Wexner’s Crystal Tubbs (left) and Hannah Miller (right) participate in a meeting about drug shortages.
AS DRUG SHORTAGES CONTINUE TO AFFECT PATIENT CARE, health systems and hospitals across the country have begun to take steps to buffer the impact of additional medication scarcities. Pharmacists at the Ohio State University Wexner Medical Center spearheaded an approach in November 2017 to improve the organization’s response to drug shortages. The initiative focuses on rapid communication among all staff involved in the medication-use process.
Crystal Tubbs, Pharm.D., FASHP, is the Associate Director of Wexner’s Department of Pharmacy. After Hurricanes Irma and Maria damaged manufacturing facilities in Puerto Rico, which left organizations without access to small-volume parenterals and other critical drugs, Dr. Tubbs and the pharmacy staff took the lead in revamping Wexner’s drug shortage management strategy.
“Our previous process was to hold weekly drug shortage meetings, mostly with purchasing and operational staff. However, clinical staff began telling us they felt ill-informed to make operational and clinical changes when a shortage hit,” said Dr. Tubbs, an ASHP member since 2000.
In response to this feedback, Dr. Tubbs and her colleagues organized a retreat with roughly 75 staff members representing departments from across the medical center. The discussions at the retreat led to a number of significant changes, she said. “We now have two weekly drug shortage meetings that include not only pharmacy purchasing and operational leaders, but also senior pharmacy administrators, our drug information team, pharmacy technicians, pharmacy representatives from each clinical area in the hospital, medication safety experts, and information technology [IT] staff,” Dr. Tubbs explained. “Now, more people feel like they’re in the know.”
EMR Tools
To expedite the communication of drug shortage information, the team drew heavily on tools in the electronic medical record (EMR) system. “We created a drug shortage database that has become our source of truth for up-to-date and real-time information on clinical and operational action plans,” Dr. Tubbs said, adding that ASHP’s drug shortage resources often help her staff decide how to manage shortages.
Crystal Tubbs, Pharm.D., FASHP
The medical center also recently launched an EMR-integrated inventory management system that pharmacy staff across the health system can access to find real-time information about the inventory of any medication.
In addition, Dr. Tubbs and her team added banners on the EMR’s login page to convey particularly important information. “A red banner at the top of the login screen communicates urgent clinical and operational changes, and a tan banner lets staff know about less urgent measures or if a shortage has been resolved,” said Dr. Tubbs. This tool has been particularly useful in cases where actions need to be implemented quickly because a medication shortage has become critical, she noted.
Any information that is not included in the database or conveyed through banners is now sent out through a centralized drug shortage email account. According to Dr. Tubbs, the medical center’s staff members feel that this new process is “seamless and consistent” compared to the previous method, which included multiple emails from a number of accounts. “It has simplified the process for staff looking for answers to their drug shortage questions, because they can now query the single email account,” said Dr. Tubbs.
A Well-Oiled Machine
According to Hannah Miller, CPh.T., CMRP, Purchasing Manager in Wexner’s Department of Pharmacy, the new drug management process runs “like a well-oiled machine.” She added that the timing of communication with the old approach sometimes delayed an effective response and was an incomplete response to a drug shortage. The purchasing team would reach out to clinical staff only if they needed to find an alternative medication or if a shortage required a product switch or a more restrictive prescribing process.
“For example, when methylene blue 1% was discontinued in November 2016, following approval from our clinical staff, we switched to a 0.5% concentration from another manufacturer, but the transition didn’t go over very well at first,” she recalled.
Unlike the 1% concentration, which had to be mixed with saline, the 0.5% product had to be prepared with dextrose and, since it was a different concentration, the product fell under a different drug entry. “Those changes led to some hiccups, especially for our IT team and clinical staff,” said Miller. “Although the purchasing staff was able to get the necessary products through the door, we struggled to operationalize the changes associated with the alternatives on our own.”
Ultimately, they worked through the challenges by assembling methylene blue 0.5% kits that included dextrose, she explained. “With the new process in place, clinical and IT staff members are involved right from the beginning, and we manage drug shortages much more effectively,” Miller reflected.
Strategic Measures
The new approach, which elicited a “resoundingly positive” response from staff, was a boon for the hospital when it faced intravenous (IV) opioid shortages in November 2017.
“As soon as we were notified of the shortages, we held an emergency meeting to evaluate stock as well as the predicted availability of more medications and the number of days of supply on hand, which we found was quite low for several different medications,” said Dr. Tubbs.
In short order, staff developed a plan for each opioid, recommending measures like switching from IV to oral administration, or evaluating other non-opioid strategies for pain management. They also used the EMR banners to encourage clinicians to order patient-controlled anaesthesia judiciously and to select alternative agents for continuous pain management in the intensive care unit. Each time an affected opioid was prescribed, an electronic alert was triggered, and the drug shortage database was updated daily. Clinical pharmacists reviewed daily reports that listed all patients with active IV opiate orders. “Within 48 hours of implementing the restrictions, we had reduced IV opiate administration by over 50 percent,” Dr. Tubbs recalled.
Pharmacy Technicians’ Role
Miller noted that pharmacy technicians have long been important members of the drug shortage team. In addition to being the pharmacy’s buyers and purchasing managers, technicians on the hospital floors provided useful input that helped shape a drug shortage management strategy, she explained.
For example, when the hospital faced a shortage of emergency syringes in April 2017, crash cart technicians pointed out they rarely used the five syringes of epinephrine typically stocked in each cart. They also said they could turn to epinephrine vials stocked in the carts and automated dispensing cabinets, if needed. “They suggested that we reduce the number of syringes per cart to three,” Miller said. “Our clinical pharmacists agreed with that decision.” This insight freed up syringes to use with other injectable medications.
Comfort with the Unpredictable
Using a comprehensive and team-based approach to managing drug shortages that now draws on a variety of tools and strategies, Wexner has proven that, although shortages are inevitable, their impact can be mitigated. “Shortages are still uncomfortable,” said Dr. Tubbs, “but we are fortunate that we haven’t completely run out of any specific medications since changing our approach and improving how we communicate information on drug shortages.”
By David Wild
