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Analysis

5 Strategies to Deal With ER Drug Shortages

By Christopher Cheney  
   July 12, 2018

For emergency medicine, the negative impacts of the drug shortage are far-ranging, says one physician.

The nation's drug and medical supply shortage is taking a toll on the country's emergency departments.

In a survey published recently, 91% of emergency medicine physicians polled said they had recently experienced a drug shortage. "Some of the most critical shortages we have impact emergency departments," says Erin Fox, PharmD, adjunct associate professor at the University of Utah School of Medicine.

Key emergency medicine medications and supplies are scarce, she says. "Why do you go to a hospital emergency department? You go for a broken leg or another broken bone—something you might need pain medication for. You go for stitches, and for those you need local anesthetics. Those items are the most severe shortages we have."

For emergency departments and the patients they treat, the drug shortage is having a widespread negative impact, says Jim Augustine, MD, FACEP, a former ER physician, and a board of directors member at the Irving, Texas–based American College of Emergency Physicians.

"These shortages affect almost all types of drugs used every single day in the ED—local anesthetics, injectable pain medications used for broken bones or trauma, common anti-nausea medications, heart medications, and even IV fluids used to deliver life-saving treatments," he says.

For emergency medicine, Augustine says the negative impacts of the drug shortage are far-ranging:

  • There have been significant increases in the cost of medications, which affects budgets and availability;
     
  • Alternate medicines may be more difficult to administer, have more complications, take longer to work, or be more expensive;
     
  • Delays in patient care,
     
  • Lost staff time searching for alternative medications,
     
  • Lack of common and safe drugs can lead to medication errors;
     
  • Emergency medical service staff also face shortages; sometimes, patients have to wait until arriving at the ER to receive drugs that should have been administered in the field;
     
  • Some alternative medications require cooling, which bears the cost of installing or expanding refrigeration capacity.

Augustine and Fox offer five strategies that emergency departments can use to ease the burdens of the drug shortage.

1. Flexibility and Planning
 

"Due to the drug shortage, a physician accustomed to using a specific strength of lidocaine or a specific size might have to use a different strength or a different size. That willingness to make do with what is available can go a long way," Fox says.

When working with alternative medications and supplies, emergency room physicians need to be flexible, she says. "In a lot of cases, we can get the physicians the drugs that they want, but it might not be the strength or size that they are used to having. The end result for the patient is the same."

Planning is crucial for emergency departments to manage the use of alternative medications, Augustine says.

"Every day when we start shifts, we have to review what is available and what is not available," he says. "We have developed lists of alternative therapies or alternate procedures that are available to manage certain patients. In general, we can come up with a list to guide us to potential alternatives."

2. Rationing
 

Augustine worked in emergency medical services in 2011—one of the early years of the drug shortage. For EMS crews, rationing was a top response to the crisis, he says.

"We developed a list of all our medicines, the potential alternatives, the use of the medicines, and drugs that had no alternatives. Then we focused on how to distribute those medicines so we had them available when needed in the emergency care environment—whether it was in the field or in the emergency department," he says.

3. Inpatient care option
 

If a patient can't receive appropriate care in the ER because of a drug shortage, a transfer to inpatient care can be the best course of treatment, Fox says.

"In an ED you need things quickly, and it's difficult to make drug changes all the time. In hospital inpatient facilities, they have other options such as a morphine drip or morphine [patient-controlled analgesia] that is not practical in the emergency room," she says.

4. Expiration date leniency
 

Asking regulators and drug makers to extend the expiration dates of medications can be the only option for emergency departments at this stage of the crisis, Augustine says.

"The current shortage is mainly a manufacturing shortage, so if everybody has hit the expiration date for medicines no one will have a supply of them. In extreme circumstances, we have asked the FDA and manufacturers to extend expiration dates on existing supplies," he says.

5. Alternative therapies
 

In some cases, surgery and other medical procedures can be viable alternatives to a drug in shortage, Augustine says.

For example, atropine, which is in shortage, is a drug used when heart rates are very slow. However, there are surgical alternatives.

"If that medicine is unavailable, we have to go to putting a pacemaker on the chest or into the heart. Those are the kinds of things you need to think through with emergency medicines that are in shortage," he says.

When all else fails in efforts to overcome a drug shortage, tenacity is an ER physician's best quality, Augustine says.

"You just keep searching farther and farther for combinations of medications or another type of intervention to provide patient care. When you know you are going to be short, you go looking for other supplies," he says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


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