Over the past weeks, I've seen plenty of in-depth coverage on the global ventilator shortage. However, caring for ventilated patients also requires a complex cocktail of medications—and many of those drugs are now facing their own shortages.
Recent reports suggest there are shortages of more than a dozen anesthetics, muscle relaxants, painkillers, and sedatives needed to care for patients placed on ventilators. Demand for the drugs has increased as providers place more and more patients on ventilators to help treat severe symptoms of Covid-19. Recent data from Vizient shows that, as demand for the drugs has increased and the drugs' supply chains have been squeezed, fill rates for the medications have lagged.
The Drug Enforcement Administration (DEA) this week raised the production quotas for many medications that can be used to care for patients placed on ventilators, but it's not clear whether companies will be able to adequately ramp up production of the medications to meet the increased demand. DEA also announced plans to increase the country's importation of several of the drugs.
In short, the shortages mean that, even if providers have enough ventilators to treat patients in need, they might not have enough of the drugs necessary to place those patients on ventilators.
But that's where pharmacists and pharmacy staff come in. When faced with a reported or expected drug shortage, pharmacists and pharmacy technicians often are able to deploy both clinical and supply chain skills to "work all the angles" and ensure that the right medications get to the right patients at the right time.
From the clinical angle, pharmacists first work with prescribers to preserve the shortage drug for patients most in need. They do this by minimizing drug waste and leaning on their pharmacy team to identify clinically appropriate alternatives for the shortage drugs.
With a list of potential alternatives in hand, pharmacists and prescribers can then work together to develop protocols to guide decisions about which medications are appropriate, for which patients, and under what circumstances.
In most cases, the swap is not as simple as administering the new drug in place of the shortage drug. Instead, administration schedules must be changed, patients must be monitored for different adverse effects, and prescribers need to be aware of a new set of potential adverse drug interactions. For example, to replace fentanyl for ventilated patients, some providers are switching to morphine. However, morphine can lead to hypotension and requires additional monitoring and potentially additional care to address this adverse effect.
Pharmacists also work closely with nurses to identify waste reduction opportunities. Amidst the Covid-19 pandemic, this has meant revamping crash cart protocols to ensure that unused medications on used carts aren't thrown away, but instead can be safely cleaned and reused for future patients. They are also developing protocols to limit wasted drugs in the long IV tubes used when IV pumps are kept outside patient rooms—a change initially made to reduce PPE needs for nurses.
From the supply chain angle, pharmacy staff demonstrate similar creative problem-solving skills. They negotiate with their primary wholesaler as well as secondary distributors to identify potential sources of drugs in shortage. They often collaborate across entities within the health system and even in their broader regions to move medications to the locations where they are most needed.
Medication management permeates every aspect of a patient's care, which is why it's essential for pharmacy expertise to be included in all sections of an organization's incident command management team to address topics ranging from the clinical and operational challenges listed above to addressing ongoing financial challenges.
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