The issue of drug shortages in emergency care has been present in the United States continually since 2010. Strategies for managing shortages at the local level have been in the EMS literature since 2011.1 The shortage issue began with injectable drugs, but over the past 15 years the shortages have expanded to include oral and inhaled medications. What should EMS leaders be preparing for next?
Shortages have been attributed to weather damage to manufacturing sites, product manufacturing problems, unanticipated demand and companies discontinuing older products. The root cause is somewhere in the American manufacturing process. The use of foreign sources for medications is extraordinarily rare.
Disputes have arisen between manufacturers and the Federal agencies that oversee drug supply over safe manufacturing and quality processes and manufacturing practices (FDA and DEA). The FDA developed a site to track drug shortages,2 but it has been inaccurate. The American Society of Health-System Pharmacists has a more reliable and timely list available for EMS managers.3 A very reliable source has been a summary of medications on backorder from Bound Tree, a leading national medication distributor to EMS, which has been used to develop monthly reports on the emergency drugs in shortage since 2012.
The current report has the smallest number of medications in shortage status in four years. Across the entirety of U.S. healthcare, there are currently 271 medications in shortage, according to the American Society of Health-System Pharmacists Drug Shortages Resource Center. At the beginning of February 2025, there are only 30 emergency medication preparations that are in shortage status. The last time that the count was that low was August of 2021.
A trend that has not changed is the increased prices of medications. There is continued upward costs of the critical EMS drugs, that challenge the budgets of some Departments. This is a continued issue since the beginning of the shortages.4,5
Current Management Issues
EMS leaders just managed through a significant shortage of intravenous fluids, prompted by hurricane damage to a key source of many of those fluids, in North Carolina. This shortage prompted profound changes in medical guidelines for fluid use in EMS and Emergency Departments across the nation. That shortage has been mostly resolved for the common IV fluids used in EMS.
The leader responsible for EMS logistics must address supply, utilization, packaging, storage and of the short medications. The physical inventory must be managed by expanding supplies through inter-agency exchanges when possible, ensure that medicines with short expiration windows are used first, and provide regular (weekly) reports on use, supply, and strategies for stretching the stocks. Medicines may be stored centrally and deployed “just in time” and based on anticipated patient need.
Services may want to consider a logistics change that has medicines or fluids now in colored containers or marked with a colored sticker, to highlight the medicine, the appropriate dosage and any warnings that are particular to that drug. A typical dose for adult or pediatric patients would be printed right on the container or sticker, to provide “just in time” guidance for the paramedic that is going to administer it.
It has been a very busy winter in emergency services across this flu season. It is a good time to evaluate the usage patterns of medications. Across the last three months, what medications have been used? That can be calculated across the number of patients managed over the last three months, to get to a utilization number of drugs per month and per 100 patients.
Then accurately count the number of doses on hand–in all active apparatus, storage, warehouses and reserve supplies. Are any of these supplies close to their expiration dates? For each medication, what “close to expiration” supply can be placed on the busiest apparatus, to increase the likelihood it will be used before expiration. This is particularly important for the expensive medications.
Then calculate the months of stock in ready supply. Is it sufficient for the next 6, 9, or 12 months at current usage estimates? Can additional purchases be made that would extend the supply to 24 months, considering expiration dates and storage capability.
As the entire health care industry struggles to implement effective information technology strategies at all levels, new uses of EMS technology may assist in the efficient use, storage and planning for medication use, with greater flexibility, accountability and regulatory compliance. This is a particularly good time to invest in technology that keeps controlled substances safe and reduces the risks of diversion. Inventory management systems beyond medications are available for many more supplies, which is timely considering the shortage of a wide variety of EMS items in these pandemic and post-pandemic years.
The rapid changes in Washington DC are a new concern to EMS leaders. The transition to a new administration has resulted in layoffs in the federal workforce, which may compromise the functions in the FDA and other agencies. That may slow the process of quality inspections and approvals of medication manufacturing sites, which could suddenly result in shortages. The pharmaceutical industry has been put under reimbursement scrutiny, which may further impact the ability to supply low cost and low margin medications. Shortages could appear very quickly
Active Inventory Management
Good EMS patient care requires active inventory management, medical guideline flexibility, provider education, and a Quality Improvement initiative that focuses on possible medication errors and rapid feedback to providers.
Medical guidelines can be modified in these post-pandemic times. Over the last 15 years, there have been shortages of essentially every EMS medication. Many EMS systems have written medical guidelines that automatically adjust for medication options. System medical directors must develop a list of therapeutic substitutions. The medical protocols must be modified to expand options for therapeutic interventions, and the agency’s drug license expanded to include any new fluids and medications, in accordance with state law and rule.
First choice medications are desired, but not always available, so secondary drugs are written in. That allows future flexibility to address supply and shortage of fluids and medications. Guideline changes can be done with appropriate in-service continuing education that focuses on drug options, any modifications in labeling, and safety elements.
Safety elements for patients and providers are a must. Even commonly used and available medications are not coming in different vials, ampules, concentrations, and volumes. This leaves a huge potential (or likelihood) for dosing errors. Signage relating to usual dosing for adult and children may be beneficial on medication packages, vials, and containers.
Beyond any expansion of supply, EMS leaders will need to develop strategies to address medicines that have gotten prohibitively expensive. Cooperative approaches across multiple EMS agencies, and maybe even regional hospitals or systems, may mitigate some cost increases. Now is the time to meet around those options.
Some leaders have developed phased approaches to shortages, that react in a dynamic situation and ensures that EMS agencies and hospitals act cooperatively with local, regional and state response strategies. During the fluid shortages at the end of 2024, regional leaders in southwestern Florida developed a sharing program that would stretch the available supplies of IV bags to all of the agencies in the emergency system, so no agency or patient would be shorted on necessary treatment.
Next Challenges
No one can predict what is ahead for medication shortages. The lessons of the last 15 years are imprinted in the minds of this current generation of EMS leaders. It is unlikely that the issue has been permanently resolved. There are current strategies that can provide reassurance for the next round of shortages.
References
- “National Drug Shortage Puts Patients at Risk”. Huff, Richard. JEMS, Nov 2011. November 2011 Issue
- Food and Drug Administration’s drug shortages. Link at www.fda.gov/drugs/drugsafety/drugshortages
- American Society of Health-System Pharmacists Drug Shortages Resource Center. Link at www.ashp.org/drugshortages
- “The Next Body Blow: Rising Drug Prices”. Abes, Benjamin. JEMS Wed, Oct 18, 2017
- “Drug prices in 2019 are surging, with hikes at 5 times inflation”. Picchi, Aimee. CBS MONEYWATCH. July 1, 2019
- “Hurricane Helene’s Unexpected Impact On U.S. Healthcare Delivery”. Glatter, Robert. Forbes. Oct 6, 2024
