton of attention to detail. So even when we are deviating from policy, we tend to have people who know their policies and know their practices and their detail oriented by nature because of the challenges that you experience in pediatric care and how focused and detailed that has to be.
Terri
Not a lot of room for mistakes.
Lacey
There’s really not. No, when you’ve got half a kilo, baby, you’ve got no wiggle room to make any kind of error. And so that level of focus and attention to detail pervades the environment and that’s wonderful to work with.
Terri
Yeah. What about are your large volumes in syringes? Does that help in any way? Okay.
Lacey
We virtually never need bags. Virtually never. I’m not going to say nobody in peas will ever give anything controlled in a bag.
Terri
There’s some big peas out there.
Lacey
We can talk all day about how metabolism differs in this weird age and childhood where you give them more drug than you would give a grown up. I don’t think that’s what we’re going to get into, but let me know if you want a sidebar. We’ll pharmacokinetics all day.
Terri
Technically. What age do you go up to at a pediatric?
Lacey
Is it age? There’s not a true age limit.
Terri
Okay.
Lacey
So we can get up into the teens, early 20s, especially if they’ve been with us long term. So we can definitely get some adultish patients and metabolisms going. So it’s a big spectrum. Right.
Terri
So you got to do it all. You got to monitor it all.
Lacey
But we do generally have most of our continuous infusions and syringes rather than something like a cassette or a bag that’s a little bit harder to detect. A volume variance lets us detect way sooner than you may be able to in a larger volume, where if there’s a variance, you’re not going to find it until you actually draw that waste out. We can physically see volume change shift over shift and measure the amount on the pump display matches the amount that’s actually in the visible container when you hand off. I think that’s super helpful in our environment. That may not be as easy with micronutrients.
Terri
Right? Yeah, for sure. Okay, so you got a one up on those syringes. All right. Well, I think this in general, the challenges are the same, but because of different patient populations and some of this could probably be translated into different unique, the challenges will be the same. It’ll be waste, it’ll be do you have a poor historian? And you need to check something, because we all know we have that in adults as well. So we’re all on the same page, I think. But we do need to be aware of the specific challenges for our hospitals, which can differ from one place to the other. I think a rural hospital is maybe different than a non rural. They have specific things that they need to deal with, and so it’s just good to keep in mind those things when you go into it. And it can be, I guess, maybe a little eye opening for somebody coming in brand new to a new space to recognize those things.
And I think some of us forget that there are those differences that are important, but we all struggle with them, and we’re all looking for the best way. And again, a lot of it comes down to culture, so we’ve got to put some time, and that’s, like, almost free.
Lacey
And it’s also one of the biggest returns on investment. If you can make it happen, it’s a long haul, and it’s hard, and it requires a constant dedication. It’s the best tool we have. And to your point, it’s free.
Terri
Yeah, I agree. Okay. All right, well, thank you very much, Lacey, for your time. Thanks for sharing. And I know this was good for me. There were some things in here that I hadn’t quite thought about. I’ve worked in hospitals that have a subset of pediatrics, but it’s not the bulk of what they do, and so that does definitely make a difference.
Lacey
Yeah, absolutely.
Terri
Thanks for having me, Terry.
Lacey
I really enjoyed talking to you today and sharing our challenges, but successes over in pediatrics.
Terri
Yes, absolutely. All right, thank you very much. And thanks, everyone for listening.
