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Drug ‘Shortage’ Led Supply Practice Evaluation

kevin-link-apr-711-D50W

Oklahoma City’s Emergency Medical Services Authority (EMSA)—the state’s largest EMS provider, serving Oklahoma City and Tulsa—has embarked on a challenging but worthwhile mission to conserve supply resources, reduce waste and (potentially) free up significant dollars that can be reinvested to improve patient care.

Presenting at the Gathering of Eagles conference in Dallas in February, EMSA Medical Director Jeffrey Goodloe, MD, NREMT-P, FACEP, told attendees the 2010 “gift of scarcity” in dextrose led them to take a hard look at the system’s supply practices. What they’re discovering is eye-opening—and likely applies to many EMS systems.

The sky is falling’
Goodloe said he received an e-mail this past spring essentially saying they had a “real problem.” That problem was a pharmaceutical manufacturing issue that meant dextrose 50% (D50) would be difficult to get, and that the system was looking at running out.

“When you’re presented with ‘a real problem,’ that’s really just an opportunity to get smarter and to find better answers,” Goodloe said. “Like so much of the rest of the country, we have a reasonably prevalent diabetic population, and certainly these folks find themselves in a hypoglycemic crisis on a frequent basis.”

The “shortage” led Goodloe and EMSA’s Clinical Services Director Jason Likens to ask the following questions, which hadn’t been asked in quite some time:

• Who are the D50 “power users”?;
• What is EMSA’s usage pattern?;
• What do they stock on apparatus today?;
• What do they have in supply today?;
• What ordering options did they have?; and
• Were they “stocking what we’re stocking” or “stocking what we’re using?”

Goodloe said he and Likens were surprised by what they discovered. “My best guess was that we were going to find probably a dozen or more of these individuals that we were giving D50 to, maybe not once a week but probably multiple times a month.” His intention was to find these “power consumers,” make contact with them, perhaps involve their primary care physician or endocrinologist, and help get their diabetes under control. “That was my mindset, but what I got was a report that said we have no power consumers.

“In a six-month timeframe, the highest consumer of dextrose 50% had utilized seven prefilled syringes of dextrose 50%, and that was exactly one patient. And then we had a couple of patients that used five, and maybe a handful or two that used three. The bottom line is, there wasn’t a power consumer group to go after,” he said.

Contrary to assumptions about usage, they also discovered that not one patient required more than one syringe of D50 over a six-month period. “I was making what I thought were some pretty educated assumptions. Well, most of them were just flat-out wrong. When the hard data tells you that, it’s a wonderful opportunity to look at this in a whole new light,” he said.

EMSA was stocking 10 syringes of D50 on every ambulance, which typically had eight to 10 patient encounters per shift. Essentially, they were stocking the ambulance under the assumption that every patient encountered was not only diabetic, but also hypoglycemic in need of D50.

Why 10 syringes?
Goodloe said his answer as to why every ambulance was running with 10 syringes of D50 was, “Because that’s what medical oversight staff told us we have to stock.” He added, “You’ve got to be careful when you put one finger pointing out; four will come right back at you.”

As it turned out, there wasn’t any data to support that level of stocking. “It just sounded like a good idea.” After looking at the numbers, they recalled six syringes of D50 per ambulance, as well as syringes from the medical backpacks many providers were using, Goodloe said. “By week’s end, we had over 1,000 syringes of D50 in the supply room between Oklahoma City and Tulsa, and we didn’t purchase one of those syringes brand new.”

That, of course, prompted broader questions about the system’s supply usage patterns, and ordering and stocking practices. “Everyone has subjective and arbitrary ideas about what is used,” said Likens, who saw the D50 issue repeat itself with other supplies. “In some cases, we had a year’s worth of medication.” They’ve found that EMSA was frequently ordering twice as much medication as needed, and stocking three to four times as much as they needed. He said they estimate about half of those medications are expiring and going to waste.

Low-hanging fruit
The analysis is a time-consuming process and still ongoing, but Goodloe said the annual savings for a system their size could run into the hundreds of thousands of dollars. “An EMS manager has to be prepared for somebody to say, ‘Oh my gosh, you mean to tell me that you’ve been wasting a quarter of a million dollars for the last 10 years? Thank you for pointing out how incompetent you’ve been,” he said. “What has to be pointed out every time you discuss this sort of thing is that it’s a new kind of analysis, to make sure that there’s not inappropriate penalization for where we’ve been.”

EMSA’s public utility model uses fire department first responders and contracted ambulance transport personnel. Involving system partners in the discussion requires candor, data and tact. How often do the first responders actually administer a particular drug? Should they even carry it?

“If we’re truly operating under a single patient paradigm, then any waste of system resources translates into real cash,” Likens said. “What other things could we be doing with that money? This is a piece of low-hanging fruit to recapture some of those budget dollars.”

Likens said that in addition to looking at and adjusting medications and supply stock, EMSA is refining procedures for communicating changes in medical protocols with the supply folks, so they can adjust their procurement practices accordingly. They’re also looking beyond system-wide consumption and “drilling down to look at individual consumption.”

Any successful evaluation will have to promote a culture of conservation among field providers. For a variety of reasons, Likens said medical professionals, and not just in EMS, are notoriously wasteful. “Everybody needs to understand appropriate use of materials and needs to embrace conservation,” he said.

Likens shared an amusing and instructive anecdote from a previous posi¬tion with an industrial manufacturer. The company was spending nearly $2 million a year on safety goggles, earplugs and gloves—things the employees viewed as free and disposable. To curb waste, management issued supervisors rolls of quarters, finite money that they had to use to replace these supplies via vending machines. Miraculously, the waste stopped, and the company saved hundreds of thousands of dollars every year.

“We have to be careful. EMS is not a production line, but there is something to glean from that,” Likens said. “There is a similar mentality in EMS. We have to get everybody involved because there is a cost to having all of these resources, and they are not infinite.”
 

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