Record-setting national shortages of drugs used to treat cancer and diabetes, as well as transplant and surgical patients, have hospital pharmacists and physicians scrambling to come up with alternative therapies when their supply lines for preferred therapies run out.
In the Inland Empire, these shortages have hit a number of hospitals, resulting in staff members spending additional time finding alternatives, higher fees for some medications and, at one hospital, delays in elective surgeries.
“I would say for sure it’s a pretty critical patient safety issue, and in my opinion, it’s approaching a public health crisis, especially in the oncology world,” said Bona Benjamin –Â director of medication-use quality improvement for the American Society of Health-System Pharmacists, an organization thatÂ tracks drug shortages.
“It sounds like to me that patients are not able to get the drugs that they need or maybe the ideal drug for their condition, and people who are supposed to be taking care of patients are instead managing supply issues.”
Pharmacists at three of the region’s largest hospitals all said they have had to devote a significant amount of time to managing drug shortages.
“We are seeing an unprecedented number of such shortages,” said Andrew Lowe, director of pharmacy services for Arrowhead Regional Medical Center in Colton, south of San Bernardino. Â “I’ve been in practice for 25 years. I’ve never seen so many at the same time.”
Many Drugs in Short Supply
Drugs that have been scarce in recent months include propofol, heparin, epinephrine, morphine, neuromuscular blocking agents and oncology drugs. Of particular concern at the moment is the shortage of oncology drugs because substitutes may have higher toxicity, can affect patient life span and may cost more, pharmacists said.
A number of factors can cause a drug to become scarce — such as companies discontinuing a drug; not being able to obtain enough raw materials; or encountering regulatory issues, manufacturing problems, or plant closures. There have also been reports of some hospitals hoarding medications, further exacerbating shortages, pharmacists said.
“First and most important to us is patient safety and efficacy of drug therapy,” Benjamin said. “When you don’t have the drug of choice, then you have to use the second line agent, and they might not treat the condition effectively.”
Sometimes alternative therapies have side effects or longer recovery times, which prolong hospital stays, Benjamin said.
Another common drug in limited supply is dextrose in 50% solution, which is used to treat low blood sugar. The drug is normally available in a syringe, but due to a manufacturing error, it has been difficult for some hospitals to obtain it. Arrowhead Regional Medical Center could only get dextrose in liter bags, and hospital staff have been filling syringes out of the bags and restocking every floor every 24 hours because the sterility time is limited for dextrose drawn from a bag, Lowe said.
“It creates a new demand in terms of labor force,” Lowe said. “It also causes a lot of waste because the syringes we removed we could not reuse, we had to discard.”
The hospital has also been affected by a shortage of furosemide, which is used to treat congestive heart failure. Pharmacy and medical staff worked together to come up with an alternative drug within the same therapeutic class.
“It’s the same classic story,” Lowe said. “If you were on a deserted island, and this is all you have, what would you use? And that is the approach we have to use sometimes.”
The hospital was also affected recently by a succinylcholine shortage, caused by a problem in the supply of the raw material used to make the drug. The anesthesia drug is used to intubate patients undergoing surgery, and the hospital was forced to cancel some elective surgeries.
“It simply would not be safe to intubate patients without the drug,” Lowe said. “This was one case where safety could have been compromised. … The head of anesthesia would call begging. When we finally got some, I personally delivered it.”
Benjamin has heard of other cases where hospitals have been forced to cancel elective surgeries.
“(Elective surgeries) are their bread and butter, which is how they stay in business because of their revenue,” she said.
Benjamin added that it is unknown whether federal health reform will have an effect on the issue.
In September, the Institute for Safe Medication Practices surveyed 1,800 health care practitioners across the country. The results were striking. Respondents described more than 1,000 errors and adverse patient outcomes during the past year related to more than 50 drugs on the shortage list that became abruptly unavailable, often without adequate notice.
Staff members’ using alternative drugs with which they are unfamiliar also can increase the chances for errors. The survey found that 35% of the respondents said their facility experienced an error that could have led to patient harm during the past year due to a drug shortage. About one in four reported errors that reached patients, and one in five reported adverse patient outcomes related to drug shortages. Switching from morphine, which is in short supply, to hydromorphone, a more concentrated form of the drug, resulted in patient deaths because of incorrect doses, the survey found.
All hospital representatives interviewed for this article said that the shortages had not compromised patient care.
“At no time do we ever put our patients in danger,” Lowe said. “The only risk is headache on our part. We have to get a lot more innovative and resourceful when these shortages happen.”
While 58% of respondents in ISMP’s survey reported encountering internal hoarding of medications associated with impending shortages, representatives from Inland Empire hospitals said that there has been a collaborative approach to dealing with the shortage.
Officials from both Arrowhead Regional Medical Center and Riverside County Regional Medical Center said the facilities have shared medications with other area hospitals that had run out and could not obtain the drugs on the open market.
Shortages Are Game Changers
Riverside County Regional Medical Center has been affected by shortages of two oncology drugs, but pharmacists were able to work with oncologists so that current patients would be able to complete their regimens and new patients would be treated with an alternative protocol, said Lee Klevens, director of pharmacy programs and services.
The problem with the shortage of chemotherapy drugs is that if a patient is started on a regimen, complications might occur if the regimen changes.
“So the product you have on hand you need to reserve for the patients that have already been started on that therapy,” Klevens said. “A lot of hospitals couldn’t do that. We could.”
Klevens also said the cost of some products, including propofol, have risen dramatically as a result of the shortages.
Loma Linda University Medical Center, which is licensed for 822 beds and is the region’s only Level 1 trauma center, has been able to scrape through the shortages.
“We’ve been quite fortunate,” said Nancy Ryu, the hospital’s pharmacy purchasing supervisor. “There have been days where we’ve been very, very low, and we’ve been going by the skin of our teeth, but we were able to survive.”
In May, the hospital ran out of the antibiotic amikacin, and switched patients over to another medication. The hospital has also been affected by the propofol shortage and has restricted the use of the drug to surgical suites only, Ryu said.
It takes an investment of time and energy to avoid falling victim to the drug shortages.
“We’re literally on the computer on an hourly basis, every 30 minutes, checking for the drugs,” Ryu said.
Some Hospitals Spared
Colorado River Medical Center in Needles, one of the region’s most remote corners, has not been affected by any of the shortages.
“I really haven’t had any supply problems. I’ve been able to work around it, or to see it coming and stock up enough to get through a particular shortage period,” said Rick Simpson, pharmacy director at the 10-bed rural hospital with a critical access designation. Â “We’ve been lucky.”
Simpson said that stocking a hospital with a low volume of cases in comparison to larger hospitals, such as Arrowhead Regional Medical Center, makes it easier to ensure enough medications are on hand. Colorado River Medical Center only conducts surgeries three or four days a month on average, he said.
“You’re going to find the problem in larger hospitals with higher patient loads and higher volumes of surgeries where they just can’t get enough medication to do what they need to do,” he said.