Exposing the "Dirty Little Secret": Random Drug Testing of Health Care Workers in the Wake of the Hepatitis C Outbreak, 14 NHBJ, 2014 Spring-Summer, Pg. 10
| Author | Mark A. Abramson, Jared R. Green & Lindsey B. Gray. |
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Spring/Summer, 2014
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\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0INTRODUCTION
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0The next time you or a loved one are about to go under the knife, consider this fact: Approximately 10-15 percent of healthcare workers (HCWs) will misuse drugs at some point during their careers, 1 a rate comparable to or exceeding that of the general population.2
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Among physicians, chemical dependence is considered the most common disabling illness.3 Alcohol is typically the drug of choice, followed closely by opioids, stimulants, and other substances.4 Indeed, in one study, 17.6 percent of physicians reported using opioids in the past year in an unsupervised manner and 11.4 percent admitted to unsupervised use of benzodiazepines.5 On average, these rates are five times higher than the public as a whole.6
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0The risks addicted health care workers pose to patients are obvious. The impaired HCW may suffer a decline in cognitive functioning, leading to errors in clinical care.7 Or, the HCW may obtain his or her drugs through diversion - the illegal removal of drugs from a healthcare facility.8 In such a case, the HCW often steals pain medications intended for patients, leaving them without the benefit of their prescriptions and causing unnecessary anxiety and pain.9 What's more, the diverting HCW may "swap" medication -replacing filled syringes with used ones, placing patients at risk of contracting blood-borne illnesses, wound infections, and sepsis, among other things.10
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0In July 2012, 32 New Hampshire patients discovered first-hand the havoc a drug-diverting HCW can wreak on innocent lives, after they contracted Hepatitis C during procedures at Exeter Hospital's cardiac catheterization lab (CCL).11 An investigation revealed that David Kwiatkowski, a CCL radiologic technician infected with the virus, stole fentanyl syringes, injected himself, filled the syringes with saline and returned them to be used on unsuspecting victims.12
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Dubbed a "serial infector, " Kwiatkowski was indicted and pleaded guilty to federal charges in connection with the crimes, for which he was recently sentenced to serve 39 years in prison.13
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Kwiatkowski's horrific actions at Exeter were not his first foray into the drug-diverting community: He admittedly swapped syringes for years as a traveling HCW before coming to Exeter.14 In fact, on at least two occasions, he was caught diverting drugs intended for patient use.15 Yet, incredibly, he was not removed from patient care until May 2012, when Exeter discovered a cluster of Hepatitis C infections amongst its CCL patients that sparked an investigation by the New Hampshire Department of Public Health.16
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Expectedly the Exeter Hospital "fiasco"17 spurred new state legislation intended to combat the problems posed by addicted HCWs, including HB-597, "An Act Relative to a Drug-Free Workplace for Licensed Health Care Facilities and Providers."18 As originally introduced, HB-597 called for mandatory random drug-testing for healthcare workers.19 Nevertheless, following stark opposition from multiple organizations concerned primarily about the bill's cost, random drug testing was taken out of the bill.20
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Today, as amended, 21 the bill simply requires licensed healthcare facilities to "adopt a policy establishing procedures for prevention, detection, and resolution of controlled substance abuse, misuse, and diversion.'' While this policy must include, at a minimum, procedures for suspicion-based drug testing, 22 the majority of healthcare facilities, including Exeter Hospital, already have such policies in place, 23 leaving some to question whether HB-597 is "worthless."24
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0This article explores the policy considerations surrounding random drug testing of HCWs, looking specifically at the Exeter Hospital Hepatitis C outbreak as a case example, and suggests that the "culture of silence" amongst HCWs contributes significantly to the high rates of drug diversion in healthcare facilities. Therefore, any successful drug-diversion policy must limit both the facilities' reliance on staff members to identify addicted HCWs and the amount of discretion accorded staff members in responding to incidences of drug diversion.
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0ANALYSIS
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0David Kwiatkowski
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0David Kwiatkowski's career as a radiologic technician began in 2003 after he completed a program at William Beaumont Hospital in Michigan.25 Upon graduating, he became certified by the American Registry of Radiologic Technicians (ARRT), 26 a credentialing organization designed to ensure registrants meet "basic education, ethics, and examination requirements."27 Most employers require radiologic technicians to be ARRT-certified as a condition to employment.28 In addition, 37 states rely on ARRT certifications as proof that an individual has the proper credentials to practice in that particular state.29
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Having obtained the appropriate credentials, Kwiatkowski soon landed a job in his field and, between 2003 and 2007, worked at several health care facilities in Michigan.30 Apparently, it did not take Kwiatkowski long before he began abusing his position as a HCW to feed his drug addiction. In fact, in 2004 he was fired from St. Joseph Mercy Health System after he tested positive for controlled substances.31 That same year, William Beaumont Hospital terminated Kwiatkowski's employment for "gross misconduct."32
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Then, in December 2006, while working at the University of Michigan Health System (UMHS), a nurse reported that a vial of fentanyl went missing after Kwiatkowski was seen quickly entering and leaving the room in which it was left unattended on a counter.33 UMHS promptly suspended Kwiatkowski's employment pending an investigation into the matter.34 When police asked Kwiatkowski to submit to a lie-detector test, Kwiatkowski declined, choosing instead to resign his position.35 UMHS barred Kwiatkowski from returning to the hospital, noting in his personal record that he "resigned during suspension while under an ongoing investigation."36 Nevertheless, UMHS did not stop Kwiatkowski from obtaining employment elsewhere, and Kwiatkowski went on to work for Oakwood Annapolis Hospital where, not surprisingly, his employment was later suspended pending an investigation into his narcotics use.37
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Having seemingly exhausted his employment options in Michigan, Kwiatkowski jumped into the world of traveling healthcare workers in November 2007.38 Working for different staffing agencies, between 2007 and 2011 Kwiatkowski accepted various short-term assignments at medical facilities across the country, including hospitals in Pennsylvania, Maryland, New York, Arizona, Kansas, Georgia, and New Hampshire.39
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Unfortunately, Kwiatkowski's drug-diverting ways did not end with his exodus from Michigan. On May 7, 2008, just 47 days into an assignment at University of Pittsburgh Medical Center (UPMC), an employee in an operating room observed Kwiatkowski enter an operating room, lift his shirt, put a syringe in his pants, move his arms quickly near a medication car [t], and exit the room. A subsequent review of the narcotics in the room showed that a syringe containing Fentanyl was missing and that it had been replaced by a syringe containing a different liquid (which was later found not to be Fentanyl). Kwiatkowski, who was acting erratically and sweating, was confronted and agreed to be searched shortly after the incident. Three empty syringes bearing Fentanyl labels were found on his person. An empty morphine sulfate syringe and a needle were later found in his locker. A drug test found Fentanyl and opiates in Kwiatkowski's urine.40
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Following the incident, UPMC immediately terminated Kwiatkowski's assignment and informed his staffing agency, Maxim Staffing Solutions (Maxim) .41 Amazingly, however, neither UPMC nor Maxim reported Kwiatkowski's misconduct to ARRT, 42 the organization arguably in the best position to prevent Kwiatkowski from obtaining future employment, and which, by its own admission, had a duty to ensure he met industry ethical standards.43 To the contrary, Maxim immediately began looking to place Kwiatkowski at another facility44 and, less than two weeks later, Kwiatkowski landed an assignment with another staffing agency at Baltimore Veterans Affairs Medical Center (Baltimore VA).45
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0While at the Baltimore VA, Kwiatkowski was suspected on at least one occasion of tampering with narcotics.46 In addition, hospital staff members located empty syringe packages in an IR storage room when Kwiatkowski was working—an occurrence that never happened unless Kwiatkowski was present.47 Therefore, after only two months into his assignment, "nursing staff made a conscious effort to control the areas" Kwiatkowski had access to, barring him from the nursing area during procedures.48 Unfortunately for one patient, such measures were too late: Kwiatkowski had already infected him with Hepatitis C during a procedure on May 27, 2008.49
\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0Toward the end of Kwiatkowski's assignment at Baltimore VA, a physician began talking about offering...
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