Atropine, diazepam, diltiazem, dopamine, fentanyl, haloperidol and magnesium sulfate. What do the above and numerous other pharmaceuticals used by EMS professionals have in common?
If you answered that each was on back order status in early October, you’ve encountered the frustration and mounting concerns regarding loss of stability and consistency in medication supply to America’s emergency care systems. While Congress and the Federal Drug Administration look to regulatory solutions in the future, we have seriously ill or injured patients to take care of today. In some cases, one or more of these drugs that are in short supply plays a critical part in our treatment plans.
We, as EMS professionals, are engineered in personality and thought to take action. So what action can we take now while others worry about the issue and debate answers? Ask yourself, your colleagues and especially your supply officer the following, “Do we stock (on my apparatus) what we stock, or do we stock what we use?” Suspension of assumptions in lieu of careful data analysis may just turn your shortage dilemma into a surprising discovery. Let’s use a real example:
In April 2010, I received an e-mail from one of the paramedic leaders in our EMS system that serves metropolitan Oklahoma City and Tulsa that our supply of pre-filled syringes of Dextrose 50% (D50) was dangerously low. At first pass, that’s disconcerting news for a medical director and serious news for hypoglycemic coma patients who depend on our system’s care for survival. Our system’s immediate response in placing an order for D50 was met with the dreaded “B” word: “back ordered.”
Plan B, as in non-back ordered, was to keep the situation analysis simple. I asked my colleagues the following four questions:
1. How much D50 do we have in the system? This included counting medication in ambulances, fire apparatus, stations and supply rooms.
2. How are we stocking each area?
3. How much D50 are we using per patient encounter? I was assuming with “infallible” medical director knowledge that at least 10–15% of hypoglycemic patients were requiring more than one pre-filled syringe of D50. (It wasn’t that many years ago that I was on the street as a paramedic, and I remembered having to use two doses with about that frequency.)
4. Can you generate for me a list of “power users” of D50 in our EMS system? Frequency of need for EMS-administered D50 was loosely defined, but anchored to comments I heard from paramedics that they were responding to the same poorly controlled diabetics on a weekly basis (which also rang a bell from my prior days).
What did we find? Let’s cover the results in reverse order because that’s how the answers led us to a solution.
A Solution Emerges
First, we explored our D50 administration documentation from electronic medical records to generate a tally of D50 uses by unique patient, with a focus on finding those requiring double-digit administrations. In the six-month period we reviewed, the most frequent user of D50 in all of the 1,100 square miles serviced by our system used exactly seven doses of D50.
The reality was simply this: Nearly all hypoglycemic patients requiring D50 in our service area used EMS only one to two times in that 180-day period. This is understandable given the complexity of managing diabetes, especially new-onset, insulin-dependent diabetes.
Second, what about all the patients requiring multiple D50 doses per encounter? Well, again our myth was busted. In the same six-month period we reviewed, not a single patient required more than one pre-filled syringe of D50 to clinically correct hypoglycemic symptoms.
Third, we found that at least 10 pre-filled D50 syringes were being stocked per ambulance and four per fire apparatus with paramedics assigned. Our plan represented nearly 1,500 doses of D50. Considering that ambulance tours are 12 hours, and the typical tour involves eight to 12 patient contacts, we were actually stocking at a level that would be sufficient if every patient we encountered was in hypoglycemic coma. What was my follow-up question? “Who came up with those numbers?” The answer was “the Office of the Medical Director.”
Let’s just say we had the ability to rapidly change the stocking requirement to four D50s per ambulance and two per fire apparatus.
Fourth and finally, back to the stockroom where this dilemma started. Our nearly empty “box” of D50 was replaced with several containers of unused D50 that we pulled from ambulances and fire apparatus. We didn’t watch hypoglycemics suffer, and we discovered months of future supply were already in-house.
This example specifically details how administrators can look inside for solutions to drug shortages. It can—and should—be done with every pharmaceutical your system uses. It’s typically a slow process in a large, urban system, but depending on your resources and system size, analysis and restocking actions may vary. The financial implications are positive, regardless of system size. Who can’t use a bit more money in their EMS operating system budget?
Two final pieces of advice:
1. Communicate openly with all providers in the system. Make sure no one feels you’re taking away truly needed items; data can often debunk a myth, but it has to be accurate data.
2. Communicate openly with local government leaders about cost savings. Make certain they realize this is a new way of looking at the supply-demand equation in EMS pharmaceuticals. You shouldn’t be penalized for not looking at the issue this way in times past.
Scarcity can be a pain. It can even cause a panic. But it can also create possibilities for better supply management. Good luck with your possibilities. JEMS
Epilogue: Data analysis over the interim has revealed multiple cases requiring two pre-filled syringes of D50, which firmly establishes two things: 1) it’s a good idea to look at data from more than one time interval and 2) this medical director wasn’t completely wrong.
Remember when you have one finger pointed, four are pointed right back at you.
Get more medical director analysis of the medication shortage at jems.com/jems.
This article originally appeared in December 2011 JEMS as “Drug Shortages: Tips to turn dilemmas into discoveries.”