Drug Shortages in Critical Care - Can Any Good Come from Them

2015 - 3 June – Targeted Temperature Management
Kevin W. Hatton, MD, FCCM
This article reflects on two healthcare systems' implementation of multiprofessional critical care teams in response to drug shortages.

The Society of Critical Care Medicine's Drug Shortages Committee is a multiprofessional group charged with providing resources to members to help optimally manage drug shortages affecting critically ill and injured patients. Committee members share their personal experiences, identify current trends in drug shortages and offer insight into various safety and quality improvement issues. Members also provide information on the safe and consistent management of drug shortages as well as on additional resources and strategies in regular Drug Shortage Alerts, which are accessible at www.sccm.org/currentissues.

Over the past decade, drug shortages have become a frequent occurrence throughout the entire healthcare industry, affecting the quality of care delivered by physicians, pharmacists and nurses alike.(1) While these shortages appear to affect many specialties across the healthcare spectrum, recent shortages have dramatically impacted critical care medicine.(2-4) While academic, legislative and regulatory bodies continue to investigate these ongoing shortages, no single cause has been identified. The extent of the likely contributory issues is beyond the scope of this article.(5-6)   

Healthcare systems have developed a number of unique strategies and solutions to mitigate the impact of these shortages on the delivery of effective patient care. Healthcare systems have developed a number of unique strategies and solutions to mitigate the impact of these shortages on the delivery of effective patient care.(7-8) Interestingly, some systems have been able to leverage limited drug supplies into the adoption of improved, evidence-based care. We describe here the responses of two healthcare systems to recent shortages in the intensive care unit (ICU) and how these events improved and aligned the delivery of care for their most critically ill patients. We also reflect on unforeseen improvements in efficiency and opportunities for collaboration.

In late 2014, the University of Kentucky Chandler Medical Center (UKCMC) in Lexington, Kentucky, USA, began to experience a shortage of piperacillin-tazobactam. At the time, this agent was a component of a frequently prescribed empiric antimicrobial regimen used for many types of healthcare-associated infections, including sepsis. Furthermore, piperacillin-tazobactam was often used for presumed or microbiologically proven infections caused by Pseudomonas species. Although the pharmacy was able to ameliorate this shortage in the short term through various purchasing actions with vendors, it became clear in early 2015 that demand for this antibiotic would outstrip the supply that could be secured.  Realizing this, the previously-established system-wide drug-shortage task force, which included pharmacists and physicians, reviewed the local microbiologic data to evaluate whether alternate antimicrobial agents could be used in these settings. In many units, the task force found that alternative antibiotics might be more effective than piperacillin-tazobactam as routine empiric therapy for healthcare-associated infections.  Based on these findings, UKCMC began a concerted and multifaceted effort, utilizing the knowledge and expertise of physician, nursing and pharmacy leaders, to revise the system-wide empiric regimen to deliver a more appropriate antimicrobial strategy, thereby reserving piperacillin-tazobactam for cases in which it was microbiologically proven as the best therapy.

At Carolinas Medical Center (CMC) in Charlotte, North Carolina, USA, a recent vasopressin shortage presented a unique opportunity to the multiprofessional critical care team. Using previously defined standard processes, which included collaboration between clinical pharmacists and intensivists, patient populations that would benefit most from the limited supply were identified. This so-called conservative-use strategy was based on review and application of the available medical literature. After therapeutic alternatives were developed, prescribers were notified via various communication channels, including an automated alert in the computerized order entry system. Patients admitted to an ICU with active vasopressin orders were reviewed daily by the clinical pharmacy team. If opportunities for alternative vasoactive agents were identified, they were discussed with the prescriber. 

When vasopressin returned to the market at a significantly higher cost, CMC chose to maintain the conservative-use strategy, in part to avoid a negative financial impact, but more importantly, because clinicians recognized the value of the process and clinical indications developed through evidence-based evaluation of the literature with local expert discussion. This decision was met with overwhelming support and soon will be presented to system-wide critical care committees for their approval.

Beyond these types of clinical changes in healthcare delivery, have other dimensions of good outcome resulted from these drug shortages? After all, we would be remiss if we did not reflect on additional successes and apply the lessons learned to other health system initiatives.

The examples from UKCMC and CMC both illustrate the importance of developing a system-wide network of individuals with diverse skill sets.  This multiprofessional group may report to the local pharmacy and therapeutics committee, the ICU committee or directly to administrators, such as the chief medical officer. Over time, both UKCMC and CMC have gained skill in leveraging their strengths and resources to other areas, have identified teams that are best equipped to complete specific tasks, and have developed the ability to reallocate clinical and administrative priorities for existing personnel. In addition, these systems have recognized the necessity of establishing temporary solutions until formal strategies can be developed and implemented—and have learned to accept that such solutions may not be perfect. Lastly, both systems have become familiar with the variety of tools available to facilitate timely mass communications across professions and throughout the healthcare system. 

Drug shortages have also fostered collaboration across healthcare professions. When the Society of Critical Care Medicine’s Drug Shortages Committee was created, a requirement deemed necessary for success was representation from multiple member sections. This diversity of perspectives facilitates development of resources that are useful to multiple end users. Such collaboration has led to professional relationships that may not have developed otherwise and exemplifies the benefits of involvement in professional organizations.

The need for rapid change and the sense of urgency imposed by drug shortages have introduced many clinicians to a change in process that involved less structure and more fluidity.  Although navigation of this model is associated with discomfort, examples of positive transformation have been realized. Drug shortages are by no means a welcome state of affairs, but in some instances, good results can come from them.   

References:

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2. Goldsack JC, Reilly C, Bush C, et al. Impact of shortages of injectable oncology drugs on patient care. Am J Health Syst Pharm. 2014;71(7):571-578.
3. Mazer-Amirshahi M, Pourmand A, Singer S, Pines JM, van den Anker J. Critical drug shortages: implications for emergency medicine. Acad Emerg Med. 2014;21(6):704-711.
4. Wiggins BS, Nappi J, Fortier CR, Taber DJ. Cardiovascular drug shortages: predominant etiologies, clinical implications, and management strategies. Ann Pharmacother. 2014;48(9):1177-1186.
5. Gupta DK, Huang SM. Drug shortages in the United States: a critical evaluation of root causes and the need for action.  Clin Pharmacol Ther. 2013;93(2):133-135.
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8. Skelton Duke M, Chambliss WG, Gardner KN, Norris DM. Mitigating the impact of medication shortages on public health.  J Am Pharm Assoc. 2011;51(5):574-578.