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Shortages are speeding up the movement to get pharmacists into the ED.
A patient in an emergency room bed needs succinylcholine, but the department doesn’t have any. In the next bed, someone has a bacterial infection, but the best antibiotic for the job isn’t available, so the physician chooses something that is not quite as good.
Drug shortages continue to be a serious problem. EDs have been hit hardest, although almost every other department in a hospital will argue that point. Several classes of agents used in EDs-including opioid analgesics, electrolyte solutions, and antibiotics-have been in continuous short supply. Many commonly used generic injectables are also affected: these include antidotes as well as drugs used for resuscitation and rapid sequence intubation and in critical care.1
Maryann Mazer-AmirshahiIn a busy ED, a drug shortage can lead to delayed or inadequate treatment. Substitution errors and compounding errors can occur when physicians, nurses, and other personnel reach for the drug they need and it is not there or if an unfamiliar drug is there instead, said Maryann Mazer-Amirshahi, PharmD, MD, MPH, assistant professor of emergency medicine at Georgetown University and attending physician at MedStar Washington Hospital Center in Washington, DC.
“My experience with ED docs is that they get used to a set list of drugs and when those are not available, then it is a challenge,” said Bona E. Benjamin, BSPharm, director for Medication-Use Quality Improvement with the American Society of Health-System Pharmacists.
While the type and duration of drug shortages are continually changing, pharmacists are seeing a definite decrease in the number of shortages. “It has gotten better,” said Erin R. Fox, PharmD, director of the Drug Information Service at University of Utah Health Care and adjunct associate professor at the University of Utah College of Pharmacy in Salt Lake City. More than 300 drugs had been on shortage for some time a few years ago, but that number is now just under 200, she noted. Shortages of bags of sterile saline and of benzodiazepines, for example, have been largely resolved, she said.
It is not just the number of drugs that become unavailable, it is which drugs are affected, said Benjamin. In the ED, a significant number of drugs used on a daily basis are in short supply. “Emergency rooms probably are experiencing shortages on a continuum of ‘better’ to ‘still pretty bad’ depending on their patient mix, their ability to keep drugs for those patients in stock, and the availability of therapeutic alternatives,” she said.
Erin Fox“Each shortage is a little different and requires a different type of management,” said Fox. The pharmacist may need to find an alternative treatment, reserve the drug for a specific patient population, or deal with the shortage in other ways. “But clinicians are spending time on these problems, figuring out a workaround, and this takes away from patient care,” she said.
Drug shortages can affect not just the ED, but also emergency medical services, said Fox. EMS units had been using expired drugs in some shortage situations, particularly epinephrine, she said.
One of the challenging current shortages is with antimicrobials, said Benjamin. “A significant number of patients are seen in emergency departments with what may be serious infectious disease.” Antimicrobial shortages may have a varying impact depending on the hospital, she added, since the prevalence of infectious diseases and their drug-resistance profiles vary with a hospital’s location.
The ever-changing nature of shortages has meant that ED personnel have become accustomed to dealing with them. Shortages are adding momentum to the movement to place pharmacists in the ED.2 Because of their knowledge of what drugs are available and what the best alternatives are, pharmacists can work directly with emergency clinicians to help them deal with drug shortages, said Fox.
Shortages can be even more difficult with certain patient groups. Geriatric and pediatric patients present special problems when a preferred drug is not available. With children, attention must be paid to ensure that the dosage is correct for the substitute drugs, said Mazer-Amirshahi. There are usually fewer drugs approved for use in children or they may not be available in forms that children find palatable. Geriatric patients may have issues with renal function that may prevent use of an alternative or they may be taking other drugs that interact with the usual alternative. Pregnant women also present problems when the substitute drug is not a good choice, she added.
Patients with rare conditions are also at a disadvantage with some shortages, said Mazer-Amirshahi. “There are 50 alternatives for blood pressure medications, but not a lot of alternatives for orphan drugs or antivenins.”
Shortages in the ED require the pharmacist to be proactive and to make sure everyone is informed as much as possible as to what drug is in short supply or completely unavailable and about the protocol for dealing with that shortage, said Benjamin.
Drug shortage is a multidisciplinary issue that needs a multidisciplinary approach, said Musselman. Everyone who has to deal with drug shortages has to be at the table talking about it, including physicians, nurses, and pharmacy personnel. “It definitely should not be isolated to one department,” she said.
“We keep open communications between the pharmacy department and the emergency department and come up with alternatives and provide education and support about dosing and monitoring those agents,” said Musselman.
ED clinicians are used to dealing with a specific medication and do not have time to check the side-effect profile or dosages for a substitute, Mazer-Amirshahi said. The need for speed means that communication about drug alternatives and substitution issues has to take many forms, said Fox. “You have to use multiple methods-e-mails, pictures, posters, posters with pictures, one-on-one talks,” she said.
Bona BenjaminInformation technology helps in disseminating information about shortages and substitutions, Benjamin said. Some hospitals have set up computers in the ED to alert users to changes in protocol or to dosage issues, or to provide a list of formulary alternatives, she said.
Benjamin said that it is helpful if the alternative drug or treatment does not resemble what it is replacing. A visual difference helps alert physicians and nurses that they are dealing with a change from the usual.
For the most part, a hospital pharmacy knows when a drug shortage is coming, said Megan Musselman, PharmD, BCPS, BCCCP, Clinical Pharmacy Specialist in Emergency Medicine/Critical Care, North Kansas City Hospital, Kansas City, MO. Information on shortages is available from a variety of sources, including ASHP’s website and the FDA, she added.
“ASHP maintains its own website with detailed shortage information and information on clinical management that complements the data on the FDA’s site,” said Benjamin. However, maintaining the ASHP website with up-to-date information depends on reports from the people who use it, she said. “People on the front lines of care are the ones who experience shortages first. We depend on them to let us know what is in shortage so that we can post it as soon as possible,” Benjamin said. When pharmacists, prescribers, or even patients report any shortages they experience, it helps keep the ASHP website accurate and current, she added. “Very often, drug shortage information can be too little, too late, especially if we hear about a shortage after it’s already serious.”
Pharmacy blogs and listservs also help get the word out about shortages and good alternative drugs, said Musselman.
“I have the luxury of working in a department with a proactive pharmacy,” said Mazer-Amirshahi. “A lot of shortages never reach the bedside in our hospital.”
“Pharmacists strive to manage shortages in a manner that allows the care process be as seamless as possible from the patient’s viewpoint,” said Benjamin. “So a lot of our work is invisible; it goes on behind the scenes with the rest of the care team.”