This Week in Surgery Centers: Alex Yampolsky – Stopping Drug Diversion at Your ASC

Alex Yampolsky – Stopping Drug Diversion at Your ASC

Here’s what to expect on this week’s episode. 🎙️

The current methods used by surgery centers for managing narcotics present numerous vulnerabilities. It creates an environment that is highly susceptible to drug diversion.

Alex Yampolski, MedServe, joins the podcast this week to share insights into how you can proactively patch holes in your process, tools that might help, and red flags to look for. Here are some highlights from the discussion.

• Prevalence of Drug Diversion: An estimated 95% of drug diversion incidents go undetected. These activities often remain under the radar to avoid bad PR, making it a silent yet pervasive problem.

• Vulnerabilities in Current Systems: Shockingly, 98% of ASCs still rely on outdated methods like double-locked cabinets and paper logs for narcotics management.

• Technological Solutions: For centers able to afford technology, digital narcotic cabinets offer the most secure solution. For centers unable to afford new technology, stringent double-check systems and maintaining clear, monitored access protocols is key.

• Behavioral Red Flags: Often, those involved are the least suspected but may display subtle behavioral changes such as irregular work attendance or increased interest in managing narcotics.

• Preventative Measures and Policies: Effective strategies include conducting mock investigations to prepare staff, implementing rigorous documentation processes, and fostering a culture where staff feel safe to report suspicious activities.

Find the full episode on Apple Podcasts, Spotify, or YouTube to hear all the details.

Episode Transcript

[00:00:00] Welcome to this week in Surgery Centers. If you are in the ASC industry, then you are in the right place every week. We’ll start the episode off by sharing an interesting conversation we had with our featured guest, and then we’ll close the episode by recapping the latest news impacting surgery centers.

We’re excited to share with you what we have, so let’s get started and see what the industry’s been up to.

Erica: Hi, everyone. Here’s what you can expect on today’s episode. Alex Yampolsky is the CEO of MedServe, and he joins us this week to share insights into how you can stop drug diversion at your ASC. This is not a topic we’ve really covered at all yet, and I think the work that Alex and his team are doing is super important.

Erica: So I’m excited for everyone to hear our conversation and hopefully implement some of Alex’s advice. We cover the most vulnerable areas in a surgery center, tools [00:01:00] that ASCs are using to help, some red flags to look for, and how to build a culture where staff feel comfortable addressing potential concerns with leadership.

Erica: And after my conversation with Alex, we will switch to our data and insight segment. And today we’ll break down the average OR and recovery times per specialty. As you know, every minute in the OR and recovery area counts. So while patient safety is of course the number one priority, it’s important to look at the industry averages to see if you have the opportunity to increase efficiency.

Erica: Hope everyone enjoys the episode and here’s what’s going on this week in surgery centers.

Erica: Alex, welcome to the show.

Alex: Glad to be here.

Erica: Can you share a little bit about yourself, please?

Alex: Sure. Alex Yampolsky, I’m a pharmacist. I’m the CEO of MedServe and MedServe is the only digital narcotic cabinet and [00:02:00] management system built specifically for surgery centers. And I live and breathe drug diversion prevention.

Erica: I love it. We got to get some merch. Maybe we’ve got a link to the, to your merch in the episode notes eventually. I know we should start

Alex: selling the shirts. Everybody I talked to, they’re like, Oh, I like it. Can I have one of those shirts? Is it also has a fancy like all of these like fancy art work on it.

Alex: Love it that people get a kick outta.

Erica: Perfect. Cool. So this is not a topic that we’ve covered yet but I think that the work that you’re doing is super important. So I’m excited to have you on so we can all learn a little bit more about how we can stop drug. diversion from taking place at surgery centers.

Erica: So from your perspective, how prevalent is drug diversion in an ASC setting?

Alex: It’s a tough one to answer. So when we look at statistics, so I know Becker said something out where it’s assumed that about 95 percent of drug diversion goes undetected. And a lot of drug diversion also goes unreported because who wants that bad PR of [00:03:00] their nurse or their anesthesiologist stealing from their center.

Alex: We don’t hear a lot of, about a lot of cases. A lot of cases we just never find out about. But yet there’s something in the news every single day. I don’t know, most people probably aren’t like me and don’t have a Google alert set up for when drug diversion in news articles, but I see something new every week.

Alex: Whether it’s a nurse at a hospital swapping out fentanyl with saline and then patients dying or a nurse at a. fertility center, stealing hundreds of vials of fentanyl, or it happens all the time, but we only hear about a fraction of what’s actually going on.

Erica: Yeah, I’m sure every nurse, you know, anyone who’s been in the industry for a while has their own stories, whether they’ve, you know, situations that they’ve been aware of, whether they’ve come out publicly or not.

Erica: So I’m sure everyone listening can relate to this in some sort of way. In a surgery center setting, what are the most vulnerable areas that you typically see? [00:04:00]

Alex: So it’s actually shocking to me when I first found this out. You know, coming from a health system, we expect technology, we expect there to be electronic medical records, we expect there to be medication dispensing cabinets, and when we step foot in most surgery centers, it’s like we’ve traveled back in time.

Alex: I’m sure you’re listeners, and you know this probably about 98 percent of surgery centers still keep their narcotics locked in a regular cab, double locked cabinet with a paper log. They may have a camera nearby, they may have another lock on the door, but the reality is like that is the most vulnerable area.

Alex: People can access it after hours. Nobody knows when it’s been opened. Nobody knows what’s gone in or out of it. And it’s an honor system. There’s a paper log where you record your activity. And for us, we see that as one of the biggest areas of. Mass diversion, where hundreds of vials can go missing over time.

Alex: Microdiversion usually happens at a wasting level, so if you, let’s say, used a fentanyl vial, but then you use all of it for a patient, and you have some left, that gets, that’s where abuse a [00:05:00] lot of times happens, is well, that half a syringe, you can, or half a vial, you can figure out a way to use it and divert it and not actually properly document the waste.

Alex: That’s a small scale. Large scale is the cabinet.

Erica: Got it. So most vulnerable area would just be the lack of documentation. Required lack

Alex: of security, and I think it’s the lack of oversight. I’d say it’s, yeah, there is an ability to access. The entire narcotics stock without any oversight.

Alex: And I think that’s the biggest issue. Sure. Anybody ever knowing that you’ve been in there?

Erica: Yeah. Wow. Okay. So considering 98 percent of ASCs, that’s their process. What tips do you have for preventing drug diversion? I guess if that is their process, but then also just in general, what tips. Do you have what tools could they be using?

Alex: Yeah. What we see really helpful. So of course there’s technology solutions out there. And I think like until, you know, our company MedServe we play in this space this is exactly what we do. And until [00:06:00] last, there really hasn’t been a solution that was priced and built for surgery centers.

Alex: So that’s why so many were stuck. They couldn’t afford the technology. So if you can afford a technology, and it is very affordable now, but if you still can’t do that having two people as much as possible, having redundancies in the process and figuring out a way to have key control and cabinet control so that, you know, when somebody has been in there, there’s oversight.

Alex: It’s hard to do because so many centers are short staffed or just staffed just right. And And that’s hard. People do struggle with it, but the best thing you can do is have somebody else looking over someone’s shoulder when they’re interacting with narcotics. And there’s different places where this happens.

Alex: A drug order comes in from a distributor, from the manufacturer, and it sits somewhere in the center. Then it gets stocked into the cabinet. Then it gets removed from the cabinet for anesthesia or for patient use. Then it gets expired or wasted. And there’s these different touch points that we talk to many customers about, and I know many in the industry who specialize in this also talk about and how to prevent it.

Alex: But there’s those specific [00:07:00] touch points where drugs are accessed, where you really should have two people. And it’s not the same two people.

Erica: Interesting. Okay. Kind of gives you those, that checks and balances. So maybe one person orders, but then somebody else documents is that

Alex: what

Erica: you’re thinking?

Erica: Okay.

Alex: Yeah. Yeah. And actually I personally was involved with a case of what, it wasn’t in a surgery center, but we had a pharmacist that I worked with who was a mentor of mine when I was a student who we ended up catching years later, stealing 120, 000 Vicodins. And thousands of oxycodone, thousands of valium, and the way that he got around it was he had he ordered medications out of the normal process.

Alex: Then they were received by him, stocked by him, and then removed by him, and they never made it into the inventory of the pharmacy. So yes, definitely having different people do different things. And what we see a lot of times too in surgery centers, there’s the pharmacy nurse. There’s that one person that takes care of the pharmacy needs because it’s a skill set that’s learned for most nurses It’s [00:08:00] not something we do we see them do in hospitals a lot And they become the one point of contact the one point of control and oversight And then that’s a problem

Erica: Yeah I can see that.

Erica: Thinking about tools, aside from having, you know, a cabinet that is built for this, let’s say they, they can’t afford it, or for whatever reason, don’t have the cabinet. You had mentioned cameras before, so like video surveillance,

Alex: what else? Yeah, so some other tools is yes Having that eye above, right?

Alex: So that at least when somebody goes into the cabinet, they know that they’re under supervision. The other thing that we see a lot of places now is badge scanning at the door. At least we know if somebody access the supply room or pharmacy room or medication room, whatever you facilities call it, we know that there’s a record of them going in.

Alex: And if somebody goes in after hours, hopefully someone’s looking at it to to understand that Hey why is this person going in after hours and spending time in this room? So that those are some tools that we see quite a bit of. And they’ve, I think they’ve been helpful at the very least to [00:09:00] deter the person.

Alex: And scare them that somebody else is looking over their shoulder.

Erica: Yeah, absolutely. What about pre filled syringes? Have you seen that help at all?

Alex: Yeah. Yeah, we have anything you can do to minimize the waste. So if you can have pre filled syringes temper, evident caps anything along the lines to help limit the waste, limit those.

Alex: Potential areas of abuse. Unfortunately, with shortages, a lot of times we saw centers ending up having to buy larger quantities. So they’ll buy five milliliter vial instead of a two milliliter vial, which they normally would buy. And then there’s quite a bit of waste left over. And again, those are big areas where they can get diverted because initially It’s just you, when somebody does it once, they, and don’t get caught, they realize they’re not being watched.

Alex: And then it just escalates, and that’s when they end up going from taking a little bit and using that once to stealing hundreds of vials.

Erica: Sure. So what would be kind of some red flags associated with a staff member who might [00:10:00] be doing something they shouldn’t be and stealing drugs?

Alex: Well, so from what we’ve seen and I’ve seen throughout my career is. Unfortunately, it ends up being a lot of times the person you suspect the least. It’s the person that puts in the most work. It’s the person that takes on majority of the responsibility. And that it’s really sad because it’s someone that you trust.

Alex: But that aside, the things that happen that we we call them red flags in behavior. Obviously outside of being impaired at work, which happens and there’ve been cases that I’ve heard about anesthesiologists being impaired at work because they’re abusing the wasted narcotics. Changes in behavior.

Alex: So somebody who’s been punctual all of a sudden starts missing work, showing up late. Somebody all of a sudden volunteering to help in the supply room or in the medication room and take control over it, even though we want people to take responsibility. To take on more and to take ownership of things.

Alex: A lot of times that is actually a red flag because the person that’s closest to it is the person that has the most access and they have sometimes [00:11:00] a reason for why they want to do that. The other thing is, and this is like very basic and I I can’t even believe that I have to say this, but.

Alex: When vial caps come off really easily, that’s not normal. There should be a click, there should be a pop. We know what it should be like normally. When patients complain that their pain isn’t well controlled, yes, some people maybe don’t respond to a pain medication like somebody else does. But when this happens over and over, we can see a trend.

Alex: And there have been many cases documented where there have been complaints and nobody paid attention. So we need to be on the lookout for it. And having a great, you know, I’m a pharmacist by training, that’s what we do now, but having a great consultant pharmacist work with the center, they can educate the staff on the things to look out for.

Alex: Like those red flag behaviors, like the policies and procedures, like what to do when there’s a shortage or when there’s a discrepancy in the inventory counts. A lot of these things could be, you can build systems around it.

Erica: Yeah, that’s actually a great segue. So with the policies and procedures, is it typical to have something in there [00:12:00] about if a staff member unfortunately becomes suspicious of another staff member, is.

Erica: How do you build a culture where they’re comfortable or someone’s comfortable reporting that or knows what to do next?

Alex: Training. Training and talking about it. That’s really the best way to do it and not blowing people off. We’ve had cases where somebody’s been like, yeah, you know, this person’s been acting goofy, but I didn’t even bring it up because in the past when they brought up my concerns they’ve been just kind of tossed to the side.

Alex: Like I didn’t mean. bother. We’ve definitely heard things like that and that’s terrible. And but yeah, it all goes back to the culture of the center and the type of team teamwork that you have and openness and communication and training. People need to know to look out for these things, what to look out for, and that they know, and they know who to report to.

Erica: Sure. And I’ve heard you mention in the past mock investigations. So how do those typically go down? And I’m sure that would help to build that culture and that transparency.

Alex: Yeah. So here’s what [00:13:00] happens in some centers. It’s end of the day, most of the people are already gone.

Alex: The people involved are definitely gone and, or could be And you find the discrepancy and you just have to just People say after work you’re trying to not let anybody leave without, until you figure it out and you’re scrambling, you don’t know where to look, you don’t know which pages. So those things can go much smoother.

Alex: You have to practice. And I suggest that people do these fun, it’s, it could be like a fun team building activity. It’s hey let’s play pretend we’re short two fentanyl. How do we, who do we look at, what do we look at and how do we get to the answer really quick? Because usually it’s not stolen.

Alex: Usually it’s just not recorded properly. Somebody didn’t add correctly or subtract correctly. It’s a goofy mistake, usually. But sometimes it’s not. And having these mock investigations, having different people involved could be fun for the center, but it also can get the center more prepared. You know, we, we do drills, we do fire drills, we do, we can do a diversion drill as well.

Erica: Yeah, I think that’s great advice. [00:14:00] Yeah, really interesting. Would love to hear from surgery centers who have done a mock investigation or something similar like that just to hear how it was received by the staff and how it went. I think that’d be really interesting to hear some firsthand perspective.

Erica: All right, so I do really want to talk about the lawsuit that’s going on right now with Yale’s reproductive is it their infertility clinic? I think.

Alex: Yeah.

Erica: That’s has, there’s a class action lawsuit. Please share what’s going on there and the latest.

Alex: Yeah. If any of the listeners haven’t heard about this It’s really a terrible case because, and I guess drug diversion in general is terrible on so many different fronts. We always, we tend to think about it from impact to the employee, maybe impact to the culture of the center, maybe DEA fines and the regulatory things.

Alex: Sometimes we think about the patient side of it. And what happened with, in this case it turned into a murder mystery podcast almost. That was super popular last [00:15:00] year. And it really, I think, shined a light on the patient harm here. So what ended up happening is there was a center where a nurse was diverting fentanyl, replacing it with saline.

Alex: Patients going through egg retrievals. basically didn’t have any pain medicine on board. No matter how much extra medicine they got, there was no pain relief. And there were many layers here from the nurse to the culture of the facility to doctors blowing patients off and thinking like, Oh, it’s something about you.

Alex: It’s not us because I just gave you some fentanyl or whatever the medication was. But at the core kind of, when we look under the hood, what actually ended up happening that led to this, and this went on for. a very long time. I can’t remember how long the nurse admitted to doing it for, but there were patient reports of same situations.

Alex: years before. Wow. This was a nurse who was the main nurse at the center. So patients referred to her, they had her as Donna REI. So like when they called the clinic, they were calling her. She handled [00:16:00] refills. She handled a lot of stuff. She was the go to for these people. She was there, the source that they, the person that they trusted.

Alex: And what ended up happening, she was having family issues, abusive husband and going through a messy divorce and a whole lot of stuff that she didn’t really bring to work. Except that she couldn’t handle it. And she started diverting. And from what we’ve learned is she was initially started diverting right in the center and using it on the job.

Alex: And eventually when she went on for so long, she started just taking vials home, using them at home, replacing them with sailing. Sometimes returning them, sometimes not because nobody kept track. And when we looked deeper, why did nobody keep track? Well, there was a new administrator that started. Trusted the team, trusted the original process and trusted Donna to continue to manage the pharmacy aspect of it.

Alex: Donna was the person ordering, keeping up the logs basically keeping track of all that paperwork. And if she never raised a flag, there was no flag raised. Other thing was the this particular center was just skeleton [00:17:00] crew. Understaffed. And the other thing was when they interviewed some nurses that work there and the nurses said they were shocked when they stepped foot in the center.

Alex: It’s like they went back in time. There was no automation for medications. They’re used to having a pixus or an omni cell in the hospital, but there was no automation in the center. It was. manual paper log, double locked cabinet. So all of those things kind of combined ended up leading to this case where so many women ended up going through egg retrieval procedures with no pain medicine on board, suffering like tremendous pain and the pain that they like, they kind of had to proceed with.

Alex: They couldn’t just, there was so much prep work, so much emotional investment and financial and time. And this is the time to do it. This is the window and I have to suffer through it. And there was so much post traumatic so much trauma after the fact that a lot of women were left very scarred by this.

Alex: And it’s just. Yeah, it’s a terrible case.

Erica: It’s such, it’s so layered because any drug diversion is horrible, but especially at an infertility clinic, to your point, it’s like, there’s [00:18:00] already been so much emotional pain, so much physical pain leading up to this, so much sacrifice leading up to this point to then that have been your experience, especially knowing that it could have been caught a while back if maybe people were paying closer attention or maybe they just had, you know, more staff.

Erica: So being from Connecticut. I’m very familiar with this case. But it’s interesting because if we go back to the red flags that you mentioned earlier in the episode, it sounds like they were all prevalent where, you know, or like the person nobody suspected You know, just happening over time, patient complaints, like there were patterns leading up to this to the point you made earlier, and what was the final straw?

Erica: Like, how did it all kind of come to a head?

Alex: Anesthesiologist noticed that the cap came off too easily on a fentanyl vial, and that triggered an investigation. And reported it and that triggered an investigation. But, you know, to your point, like it had somebody else, there were red flags.

Alex: There were patients [00:19:00] complaining of pain during after and some people have to come back time after time to do this because the first attempt may be unsuccessful. Had this been had flags been raised earlier it would have triggered an investigation earlier. But yeah, so an anesthesiologist popped a fentanyl cap, came off too easily, reported it, triggered an investigation and then Donna knew that was it.

Alex: And over the weekend, I believe she brought in 175 vials and dumped them into their sharps container. Like she was ready to get caught at that point.

Erica: Yeah. Jeez. Jeez. Is it completely? Over they still or they’re in court going through settlements. Now, I think

Alex: it’s going to be going on for a while.

Erica: Okay.

Alex: Yeah. The case itself is the charges have been like the legal aspect of it with the, with Donna that, that’s been that’s been dealt with and okay. That’s over now. But The lawsuits that’s gonna probably continue.

Erica: Yeah, geez. Well, I hate to end on a heavy note, but I think that’s a it’s an unfortunate but realistic case, right?

Erica: Of how [00:20:00] easily this could happen and how prevalent it is. And you might not think it’s happening at your surgery center. No one wants to think that it is. But it very well could be. But I think you’ve given a ton of great advice and just reminders for everyone listening of how they could kind of do their part.

Erica: So we do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?

Alex: So I’m going to do two, I’m going to say look into technology, of course. But secondly do these mock investigations. And see where you have areas where you have a hard time pinpointing who the offender is.

Alex: And those are the areas you should focus in on having extra oversight in.

Erica: Perfect. Thanks, Alex. We appreciate you coming on. Thanks for having me.

Erica: Welcome to Data Insights, where we turn data into dialogue and numbers into narratives. So HSE Pathways released a [00:21:00] state of the industry report late last year, highlighting best practices, key process steps, and KPIs for every step of the patient journey and for nearly every recurring administrative duty.

Erica: Most importantly, using our own unique data set from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers. Two quick disclaimers, we only pulled data from clients who gave us permission and we omitted any extreme outliers. So today we’ll be looking at two very important metrics, OR duration per specialty and recovery times per specialty.

Erica: So let’s start with, Oh, our duration. After analyzing data from over 450 ASCs across the country, we determined that on average, the two, The top three longest OR times are plastics with 164 minutes, dental with 67 minutes, and ortho with almost 62 minutes. Our data [00:22:00] analysts derived this metric by first categorizing each primary CPT code into one of the top 12 specialties.

Erica: They then subtracted the procedure end time with the procedure start time and averaged that number by specialty. Why does this data point matter? The time spent in the OR directly influences operational costs. Monitoring average OR duration helps manage costs by identifying areas where efficiency can be improved.

Erica: This ensures that operating rooms, equipment, and staff are all being used effectively. So if you’re not seeing the success that you’d like to, or maybe when you’re looking at your month over month trends, you’re seeing upticks in certain areas where you would like it to stay stagnant, you must try to identify patterns.

Erica: So factors could include the surgeon assigned to the case. patient characteristics, complexities of the case, even days of the week, you never know. And every minute matters in the OR. So the more efficient you can be while [00:23:00] maintaining the highest levels of patient safety, of course, the better. The second data point I’d like to dive into is average recovery times.

Erica: So using the same data set, we determine that on average, a cardio case will take 83 minutes in recovery. Plastic cases will take 82 minutes. They were super close and ortho cases will take 62 minutes And our data analysts derive this metric by following a very similar process as for OR times, but instead looking at recovery end time and recovery start time.

Erica: So why does this data point matter? The time patients spend in the recovery room is critical for their safety and comfort post surgery, but it’s also critical for your bottom line. By ensuring that patients are moved efficiently through the recovery area, it will guarantee that your nursing staff and other resources are utilized efficiently and that you’re not hemorrhaging money for no reason.

Erica: Of course, [00:24:00] patient safety is the number one priority, but if your recovery times are way above average, there might be an opportunity to, let’s say, Adjust your anesthesia and medication combo, or maybe you just need to lead into some extra staff training

Erica: and interestingly enough the National Library of Medicine also released a paper last year or so sharing the results from a study they did that tested the benefits of something called Post Ease, which is a custom essential oil aromatherapy blend that’s known for decreasing that post op nausea and vomiting.

Erica: So depending on what your analysis shows, there might be a simple fix or at least things that you could try To get those recovery times down and I will leave you with this. When looking at both OR and recovery times per specialty, both data points share four of the same five specialties for the highest averages.

Erica: And those are cardio, plastic, ortho and podiatry. If your ASC covers any of these [00:25:00] specialties, you’ll absolutely want to make sure you’re closely monitoring both of these metrics and moving patients through as efficiently and safely as possible. If you’re interested in more data points and use cases, subscribe to the podcast so that you don’t miss any upcoming segments.

Erica: Or you can head to our website to check out the full state of the industry report to get your hands on even more data. And that officially wraps up this week’s podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you’re listening from.

Erica: I hope you have a great day and we will see you again next week.