January February March April
System average Provider B Threshold
December January February March April
System average Provider B Threshold
g ) 1,600
— Continued on page 62
inappropriate, two things happen:
1) Paramedics are brought in for face-to-face QA reviews to better understand
their critical thinking and clinical decision-making. Although they may be educated
or remediated, the process is entirely
non-disciplinary and nonpunitive in nature.
2) Individual cases are also independently
reviewed by the system compliance officer
to determine whether drug testing
is required, including urine or hair
follicle evaluation for either recent
or remote substance use. If either of
these tests are positive, the results are
evaluated by an independent occupational health physician to correlate
them with the individual’s personal
prescriptions and medical record.
Diversion can be subtle and the
devil is often in the details. Most EMS providers typically have a “style” to their treatment, and the rate at which they administer
controlled substances doesn’t vary greatly from
month to month. When reviewing their cases,
we get a feel for this style and a reasonable sense
of the types of calls for which they administer these drugs.
Since protocols are also meant to be guide-
lines, there will always be exceptions. Thus, the
QA process doesn’t seek to identify a single
out-of-protocol violation so much as it looks
for multiple instances, especially those where
inappropriately high doses are used.
There are times when paramedics have
high administration rates but, regardless of
the results of drug testing, we find that they
may not have good understanding of pain
management protocol, whether with regard to
dosing,indications or contraindications.
As a result, the process provides an opportunity to educate not only the provider, but
sometimes the entire system as well.
IS THERE A DOWNSIDE?
Although systems should take pride in con-
trolled substance tracking processes that might
point to suspected instances of diversion,
reporting these cases can also raise some eye-
brows. They may lead to the perception that
something is wrong with an agency’s processes,
and that they may be increasing the opportu-
nities for misuse of drugs.
It’s also worth recognizing that the commitment to a philosophy which critically evaluates controlled substance use also often leads
to further investigation at the state level, not
to mention potential fines, DEA
involvement and a mountain of
paperwork. It doesn’t take a great
leap of understanding then to imagine how all this might not encourage
self-reporting or the development
of tracking processes that might
uncover such cases in the first place.
System executives and managers
may be inclined to take a “hear no
evil, see no evil” approach, especially if they
believe they have the best tracking systems
already in place and don’t understand how
diversions might be occurring right under
The way this often plays out is that, even
when the limited processes identify a suspected
diversion, personnel may resign and move on
to the next agency in lieu of taking drug tests.
In those instances where drug tests actually
“pop” positive, individuals may be fired—but
not always reported to the state.
It’s no surprise that, with the potential for
complicated and time-consuming state investigations, fines and possible media attention,
termination of employment without a report
to regulatory authorities may just simply be an
easier and less messy option.
Finally, it’s worth noting that, in addition
to any other system QA initiatives for which
there may already be limited personnel and
technology available, a critical approach to
controlled substance monitoring requires a
nontrivial commitment of both human and
Diversion is a difficult problem because it
deals with our friends and EMS family, and
the inherent difficulty of our jobs. It’s unlikely
that someone begins a career in EMS because
they want to divert controlled substances.
The nature of our job places us in stressful
situations every day. We work long hours, get
little sleep and rarely have sufficient time to
decompress. This can lead to stress and anxiety
and, in some
Don’t rely on vial tracking
systems as the sole means
to prevent diversion.
Figure 2: Monthly controlled substance administration
(Provider B vs. system average)
Figure 3: Monthly controlled substance waste (Provider B vs. system average)