Oct. Nov. Dec. Jan. Feb. Mar. Apr.
System average Provider A Threshold
tampering, as well as policies for dealing with
These processes are designed to track vials
and, to a lesser extent, the medication within
them. Specific tracking numbers are used to
account for vials from the minute they leave the
pharmacy to the time they’re returned. There
are rules about where they’re stored, how they’re
secured while in the possession of paramedics
and how the medications should be wasted.
There are mountains of policies, procedures
and foolproof standard operating procedures/
standard operating guidelines (SOPs/SOGs)
to ensure that what goes out and what comes
back in all add up.
The question, though, is whether “
foolproof” actually means that we’re fooling ourselves. It may be that all these processes really
do is keep us off the radar of our state regulatory agencies and the DEA—and do little
to address the underlying problem. Although
amounts of drugs administered and wasted
are carefully documented and empty vials are
returned for resupply, what happens to a drug
once it’s drawn up in a syringe is a lot harder
MEASURING THE PROBLEM
In a recent survey of large metropolitan 9-1-1
EMS systems around the country, medical
directors were asked how many instances of
diversion they’ve had. Nineteen of the 23
responses reported no cases in recent memory. Of four agencies that reported diversions,
there were a total of six individual cases. 3
This means that at some of the largest EMS
agencies in the country, there have only been
six instances of diversion among millions of
patient encounters and tens of thousands of
controlled substance utilizations.
Here in Texas, there were 15 investigations
into suspected controlled substance diversions
in 2016 alone, three of which were reported by
our organization, MedStar Mobile Healthcare. 4
The only reason these cases were discovered by MedStar is because the system measures each paramedic’s controlled substance
use and waste, and then compares these metrics monthly to every other paramedic in the
system. To benchmark potential outliers, we set
the threshold for abnormally high use or waste
as three times the system average.
An example of what such a spike might look
like is shown in Figure 1. For the months of
October, November and December, provider A
(blue) has typical use compared to the system
average (green). In January and February, we
begin to see an increase in use but it’s still not
over the threshold. Finally, in March and April,
there’s a dramatic increase in use.
At this point, the individual’s use is evaluated for drug administrations that don’t seem
appropriate to the clinical circumstances. This
information is typically picked up from several
locations on the electronic patient care report
(ePCR), including the narrative, physical exam,
vital signs, oxygen saturation (SpO2), and end-tidal carbon dioxide (EtCO2).
In our protocol, the use of the narcotic fentanyl isn’t indicated for chest pain due to suspected acute coronary syndromes (ACS), nor
is it indicated for any patient with pain documented as less than or equal to 6 out of 10 on
a pain scale. We also wouldn’t expect fentanyl
to be administered to a patient with inadequate respiratory status, severely diminished
mental status, or with a potentially significant
head injury. An example of one such individual’s possible out-of-protocol administrations
is illustrated in Table 1.
Each individual’s pattern of drug wasting is
also compared to monthly system averages. As
illustrated in Figures 2 and 3 (Page 48), provider B (green) administers does of fentanyl
that don’t exceed the system threshold—but
their monthly pattern of wasting does.
To put this in better perspective, a paramedic
may use fentanyl in doses of no more than 100
mcg several times a month and never exceed
the threshold. If, however, several of these cases
included drug administrations where only 25
mcg of fentanyl are given to patients and the
remaining 75 mcg wasted, the total might
exceed the threshold.
Looking at all of this from the system perspective, Figure 4 (Page 62) illustrates the total
number of above threshold notifications for the
three controlled substances currently utilized
at MedStar—fentanyl, midazolam and ketamine—representing a total of approximately
10 to 25 cases each month that require individual QA and ePCR review.
WHAT HAPPENS NEXT?
In those instances where paramedics not only
exceed the system threshold, but their pattern of use or waste appears to be clinically
Table 1: Example of possible out
of protocol drug administrations
Count Clinical findings
6 Inadequate respiratory status
2 Altered mental status
17 Chest pain due to suspected ACS
2 Doses higher than prescribed by protocol
1 Pain ≤ 6/10
8 Suspected head injury
Figure 1: Monthly controlled substance administration
(Provider A vs. system average)