When staff members become substance abusers: Identifying the drug-impaired clini
December 1, 1997 7 minutes read
When staff members become substance abusers: Identifying the drug-impaired clinician
Long hours, job stress put ED caregivers at high risk
Having a drug-impaired nurse or physician on staff is among an ED manager’s worst nightmares. But it’s a common reality, since ED clinical staff are at higher risk for problems with substance abuse than those who practice other specialties, according to Dennis Whitehead, MD, FACEP, chief of emergency medicine at Dickinson County Memorial Hospital in Iron Mountain, MI, and the former chairman of the American College of Emergency Physicians’ (ACEP) wellness committee. "Addiction is an occupational hazard of emergency medicine, and it’s fairly pervasive."
The fast-paced, stressful nature of the ED is partially responsible for the high prevalence of substance abuse, Whitehead suggests. "It’s very easy for physicians working [long] shifts to start self-medicating, since we may need something to stay awake during night shifts and then need medication to go to sleep," he says. "Also, people that practice emergency medicine have a reputation for being adrenaline junkies’ focused on immediate gratification. A lot of the same qualities that make a good emergency physician will predispose somebody toward addiction."
It’s a disease, not a moral problem
Until recently, clinicians with drug or alcohol problems were routinely terminated and lost their licenses, but today’s ED managers should be more enlightened, says Whitehead. "The AMA recognized this as a treatable illness back in 1953, but it’s only now in the ’90s that people have been treating it as such," he adds. "Managers need to look at this as a medical problem, without making judgments about people’s morals."
That includes respecting the impaired clinician’s confidentiality. "There is an enormous amount of shame and embarrassment involved with these issues," stresses David Keseg, MD, FACEP, chief operating officer of Premier Health Care in Dayton, OH. "That’s why it is imperative to ensure as much confidentiality as possible. You shouldn’t discuss your suspicions with anyone other than the responsible parties, although, if necessary, the hospital CEO and medical chief of staff may need to be informed."
On the other hand, staff members need to be given some understanding about why a colleague is suddenly on leave. "If Dr. So-and-So isn’t going to be there for 30 or 90 days, I think it’s the right of everybody who’s going to cover for them to know where that person is," says Adrian de la Torre, MD, an emergency physician at Lancaster (CA) Community Hospital. "We all have constitutional rights, but the fact of the matter is somebody is gone, and it’s the right of the people you work with to know why they are being asked to work extra."
Still, it must be the impaired clinician’s decision, emphasizes de la Torre. "The worst thing is to set up a situation where you’re humiliating the person by bringing them into a staff meeting and then announcing they’re going into treatment," he says.
The ED manager should explain that the clinician is on medical leave, he recommends. As a result, staff will probably be more willing to cover the clinician’s shifts. "People will bend over backward if they realize someone is trying to help themselves," says de la Torre. "People are more understanding than you give them credit for. There aren’t a lot of people with hard hearts out there."
Being open is healthy for the impaired clinician. "There is a lot of shame associated with substance abuse. Because of that, people hide and engage in stalking in the shadows type of behavior," says de la Torre. "The key is to bring it out into the light and engage in an open discussion and look at it as a disease rather than a social condition."
Clinicians who are upfront with colleagues about their problem tend to do best, emphasizes de la Torre. "There is a tremendous amount of support out there for that type of person," he says. "There is no better way to dispel rumors than to confirm it and say, That’s the truth.’"
Since impaired clinicians are usually the last ones to acknowledge a problem, staff should be encouraged to report suspicions about substance abuse. "The nursing and ancillary staff can be an effective barometer of physician behavior and attitude," says Keseg. "If you assure staff of anonymity and confidentiality, people are more likely to come forward with their suspicions."
Staff should be alert for the following signs, says Keseg:
extreme mood swings from euphoria to deep depression
• irritability and short fuse
• hard to get out of call room and difficult to awaken
• patient complaints about short temper or acting in a daze
Make sure you confront the right person
Many ED managers find that medication dispensers such as Pyxis machines are helpful in keeping tabs on withdrawals of controlled substances. Still, a nurse or physician who is truly desperate can bypass the technology designed to prevent drug theft. In one ED, it was determined that the Percocet count was off. A 24-hour user report was run, revealing that several patients had been given two Percocet pills apiece, which was unusual. "All the withdrawals were by one nurse, so we pulled the patient charts," recalls the nurse manager, who asked to remain anonymous to protect the impaired nurse’s confidentiality. "As I suspected, there were no orders."
Another Pyxis machine showed four withdrawalsbut no patient ordersall by the same nurse and all taken after the patient was discharged. When the hospital pharmacy ran a week’s report on the nurse, 50 inappropriate withdrawals were discovered.
Right before the nurse was confronted, mangers ran a random user repor. The nurse manager was shocked to find that the nurse under suspicion was off many of the days the withdrawals were made. "I was completely shocked, and I realized that another nurse must have been using this nurse’s code," says the nurse manager. "We then had to look at the previous month’s schedule and saw a clear pattern every time a particular nurse worked."
The next time the nurse came to work, she accessed the Pyxis machine within 45 minutes, using the other nurse’s code. Within an hour, a second withdrawal was made. At that point, the nurse was confronted and admitted she needed help.
The Pyxis machine eliminates several days of digging through paper records, says the nurse manager. "Without Pyxis, the process would have taken a week or two, and it took us only 30 minutes, yet here was a new wrinkleit led us to the wrong nurse," she says. Nurses should protect their passwords and change them frequently, she urges. "Nurses come to the Pyxis and log in their codes so many times a day, it’s not that difficult to see someone’s code if they’re not paying attention."
Here are some issues to consider when managing an impaired clinician:
Have a written policy. Having a written protocol in place can make things a lot easier, says Whitehead. "Having the medical staff sign off on a policy that states that if there are suspicions of substance abuse, there will be a process of investigation is a good idea," he advises. "If everybody agrees on a reasonable way of acting when confronted with this, it’s a lot easier to go ahead with removing somebody from the clinical duty roster pending an investigation and taking whatever steps are necessary to protect the patients." The policy should focus on objective problems such as poor quality of charts, missing medications, and lateness, Whitehead recommends. "Stick to the facts. Then, if you have good reason to think there is a problem, the protocol can be initiated," he says. "Physicians tend to rationalize their way out of it, and having a set protocol makes it harder for them to do that."
Bring your evidence. Before confronting a clinician, gather all your documentation together. "Most of the time, they won’t ask you for it because they don’t want to see it, but you need to lay it on the table if the person challenges you," says Anita Black, RN, MHSA, acting director for clinical services in the emergency services department of Medical College of Georgia in Augusta.
Be direct. ED managers need to have an honest, candid discussion with the clinician without skirting the topic of substance abuse, says Keseg. "There can be a tremendous amount of denial with this type of individual, and there needs to be tactful directness employed when discussing the issue," he notes.
Get help for the impaired staff member. "One of the worst things that can be done is to tell an impaired clinician to get lost and go someplace else," says Whitehead. "Substance abuse is a condition with a high rate of recovery when it’s properly monitored."
Watch closely for signs of relapse. Clinicians who return to work after treatment need to be monitored aggressively. "It’s up to the ED manager to head off problems and avoid a relapse by noticing when problems start to surfacewhen the clinician starts to manifest the same type of behavior, work too many hours, or has difficulties in interactions with staff," says Whitehead. "That’s also for the staff member’s own protection, because if a relapse is caught early, less harm is done."
Get the staff member into treatment immediately. Staff members who are confronted may become suicidal. "We make arrangements in advance and take them from the meeting directly to treatment," says Black. "We never leave them alone, not even for a minute."
Don’t hesitate to speak with a staff member. Even before your suspicions are confirmed, it’s helpful to let a clinician know about your concerns. "It may be that a staff member who is suddenly chronically late or undergoes changes in personality is going through personal problem or depression, but you need to sort that out," says Whitehead.
Present a firm plan of action. There are two main goals an ED manager should have when confronting an impaired clinician, says Keseg. "Your main objectives are to get the physician the help they need to address the problem, and also make sure that they are not involved with direct patient care until they are cleared by the appropriate professionals."
Recommended Reading
A policy statement on physician impairment is available from the American College of Emergency Physicians. To obtain a copy, contact ACEP at (800) 798-1822, or via FaxBack at (202) 728-0161.
Talbott GD, Gallegos KV, Wilson PO, et al. The Medical Association of Georgia’s impaired physicians program. JAMA 1987;257:2927-2930.
Whitiker GR. Keeping the emergency physician healthy and effective, N C EPIC 1990:1-2.
Shore JH. The Oregon experience with impaired physicians on probation. JAMA 1987;257:2931-2934.
Whitehead DC. The impaired professional. In: Salluzzo R, et al, eds. Emergency Department Management St. Louis: Mosby Year Book; 1987:725-728.
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