TN hospitals facing a lack of vital drugs
For five days in May, ambulances in Putnam County, Tennessee, lacked a tool that acts as the first line of defense against heart attacks and other emergencies: basic adrenaline.
“It comes in a different form, a different concentration. But we were out of that, too,” said Sullivan Smith, medical director for the county’s EMS team. “That’s the first drug you give when somebody’s heart stops. That’s the drug you give when you have that life-threatening allergic reaction to a bee sting or peanut allergy.”
As hospital emergency departments across the nation experience crucial drug shortages, some Tennessee physicians say they, too, are dealing with the impact.
In May, 247 emergency physicians across the country responded to a poll conducted by the American College of Emergency Physicians (ACEP). Nine in 10 of them said they didn’t have access to critical medicines. The same ratio said as a result of such shortages, they have taken time away from patient care to find alternative treatments.
Smith, a physician from Cookeville Regional Medical Center in Putnam County and Tennessee chapter president of ACEP, was one of the survey’s respondents. He said that, along with adrenaline, he lacks other vital drugs such as the painkiller morphine, numbing medicine for stitches and even sterile water.
Intravenous fluids such as saline, which treats dehydration, are in short supply, as well as small IV bags that doctors use to mix medicine to transfuse into patients, Smith said.
Shortages cause inefficiency
The low supply of the bags, which allow IV fluids to flow into a patient’s veins unattended, has caused nurses in his hospital to have to inject the medicine with syringes, Smith said.
“So instead of mixing it in a bag and let it drip in, it actually requires a nurse to stand at the bedside and very slowly push these medicines by hand,” Smith said. “While the nurse is doing that, that nurse is not caring for the other patients that he or she has in the emergency department.” In the survey, four out of 10 respondents said patients have been negatively affected as a result of drug shortages.
Saline and IV bag shortages stem from when Hurricane Maria damaged pharmaceutical manufacturing facilities in Puerto Rico a year ago.
Baxter, the largest provider of the small volume bags, went into “limited production” within a week of the storm, according to Baxter spokesman Bill Rader, and has been back in production in Puerto Rico this year.
But at Vanderbilt University Medical Center in Nashville, physicians are still facing IV bag shortages. Michael O’Neal, a director of pharmacy management at the medical center, said physicians there also began injecting IV fluid through a syringe.
“We were on an hourlong call with our IV vendor, and we are nearly a year out,” O’Neal said. “We are still dealing with the aftermath of Hurricane Maria and the supply chain not being recovered from that instance.”
Quality issues at Pfizer
Both hospitals in Cookeville and Nashville are also short of crucial painkillers, such as morphine and hydromorphone.
O’Neal said Vanderbilt began facing significant shortages of pain medication from fall 2017 to early 2018 because of quality control issues with Pfizer, one of its main suppliers.
Over the course of the last year and a half, a series of events have affected production of Pfizer equipment that’s used to administer drugs.
In February 2017, the Food and Drug Administration accused Pfizer of not adequately investigating complaints that some of its vials had been contaminated at its plant in McPherson, Kansas.
Four months after the FDA’s complaint, Pfizer notified its customers, including O’Neal’s hospital, that the company would temporarily reduce its supply of syringe products due to “remediation efforts.” Carpujects, syringe devices physicians use to inject fluid medication, were among the products Pfizer said that it would supply fewer of last year.
Then, in January, Pfizer temporarily stopped producing carpujects after a third-party supplier, responsible for a piece of the device, notified it about a problem with its part, according to Pfizer spokesman Steve Danehy. In May, Pfizer notified customers that multiple carpujects were found to have been contaminated and to have cracks in needle hubs.
Danehy said the company resumed some of its production in July but won’t reach “full recovery” until mid-2019.
“A lot of these carpujects (administer) the opioids that we use in the acute setting, like morphine, and so it put a strain on the entire industry,” O’Neal said.
“And so January was just a kick in the teeth when we were already down.”
Finding needed drugs
As many hospitals and medical centers across the country struggle to make ends meet, national regulators are searching for a solution.
On July 15, FDA Commissioner Scott Gottlieb announced that the federal agency will form a task force to look into drug shortages.
“I’m charging the shortages task force to delve more deeply into the reasons why some shortages remain a persistent challenge,” Gottlieb said in a statement. “The charge to this new task force is to look for holistic solutions to addressing the underlying causes for these shortages.”
The statement said low profit margins and high manufacturing costs have caused the pharmaceutical industry to consolidate.
With fewer manufacturers, problems at just one company can cause shortages. In Nashville, Vanderbilt University Medical Center has adapted to shortages by dedicating a pharmacist to contact vendors to find alternate forms of vital drugs, O’Neal said. His position as a pharmacist manager was formed five years ago.
“Drug shortages have gone way beyond just logistics and trying to source medication, and have become rather complex,” O’Neal said. “I really felt that it was time to have a pharmacist to be able to interface with our clinical teams and our operations teams and function at a level as a practitioner to help navigate solutions during shortages.”
Casey White, the pharmacy director at Cookeville Regional Medical Center, said the hospital has had to “invest in significantly more resources to find supply of medications than before.”
White said his medical center has relied more on its two compounding facilities — where drug ingredients are combined, mixed and altered — over the past three years to respond to shortages. He also said his hospital is considering using two more facilities if problems persist.