May 15, 2020
Michigan’s drug shortages team meets twice a week and includes clinical pharmacists, pharmacy technician buyers, and pharmacy managers.
AS SHORTAGES of injectable hydromorphone, morphine, and fentanyl show few signs of abating, health systems across the country are finding themselves in a perpetual state of crisis management. Although coping with a shortage of drugs as essential as opioids is a systemwide task, pharmacists have been at the center of many organizations’ shortage management strategies.
Staying Above Zero Stock
At the University of Michigan Hospitals – Michigan Medicine in Ann Arbor, pharmacy-led operational changes, collaborative decision-making, informatics tools, and clear communications have helped stave off total inventory depletion, ensuring that opioids are reserved for the patients who need them the most.
“We spend a lot of time and energy managing opioid shortages, and our work has paid off and kept us above zero stock,” said Janine Lee, Pharm.D., Coordinator for Medication Contracting and Purchasing at Michigan Medicine. “I think there are a lot of institutions that haven’t been as lucky.”
Injectable opioid shortages have been widespread, according to a nationwide ASHP survey conducted in April 2018. The survey found that 98% of 343 pharmacist respondents had been affected by these shortages, with nearly 70% considering them severe. Hydromorphone has been the hardest-hit injectable opioid, with nearly 20% of surveyed pharmacists reporting that they had no drug on hand and nearly 39% indicating that their supply would last seven days or less. Access to injectable fentanyl was least impacted, the survey found.
Coping with a Shortage
With this degree of scarcity, drug shortage leaders like Sharon Salah, B.S.Pharm., Medication Use Systems Clinical Pharmacist at Michigan Medicine, have been devoting a significant amount of time to encouraging use of injectable opioids only when necessary.
Sharon Salah, B.S.Pharm.
“When the hydromorphone shortage began affecting our health system in the fall of 2017, we had some stock but not enough to ensure widespread use,” recalled Dr. Salah, who heads Michigan Medicine’s drug shortage management team.
She quickly convened a team meeting, bringing together a pharmacy buyer, assistant directors of pharmacy, pharmacy and technician managers, clinical specialist pharmacists, electronic health record and automated dispensing cabinet (ADC) managers, clean room staff, and infusion managers.
“We documented our existing supplies and started identifying steps we could take to help with the shortage,” Dr. Salah recalled. Clinical specialist pharmacists consulted with the pain service and identified measures they could take to conserve medication inventory without compromising patient care, she said. “One thing they did was recommend that clinicians use oral morphine when possible, unless a patient had a true allergy or a special consideration, like a strict nothing-by-mouth order,” said Dr. Salah.
Juggling Multiple Shortages
That restriction helped conserve the supply of hydromorphone, but several months later Michigan Medicine’s drug shortage team had to also contend with emerging shortages of most forms of injectable fentanyl and morphine. This time, the drug shortage and clinical specialist pharmacists met with anaesthesia experts and devised a management plan that included using alternate sizes and concentrations of these drugs.
“Where we used to have 20 mL fentanyl vials in cardiac kits, we now began stocking four 5 mL vials,” Dr. Salah said. “We also reserved smaller doses or concentrations of morphine for pediatric patients in order to reduce the risk of patient harm if a medication administration error were to occur.”
The team also made some operational changes, such as moving opioids from low- to high-use areas where they were most needed, centralizing stock in pharmacies, and loading injectable opioid doses into ADCs only if there were active approved orders. “These inventory management strategies were essential in helping us make it through these shortages,” Dr. Salah emphasized.
Getting in Front of Shortages
According to drug shortage team member Matthew Tupps, Pharm.D., Manager of Central Pharmacy at Michigan Medicine, “Getting in front of a shortage makes all the difference” in helping to manage existing stock.
“In two instances, we identified shortages early on while we still had a two-week supply on hand and were able to make some quick changes that our providers could easily buy into, such as switching concentrations of morphine for certain populations,” said Dr. Tupps, an ASHP member since 2008. “Changes like this allowed us to stretch our inventory for eight weeks.”
Ramping Up In-House Compounding
Another prong in the health-system’s drug shortage management strategy has been to increase in-house compounding, said Dr. Tupps, who manages the pharmacy clean room. Although this helped fill some of the need for injectable opioids, increasing production has also had operational implications.
“Products made by 503B vendors can be stored at room temperature and have beyond-use dates upwards of 90 days, but the same products compounded in-house need to be refrigerated and have to be used within nine to 14 days after compounding,” Dr. Tupps explained.
Because of this change, he and his colleagues have had to closely monitor usage patterns to avoid potential waste, “particularly since it’s difficult to procure sterile ingredients for some of the injectable opioids,” Dr. Tupps added. They also had to allocate more refrigerator space for storage of in-sourced drugs.
Using Informatics Tools
Computerized physician order entry (CPOE) alerts and other informatics tools have also proved helpful in preserving opioid stocks for the most appropriate patients, according to Dr. Tupps. Some alerts recommend alternative medications and can be bypassed by the prescribing physician for developing shortages.
During critical shortages, however, a more stringent alert appears when an order for a drug in short supply is placed, Dr. Tupps said. These alerts also recommend alternatives and use stronger wording, reflecting the greater urgency of the situation. “They require providers to contact a pharmacist to place the order if they wish to proceed,” he said.
Communication Is Critical
Barriers like CPOE alerts can frustrate some providers, noted Barbara Higgins, Pharm.D., Assistant Director of Pharmacy, Medication Use Systems at Michigan Medicine. For example, she has had to counter misperceptions among some providers that these usage restrictions were due to pharmacists’ mismanagement of stock rather than supply shortages.
“In one instance, we had to strictly ration papaverine [an opioid alkaloid antispasmodic drug], which our surgeons use for certain patient populations,” said Dr. Higgins, an ASHP member since 1996 and a member of Michigan Medicine’s drug shortage team. “Shortly after we put this restriction in place, one of our surgeons called up a pharmacy buyer and complained that a sister institution just down the street had plenty of the medication and that we must be doing something wrong in managing our stock.”
After receiving that complaint, one of the pharmacy buyers contacted that sister institution and found out the drug was used much less frequently at the other hospital. “We had to explain to this particular surgeon that a month’s worth of the drug at our institution would have lasted the other hospital a year,” noted Dr. Higgins.
As this example illustrates, pharmacists at the University of Michigan have had to not only put their drug knowledge and inventory management skills to use during shortages, but they have also been called on to exercise softer skills. “It’s been an ongoing priority for us in pharmacy to make sure our providers always understand that we’re rationing a drug so that the patients who really need it can access it,” said Dr. Higgins.
By David Wild
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