Columns, Patient Care

Researchers Offer Strategies for Overcoming Drug Shortages

Issue 10 and Volume 39.

In Low Supply
Mazer-Amirshahi M, Pourmand A, Singer S, et al. Critical drug shortages: Implications for emergency medicine. Acad Emerg Med. 2014;21(6):704–711.

The highly publicized United States drug shortage has left ED and ambulance services alike scrambling to find alternatives. Here, researchers from Washington, D.C., take an in-depth look at the problem and review the complications that may develop.

While not research in the same sense as we traditionally review, the authors, including a pharmacist and members of adult and pediatric emergency medicine departments, did their due diligence in researching the impact of drug shortages. The problems they found seem staggering in size, but are they things we can avoid in EMS?

Results: The authors point toward several reasons for the drug deficits: Increased demand when related to the supply, such as with chemotherapy drugs and oseltamivir (Tamiflu) during flu season; contamination in sterile products; and the cost associated with creating generic medications that aren’t as expensive to purchase.

From their research, the authors found cases of increased medication errors during drug shortages in which a replacement is easily available, such as when ketamine is available in place of etomidate. They also point to a delay in administration of medications given when the provider’s comfort level with the available medication may be low, requiring providers to consult references or colleagues. In the EMS setting, this could lead to a delay in rapid sequence intubation, in large part due to a change in induction or paralytic agents.

Researchers also found cases of accidental overdose by hospital staff when a drug is available but in a different concentration.

Let’s say this happened to your supply of opiates or sedatives. How would you react? Sure, we have narcan and supplemental oxygen to remedy the problem, but is this something you want to explain to the hospital or your medical director?

Thanks to the Food and Drug Administration (FDA) Safety and Innovation Act, the FDA will now receive advanced notification of drug shortages for “medically important drugs.” This same legislation requires yearly reports to Congress on drug shortages and allows flexibility for hospitals repackaging drugs that are undergoing a shortage.

Discussion: Although drug shortages are problematic for hospitals nationwide, we also understand this could affect EMS even more. All agencies—small and large, municipal and private—stand to lose medications and tighten belts as costs rise.

But this research also points to an alarming possibility: medication errors. We get it—mistakes happen from time to time. But lacking an understanding of the medications you carry, be it a new concentration or a new medication, is inexcusable. We need to stop forgiving cavalier behavior.

The time has come to stop changing protocols and start changing the way we think. Medications should be checked for changes in concentration at the beginning of each shift, and working knowledge of the substituted medications should be ensured by the medical director and management staff.

Drug shortages will never go away, and healthcare will change, grow and adapt to face them. We should lead by example, and create a safe, healthy work practice for ourselves and our patients.

Bottom Line
What we know: Drug shortages are directly affecting all aspects of American healthcare, with seemingly no end in sight.
What these studies add: Diligent research has shined the spotlight on specific problems that need to be addressed in emergency care.

WATCH BOX
Warming Mattress Shows Promise
Aléx J, Karlsson S, Saveman BI. Effect evaluation of a heated ambulance mattress-prototype on body temperatures and thermal comfort—an experimental study. Scand J Trauma Resusc Emerg Med. 2014;22(1):43.

This month, we take a quick look at an experimental study created by ambulance nurses in Sweden, intended to evaluate the effectiveness of warming mattresses. A small group of patients were placed in a cooling chamber in a thin, single layer of clothes. Some patients were placed on a standard stretcher with a blanket and allowed to rewarm, while another group of patients were placed on a novel warming mattress heated electrically. Not surprisingly, patients who were on the heated mattress not only rewarmed faster, but also reported increased feelings of comfort and security. We applaud the early research of a simple, novel device meant to increase patient comfort and prevent hypothermia.