“In the systems where I work, we’ve tried to instill in our people that we really need to hear about near-misses related to this shortage,” Augustine says. “I think we’ll see systems developing some form of no-fault safety reporting process, so that we’ll be looking at both near-misses and misses prompted by this drug shortage. That would be a silver lining. Where errors or near-misses occur, we’d like to hear about them so we can attempt to address both the current issue and future risk management.”
Expired medications?—Drug expiration dates are generally pretty conservative, but your state will have to guide you here. Some are at this point: In April, Utah moved to allow 18 different medications to be used up to six months post-expiration. Others have been more resistant, so don’t expect blanket permissions to give expired drugs, even if no alternatives are available. Some states have indicated they may not sanction those who have no other options. Some services have moved to test expired medications for potency, and some medical directors have authorized their use. The NAEMT survey found 22.5% of providers approved to use meds past their expiration dates.
“To be able to use Valium that is a month or two months past its expiration date for a seizing child is very much safer and better for that child than to not use the Valium and allow him to continue seizing,” Utah’s EMS medical director, Peter Taillac, MD, said of his decision.
“I think you really hate to waste something that’s in short supply when in your heart you know, and if scientifically it can be proven, it still works and will still benefit patients,” says Cunningham. “Wouldn’t you rather be able to give it and have it be 90% effective than not have it at all?”
Weigh this carefully if you’re pushed into a corner, and confer with your relevant state bodies, medical director and legal counsel now.
Finally, here are some bigger-ticket, longer-term ideas that may take some time to establish, but can help systems weather the current crisis (however long it lasts) and any future recurrences.
Work collaboratively—The post-9/11 emphasis on regionalization, collaboration, mutual aid and helping each other out will pay off here.
In Texas, where they’ve recently dealt with things like hurricanes and H1N1, the regional structure is robust. STRAC is one of 22 such regional bodies across the state, and represents 71 EMS agencies and 53 hospitals. That’s provided a framework for cooperative response among a lot of people, sharing not only meds, but information, ideas, economics and the burden of coping.
“We had the table to sit at,” says Craig Manifold, DO, medical director for the San Antonio Fire Department. “It let us get the right participants together and brainstorm. We came together as agency directors and medical directors and said, ‘These are what we think the best practices are.’ As people had good ideas, we could incorporate them, and instead of individuals and specific agencies, we could put those best practices out on a regional basis, with direct communication with the people making the changes. That’s what really cements those processes in place.”
“We’re on the same charting product, and we meet together monthly, so we’re able to fall back on that when a crisis happens,” says Dudley Wait, EMS director for the city of Schertz. “If one of us is having trouble, it helps us get connected, even 100 miles away.”
Regional buying—Collective approaches like the one in the San Antonio region also bring purchasing power. This will be especially important as you forge new relationships with people like compound pharmacists, whose services will be increasingly in demand (more on that in a moment).
“Instead of an individual organization contacting a compounding pharmacy, it’s better for a large group or region, because it decreases the cost significantly,” says Jeff Carson, RPh, chief of staff for San Antonio-based Oakdell Pharmacy, which is handling compounding needs for STRAC members. “If we were dealing with an individual EMS organization, the prices per unit would have been higher. With a regional group, we had some assurance there’d be a certain level of volume that allowed us to purchase raw ingredients at a much larger quantity, which lowered the cost.”