Drug Shortages

[CrufflerJJ]

Last week, I spoke with my father about drug shortages - whether they really exist in our hospitals.

The brief answer is YES. Drug shortages not only exist in hospitals, but also in "the field", as seen by EMS providers. There was a radio program today on NPR, in which the host interviewed James Augustine, MD. Jim Augustine currently works in GA/FLA, but used to be an ER doctor at Miami Valley Hospital in Dayton, where I regularly saw him when I was volunteering as a paramedic on my local fire dept.

Augustine is a "real world" physician, not somebody working in a fantasy land. In addition to being an ER doc, he maintained his EMT certification, and volunteered as a fire fighter on his local fire department. I trust his judgement.

The radio program documented the fact that Oregon paramedics may carry and administer EXPIRED drugs to their patients. Not as any sort of grand cost saving measure, but due to the fact that new (unexpired) drugs are not available. Welcome to the new 3rd world nation....the USA!

"In the Las Vegas, Nevada area, public health officials extended the expiration for drugs on the federal shortage list for up to a year" (somewhat amazing, since we put lethal injection executions "on hold" when the drugs expire, yet it's apparently OK to use expired meds on non-criminals).

"In Arizona, nine EMS agencies or the hospitals where they're based have told the state they can't get all the drugs they need to meet the state's minimum supply that ambulances are required to carry. "

I see drug shortages on a regular basis in my ICU. The shortages range from pain killers (morphine, fentanyl) to paralytics such as Zemuron to sedatives (Versed) to basic electrolytes (salts like magnesium sulfate...Epsom Salts, sodium bicarbonate...Baking Soda, and potassium and phosphorus compounds). These drugs are very basic - not complicated at all.

IMHO, what complicates the availability of basic drugs are several factors:

- FDA stringent regulations controlling the manufacture/testing of the drugs

- low profit margin/selling price of basic meds

- high expectations (perfection) demanded by drug customers & their contingency based, fee-seeking attorneys, and the large financial liability to which drug makers are exposed.

Given these factors, why SHOULD a drug maker continue to supply basic, low profit, high financial risk meds to consumers?

Sad, but true.

Welcome to the Third World!

See:

http://journals.lww.com/em-news/Fulltext/2012/06000/Breaking_News__Short_Term_Ideas_Failing_to.2.aspx

http://hereandnow.wbur.org/2012/08/08/drug-shortage-ambulance

http://bigstory.ap.org/article/paramedics-turn-expired-drugs-due-shortages

[RNsRWe, ASN, RN]

I can't believe there are nurses who still do not see the value in single use vials.

I wonder what the patients with Hep C in the Vegas clinic, which helped to result in the infamous propofol shortage, would say about multidose bottles.

The problem is with the shortage, not with the safety rules.

I see the value of single-use bottles, as evidenced by my post you quoted; it is my clear preference. It is not, however, for safety reasons but for waste/ease of administration reasons. The problem is not multi-dose bottles; they're an infection problem only when NOT following the safety rules. And we follow those rules just fine, thanks.

The patients who got Hep C were treated by people who did not follow any semblance of those rules. Actual, criminal conduct was involved. Hep C does not simply appear in a multi-dose vial through careful, standard practices of infection control.

Using a new sterile needle/syringe to draw from an alcohol-swabbed bottle, tossing the needle/syringe and using a second sterile needle/syringe in NO WAY can give ANYONE Hep C.

I can't believe there are nurses who don't know how the pathway to infection works.

[NotReady4PrimeTime, RN]

The current shortage of garden-variety injectable drugs stems from a production line issue at Sandoz's manufacturing plant. They had one production line that was closed for maintenance and then were required to close a second line due to failings found on inspection. It will take them the better part of a year to get the two lines back up and running. I work in a PICU; the way we've chosen to cope with the shortage is to minimize waste wherever possible. RAther than mixing up several days' worth of some infusions we mix up 24 hours worth. If the infusion is discontinued then we're not throwing away a significant volume of drug. We also draw up the entire content of ampoules (Lasix, morphine, fentanyl etc) into a sterile syringe, label it with the patient's name and tape the empty ampoule to the syringe before storing it in the patient's medication bin. Then we can use the whole ampoule over the course of a shift, only wasting at the end of the shift. We've made some substitutions; rather than use IV Maxeran for placement of small-bore post-pyloric feeding tubes, we'll use enteral Maxeran and give it an hour before we want to drop the tube. We've replaced IV ranitidine with IV famotidine. We transition patients from infusion meds to enteral ones as soon as is practicable. There are ways around the issue. It just takes some out-of-the-box thinking.

[RNsRWe, ASN, RN]

..... We also draw up the entire content of ampoules (Lasix, morphine, fentanyl etc) into a sterile syringe, label it with the patient's name and tape the empty ampoule to the syringe before storing it in the patient's medication bin. Then we can use the whole ampoule over the course of a shift, only wasting at the end of the shift.

This worries me a touch. Having grown up on the teaching "if you didn't draw it up, you don't administer it", I'm not sure how comfortable I'd feel giving something from a syringe that SAYS it's Lasix/morphine/whatever.....but how do I know that's what it is? Then again, I know the answer is I wouldn't.

Unless you're talking about only ONE nurse giving from that syringe...? And that way just wasting her own meds at the end of the shift?

[NotReady4PrimeTime, RN]

That's what I'm saying.

[RNsRWe, ASN, RN]

Gotcha. And it makes sense.

[Cold Stethoscope]

What is sad is that so many people, and their lawyers, see the right lawsuit, against the right company, as a retirement plan.

So then, are there valid cases of malfeasance on the part of corporations, with their fiduciary responsibility strictly to the shareholders, or is that just a bunch of lefty propaganda? If a company decided to cut a safety corner to increase their profit, and that decision costs someone their career, is it tough luck for the victim? Should he just stop whining (if he still has the power of speech)?

Of course there is abuse of the system, as there is in all human systems. So what is the solution? To blow it up?

[monsignormitch1]

0.9% Normasaline, simple isotonic salt water that is used on a daily basis on every med - surg floor in if not the world, then this country. Why is it so difficult to keep in stock. Baffled!

[NotReady4PrimeTime, RN]

Probably because your inventory control people have determined that in an average supply cycle your unit uses x number of bags, back in the day when patients weren't as ill as they are now, no changes have been made to the standing order, and now you're using 2x number of bags per supply cycle. Our unit has this problem with a number of supply items, one in particular that has been a big problem. The administration has opened 10 more beds and split our unit into two physically separate areas. The base number of urometers has remained unchanged. In the meantime, we've been using manual peritoneal dialysis more and more and a practice change now has us changing the whole PD setup q day. If we have several patients on PD at the same time, we run out of urometers on a regular basis. Our patient care manager didn't understand the problem and when asked to adjust our standard supply, she got even more confused. So on it goes.