Welcome back to the show. Today we’re diving into a critical but often overlooked aspect of drug diversion investigations – the role of infection prevention. While most facilities focus on the regulatory and criminal justice aspects of diversion cases, there’s a vital public health component that frequently gets pushed to the sidelines until it’s too late.
My guest today is Michelle Nation, a nurse with extensive experience in infection prevention. Michelle has witnessed firsthand how the disconnect between diversion response teams and infection prevention departments can leave patients at risk and facilities scrambling to address preventable outbreaks. She’s been advocating for a more integrated approach that brings infection prevention expertise to the table from day one of any diversion investigation.
While we’ve all read about the serious cases documented on the CDC website where infection prevention ultimately played a crucial role, by then the damage was often already done. In this episode, we explore how facilities can bridge this gap proactively, what the patient notification process should look like, and why every diversion response team needs an infection preventionist at the table from the very beginning.
Transcript
Terri Vidals
Welcome back, listeners. My guest today is Michelle Nation. She is a nurse and has a lot of experience especially in the area of infection prevention. Infection prevention plays a key role in diversion investigations and yet I think that department is routinely overlooked in programs. That is what we’re going to talk about today. Welcome. Michelle, let’s start with you telling us a little bit about your background.
Michelle
Thank you. Yes, I have a microbiology degree. I started work in the biotechnology sector for a while and then I decided to go back to nursing school.
As I was progressing through my nursing career, I found infection preventionists. That was a method of me being able to combine my microbiology degree and nursing. And so that’s how I got into infection preventionist and I was able to get my certification, infection control back in 2016. So I’ve been doing this since 2014. So have at least 11 years experience infection prevention.
Terri Vidals
Great. All right. Yeah, that makes sense. With your undergraduate degree for sure. Based on your experience, do you find that facilities underutilize their infection prevention team when it comes to diversion related incidences or their program in general?
Michelle
I do. When I first got into infection prevention, drug diversion was not really anything talked about in our circle. You know, were, we seemed to be quite separate from the pharmacy department and otherwise, you know, the things that we talked to pharmacy about was antimicrobial stewardship. So that was something we would talk with them about, but not really drug diversion.
We weren’t included in those conversations and even if we did have bloodstream infections that wasn’t like drug diversion was not part of our thought process of what could have caused those bloodborne pathogens or other bacterial fungal infections.
Terri Vidals
Yeah, I was going to say I feel like the breakdown is probably on both sides as diversion teams don’t think about infection. And then I was going to ask you if the infection prevention has thought about diversion as a risk for infection.
Michelle
Yes, I think it’s getting more noticed now.
Last year at apic, the association for professionals infection Control had a drug diversion topic. And then I’m going to be talking with the group at APIC with a pharmacist and epidemiologist on the same subject this year to go more in depth about drug diversion, so I think these are times that we’re going to be able to bring drug diversion into focus for infection preventionists.
Terri Vidals
That’s excellent. It’s nice to hear it’s moving in that direction, that education piece of it. What typically, where do you think IP should be brought in. You know, people talk about if they have a diversion response team, should IP be on that response team? Should they be ad hoc if you have a case? If they are ad hoc, when should you think about bringing them in? Is it just with injectables? I mean, that’s where your main risk is. What are your thoughts on that?
Michelle
Yeah, I definitely think they need to be ad hoc. There’s diversion of pills, the infection preventionist doesn’t need to be privy to that information. But when you’re talking about injectables, even if it’s theft of whole vials and there could be a potential for some type of tampering that wasn’t thought of, it’s great to bring the IP in because they are the ones that are monitoring bloodborne pathogens, bloodstream infections.
So maybe they’re seeing some kind of uptick that the diversion team may not be aware of. It kind of goes both ways.
If the infection preventionist is seeing some kind of uptick in, say, waterborne pathogens that are causing bloodstream infections is to bring that to the diversion team just so that they could look to see, is there a potential of drug diversion out there that were just haven’t been detected yet?
Terri Vidals
Sure. Yeah. Interesting. That is one way that the diversion specialist, whoever’s doing the monitoring, might become alerted to something. We’re seeing things on this unit, you know, take a look at diversion. So I like that from that perspective. And, and what you said reminds me of, I tell all the diversion specialists that I work with, be sure that you have a really good line of communication with your risk department along the same lines. Right. The risk department sees things that we don’t see and we are not privy to. But if they’re educated on diversion, then they’re a great partner because, you know, there could be things coming from that department, too. And it’s getting everybody on board to think that diversion might be some. Or substance use disorder in the case of risk might be part of the problem. If you’re seeing things.
Michelle
Yes. You know, the same thing if the risk department is seeing something. You know, they do have someone that they’re suspecting of having a substance use disorder is, you know, ask the iep. Can you monitor, you know, look back for the last six months and see if there’s anything that can correlate with this person’s practice as well?
Terri Vidals
Okay. Yeah. Nice triangulation. You just connected all three departments together instead of going to the diversion department. Right, that. That makes perfect sense. So take us through the process of possible infection, how is it typically identified that there may be an issue? Does it usually start with seeing that uptick? Are there times that maybe you haven’t seen an uptick, but they’ve got a suspected diversion that involves injectable that would cause an IP department to then look at things a little bit differently, maybe, and then see something?
Michelle
Yeah, I mean, thankfully, it doesn’t happen very often, you know, that we’re seeing those infections, but you know, it can be, you know, it can come from different ways of detection, you know, so from an IP point of view, it is looking for those waterborne pathogens or other kind of odd pathogens that you shouldn’t see causing infections, as well as being able to monitor down to each unit or area of concern.
So if you’re in a hospital, you want to look at trends in your ICU as well as your med surg, not just an overall trend in the hospital, because you may not pick up those small nuances.
If it was a specific person that was causing infections in a facility, in a unit, you know, having the monitoring and surveillance down where you can compare what is kind of normal for areas so you can know what is an outlier.
Terri Vidals
Yeah. Okay, that makes sense. What are your thoughts on. I know there are some programs out there, some facilities that incorporate testing. If they have a healthcare professional that they either have confirmed or highly suspicious of diversion. Part of the whole investigative process is, you know, drug testing, but then also testing that person for any infections that they may have. This is obviously, if it involves an injectable, and it’s just a part of their program, they just do it for everybody. I’ve had other people, other facilities say, well, that’s a real invasion of privacy. That’s going a little too far. What are your thoughts on that?
Michelle
So I believe, you know, from a public health point of view, it is very important that we are asking people to get tested at the time that we have them with us. Because if you have someone that is diverting medications that are doing risky behaviors like tampering and substitution of your medications and putting patients at risk, it is better to ask them to get tested at that point.
So you know what your risk is to your population, to your facility and to your patients. And also we need to also convey that we care about the people that are our co workers and our staff members, so if they are diverting, they have a substance use disorder, we want to let them know that we care about them and we don’t want to see them with any kind of bloodborne pathogen, so we want to get them connected to care if they are positive for hep C or hep B or HIV.
We want to make sure that, you know, they know we are looking out for them as well. So I think that is one way to kind of. To put it in perspective that you’re not trying to invade their privacy, you’re actually trying to help them because, you know, they are people too. And we want to make sure that they are being as safe as possible, too.
Terri Vidals
That’s true. Depending on what their method of diversion is, they may be infected and don’t even realize it.
Michelle
Right. And even if they are using, you know, street medication, street drugs, you know that they are doing some risky behaviors. So, you know, if there is that potential for something being transmitted in our walls, we still want to be able to offer that to them so they can get the help they need.
Terri Vidals
Right. Okay. As you said, it doesn’t happen too often, these big infections, but when it does, it can be pretty substantial. What does the patient notification process look like? I mean, that must be a pretty daunting process and one that you don’t necessarily want to unleash, but sometimes it’s necessary. So what does that look like?
Michelle
Usually you want to work with your public health to try to really get down to who needs to be notified. Who was at risk of being exposed to any bloodborne pathogens, that’s your step number one is making sure you’re working with someone that understands the risk that’s out there. So public health can be a great avenue for that. So, you know, what we kind of want to do is almost like if there’s a outbreak of, say, measles, you want to start smaller with your circle.
And then if you see infections in that small circle, then you want to get a little bit larger. So that’s why you really want to kind of pinpoint who’s at most risk. Who would benefit from being tested so that you’re not causing, like, a widespread panic or, you know, having this, like.
Wider net out there that you’re not going to catch many positives. So, you know, if it’s, say, a fentanyl bag that you are thinking that’s what the medication was being diverted and the diverter said, yes, that’s my drug of choice. Maybe you’re going to test the people that have received fentanyl from the certain amount of time that you’ve looked back at, then if there Is infections in that group maybe you go to a little bit larger group. Maybe not just the people that diverter took care of, but anyone that was in the same locale that was, that had that medication.
Terri Vidals
Okay, yeah, that makes sense. Do you have any idea of what percentage of reported diversion cases, and by reported, I mean reported to the licensing board, what percentage of them do involve infection? I mean, we hear about the big ones, right?
Michelle
And I think the others. Yeah, I think it’s still pretty low. I mean, you know, I don’t have a specific percentage, but from my experience it’s. It is, you know, it is harder, I think, to transmit than we, you know, really want to look at. But we do have to take that.
Michelle
It can happen.
Michelle
So, you know, we don’t want to just say don’t test anybody because the percentages are low. Because when you do have one, as.
Michelle
We’Ve seen across the nation there.
Michelle
Can be great, you know, pretty wide outbreaks caused from drug diversion.
Terri Vidals
Right. Maybe that’s why the IP department is overlooked because it doesn’t happen too often. So. But you’re right, it has big ramifications when it does happen and you want to jump on that. And there’s the liability for the hospital as well, right?
Michelle
Yes. Nobody wants to be in the headlines that’s for certain, but I think we also have to understand that it’s happening everywhere.
You know, it doesn’t matter what type of facility that is, you know, that has diversion. So it could be, you know, from anywhere from your long term care facilities to acute care facilities big and small but that we just don’t need to brush it
under the rug. We need to bring it to light. Because the more that the public understands what is going on, I think the more they can rest assured that we’re doing everything we can to stop diversion and to protect their health.
Terri Vidals
Right. When we last spoke, you mentioned that you were working with IHFDA to bring them on board with more of an official stance on the involvement of infection prevention. What is the. Can you even tell us what is the status of that? Or maybe we’re going to hear at the conference in a few months, but what are their thoughts on it?
Michelle
So we have been able to add bloodborne pathogen testing as an official recommendation from IHFDA when there are injectable medications involved in drug diversion.
So I think that is a big win to have that as a recommendation because it is like you said, it is so hard for facilities to know what they can do, what they should.
Do you know where the line is? Of crossing someone’s privacy versus what is best for public health? So, you know, I think I’ve already explained, you know, how it’s not just for public health. It’s for the person that is suffering from substance use disorder as well.
Terri Vidals
Yeah. Is there anything else that you’d like to share with the listener? Things that they should consider or perhaps lessons that you’ve seen others learn the hard way?
Michelle
