Narcotics Control Policies in EMS Avoiding Stressful Experiences

Narcotics Control Policies in EMS Avoiding Stressful Experiences with the DEA Raymond L. Fowler, MD, FACEP Chief of EMS Operations UT Southwestern Medical Center and Parkland Memorial Hospital

A recent case in Texas ØVolunteer EMS Medical Director ØTiny Volunteer Service ØNarc Control Policy in Place ØConducted Annual Audits Ø 20 Year Relationship ØTrusted PM Director

A recent case in Texas ØMed Director rolled out fentanyl ØConducted audit in November ØPM Dir began stealing fentanyl “for his wife’s headaches” Ø“Diverted” ~240 ampules over a year’s time

A recent case in Texas ØWhen questioned by partner Said “have Med Dir’s permission” ØKept separate med records ØMother complained to DSHS ØDSHS contacted Med Dir who promptly conducted audit

A recent case in Texas ØMed Dir discovered the diversion ØReported PM to state ØReported matter to DEA ØAssumed that all was well

Then it got ugly

A recent case in Texas ØHearing before ALJ ØPM decertified ØNo recommendations ØThought all was okay

A recent case in Texas ØWithout an order from ALJ, DSHS reported MD to BOME ØBOME began license revocation ØDEA initiated investigation

A recent case in Texas ØDEA found Med Dir liable ØDEA found PM partner liable

A recent case in Texas ØDEA fined the Medical Director $7, 000 in total due to the fentanyl “diversion” ØSame fines against the PM’s

A recent case in Texas ØAttorney R. Jack Ayres was engaged to defend the case ØSuccessfully argued before the Texas BOME ØDEA action pending

The DEA is not playing DEAdiversion. gov

From this case the DEA’s position is that the Medical Director is absolutely liable for the narcotics authorized for purchase under that physician license

When was the last time that you REALLY reviewed: üYour narcotic control policy üThe receipt into inventory üRunsheet documentation üPeriodic inventory üInvestigations

YOU MUST HAVE A WELL CRAFTED NARCOTICS CONTROL POLICY

I AM SHOUTING!!!

The policy must provide accountability for every single molecule üEVERY AMPULE üEVERY TIME üWITHOUT EXCEPTION

It’s apparent from the recent DEA action that anything other than a very precise narcotics control policy is unacceptable

As It SHOULD be

Four essentials of a solid narcotics control policy üInitial inventory üReordering based ONLY upon documented usage üPeriodic Inventories üStandard investigation

Initial inventory This is the basic stock of drugs that were set out for usage at the beginning providing initial stocking and for which “re-supply” was made

Reordering and Resupply ØMust be based strictly upon documented usage ØMust include written documentation of the usage ØMust include wastage ØDO NOT REORDER/RESUPPLY WITHOUT CONFIRMED USAGE

Periodic Inventories ØDaily in the central storage ØDaily on the ambulances ØDaily on any intermediate locations Ø“Spot unscheduled inventories ØSignatures coming on and off

Test your system ØCome in on a weekend ØCheck drug box during rideout ØMake sure all locks are in place ØHave a unit come in for a random spot check ØBE CREATIVE!

Investigation Policy ØEvery missing drug, every time ØIncludes ALL involved staff ØInitiated AT THE TIME of discovery of inventory mis-match ØGet the shift OUT OF BED ØDrug screens where indicated ØDocument

New Ideas for the Electronic Age ØElectronic PCR inventory control program ØEPCR Notification system Ø“STAT tracking of documentation errors

Documentation Errors ØUnacceptable ØMust be treated JUST LIKE an error in a hospital Ø“Take no prisoners”

The Primary Understanding A missing ampule of a scheduled drug can no more be tolerated in the EMS world than it would be in a hospital

“Enlightening Discoveries” made along the way ØDEA investigator said that Øfentanyl had no place in the prehospital arena rd copy ØDEA 222 form 3 Ø“Authorizing vs. Ordering Entity”

Ruminations upon Closing

An Ethical Imperative You do people a favor when you HELP keep them honest

Thoughts upon going home ØLook at your policy ØAsk about the inventory ØGet buy in ØShare war stories ØKeep an eye on the store!

May you live in interesting times Crisis is DANGER mixed with opportunity Always create the crisis on YOUR timeline!

www. rayfowler. com

? or !