Hospitals and healthcare providers continue to face challenges due to drug shortages. As we know, shortages affect both patient care and treatment protocols. Many life-saving medications have been identified in short supply, posing potential risks to patient outcomes and requiring strategic management and alternatives by healthcare professionals. Hospitals must stay ahead by ensuring the availability of robust strategies to manage these shortages, ensuring that patient care remains uninterrupted and safe.

Here are some actionable strategies and reminders to consider for managing drug shortages effectively.

Strategies for Managing Drug Shortages

Alternative therapies: Identify and validate alternative drugs or therapeutic modalities that can effectively replace the shorted medication without compromising patient care.

Supplier diversification: Work toward diversifying suppliers and manufacturers for critical drugs to reduce the impact of a shortage from a single supplier.

Usage guidelines: Implement guidelines for the use of drugs in short supply, prioritizing patients for whom the medication is most critical.

Stock management: Optimize stock levels by monitoring consumption patterns and adjusting stock levels accordingly to prevent overstocking and understocking.

Collaboration: Engage in collaborative efforts (if possible) with other hospitals and health systems for sharing resources during acute shortages.

Patient communication: Ensure transparent communication with patients regarding drug shortages, potential impact on treatment, and available alternatives.

Long-term Solutions

Advocacy: Participate in advocacy efforts aimed at addressing the root causes of drug shortages through regulatory reforms and industry engagement.

Technology adoption: Utilize technology for better forecasting and managing of drug inventories, including the use of artificial intelligence (AI) and machine learning algorithms.

Education: Keep the healthcare team informed and educated about managing drug shortages, including training on the use of alternative therapies and adjusting dosages.

Some Key Drug Shortages

These are a few of the current drug shortages, focusing on medications that may be critical for patients in the hospital setting. These medications are often used in acute settings, emergency care, or the treatment of serious conditions, making their availability crucial.

Amiodarone injection

Significance: Critical for use in the treatment for serious arrhythmias, such as ventricular tachycardia. Its importance lies in its ability to stabilize heart rhythms.

Ciprofloxacin injection 

Significance: As a broad-spectrum antibiotic, ciprofloxacin injection plays a critical role in treating bacterial infections. It is especially valuable in treating infections in patients who cannot tolerate or absorb oral antibiotics.

Methotrexate injection 

Significance: An essential chemotherapeutic agent and immunosuppressant used to treat various cancers. Its injectable form is crucial for cases requiring high bioavailability and rapid onset of action.

Midazolam injection

Significance: A benzodiazepine used for sedation, anxiolysis, and amnesia before medical procedures and in the ICU for sedating patients.

Nitroglycerin injection

Significance: Nitroglycerin is a critical medication used primarily in the management of acute episodes of angina pectoris and the treatment of heart failure associated with acute myocardial infarction. Its rapid vasodilatory effects can relieve chest pain by increasing blood flow to the myocardium and decreasing the heart’s oxygen demand.

Somatropin injection

Significance: A synthetic growth hormone, somatropin is used to treat growth hormone deficiency in children and adults. Its role is crucial in promoting normal growth and development in children.

For a detailed and up-to-date list of all current drug shortages, healthcare professionals should consult ASHP and FDA drug shortage lists directly. These resources offer comprehensive information on each shortage, including reasons for the shortage, available products, and estimated resupply dates, all of which are crucial for effective shortage management and patient care planning.

Drug shortages pose significant challenges to healthcare teams, requiring a proactive and strategic approach to ensure uninterrupted patient care. By staying informed about the current shortages and utilizing a combination of short-term management strategies and long-term solutions, hospital pharmacies can navigate these challenges more effectively.

The inclusion of virtual pharmacy in the inpatient hospital setting is a significant shift towards integrating technology with healthcare, presenting unparalleled opportunities to elevate patient care. As we progress towards the 2030 American Society of Health-System Pharmacists (ASHP) healthcare initiatives, the adoption and optimization of Virtual Pharmacy stand out as key priorities for integrated health systems.

Strategic Implementation and Focus Areas

The strategic deployment of Virtual Pharmacy has revolutionized traditional pharmacy roles by transitioning aspects of order verification to environments with fewer distractions. Virtual Pharmacy associates are equipped with a focused work queue that aligns with the organization's strategic goals. This approach has allowed Virtual Pharmacists to concentrate on high-volume orders needing quick turnaround times, specifically targeting departments such as the Emergency Room, Surgery, Maternity, Postpartum, and Nursery. By reallocating these tasks off site, on-site pharmacists are afforded the bandwidth to focus more on operational duties and specialized clinical care, perfecting the balance between efficiency and quality patient care.

Operational Efficiency and Patient Care

An extensive review of hospital operations in one health system from January 2018 to June 2023 illuminates the substantial impact of Virtual Pharmacy, particularly within the Emergency Department (ED).

Efficiency in Order Verification

A notable achievement within the Virtual Pharmacy initiative has been the significant improvement in the order verification process. Order verification within 10 minutes significantly improved by 16.7%, jumping from 73.6% to 90.3%. This progress not only met but exceeded the system's target, confirming over 90% of orders are verified within a critical time limit. This is only made possible by the improved efficiency of Virtual Pharmacy.

Accelerated Antibiotic Administration

The efficacy of Virtual Pharmacy extends to enhancing the timeliness of antibiotic administration for critical cases:

• Pre-Virtual Pharmacy: 28.2%
• Post-Virtual Pharmacy: 50.9%
• One specific Location:
  • Baseline: 35.3%
  • During Virtual Pharmacy: 68.6% (↑33.3%)
  • After Virtual Pharmacy Removal: 54.9% (↓13.7%)

These statistics highlight Virtual Pharmacy's vital role in speeding up essential interventions, thereby improving patient outcomes.

Expansion Opportunities and Patient Engagement

Virtual Pharmacy's existing structure offers significant potential for growth and expansion to the outpatient settings. Examples include Medication Therapy Management (MTM) and patient counseling. By providing personalized care through tailored MTM and counseling, Virtual Pharmacy could significantly boost patient engagement, promote shared decision-making and adherence to treatment plans. This approach not only elevates patient safety and outcomes but also presents scalable opportunities for the further integration of Virtual Pharmacy services within the healthcare delivery framework.

Conclusion

Virtual Pharmacy is not an entirely new concept but is at the forefront of healthcare innovation and is strategically positioned to fulfill the ambitious goals of the 2030 ASHP healthcare initiatives. Through strategic implementation, operational efficiencies, and expansion opportunities, Virtual Pharmacy is reshaping the healthcare landscape, setting new benchmarks for efficiency, clinical outcomes and patient engagement. As the healthcare sector continues to evolve, the ongoing enhancement and integration of Virtual Pharmacy will be crucial in realizing a more efficient and patient-centric healthcare ecosystem.

Leonid Gokhman, PharmD, manager of pharmacy business operations at Harris Health System, takes a proactive approach to running his operation, rather than being reactive. He encourages his pharmacy, nursing, IT and revenue cycle peers to adopt this mindset.

“If you’re reactive, you’re creating so many other issues — not only for yourself, but for multiple teams,” Dr. Gokhman says. “If you're able to put things in place that prevent issues from happening in the first place, you drastically cut down on a lot of clutter, errors and unnecessary work.”

Part of taking a proactive approach means working directly with the frontline staff not only on project development and implementation, but maintenance as well. Staying within the pharmacy walls and only working with your team means you’re not getting the bigger picture of how the hospital system operates, he says. 

Plus, when major departmental initiatives are carried out in silos, crucial components may be overlooked. This oversight could result in either beneficial or detrimental downstream effects for other departments.

Five years ago, he was asked to participate in the hospital system’s vaccine redesign project. When he first started the project, the error rate was almost 50%. (Yes, you read that right. 5-0.)

“If you have errors in your clinical documentation and on your charges, you will not get paid or get paid inappropriately,” Dr. Gokhman says. “As I was digging through the system build and working with nursing leadership — it became clear to me that the system build was way too complicated. Our providers had five different workflows, requiring them to memorize numerous charge codes to manually post administration charges and contend with confusing order names. This diverted their attention away from direct patient care.”

Five workflows were four too many. His first step was to consolidate multiple provider and nursing workflows into one. Next, vaccine order names were updated according to ISMP (Institute for Safe Medication Practices) and Epic guidelines. Finally, a system build was implemented to automatically post vaccine and vaccine administration charges based on the documentation for each vaccine.

“Keep it simple,” Dr. Gokhman says. “When frontline staff are presented with too many options, they are prone to choosing incorrectly or resorting to workarounds. These workarounds might seem beneficial, but on the frontend, they lead to order entry and documentation errors. This causes multiple coding, billing and reimbursement issues on the backend.”

By simplifying and automating the workflow, they’ve drastically cut down the number of errors.  Recently, a third-party audit revealed a 100% vaccine billing compliance rate, surpassing the industry standard of 95%.

The day before I was expecting an employee to return from maternity leave, I received her resignation letter, citing reasons of wanting to focus on motherhood. The timing was unfortunate, but I was happy for her. As a mother, this made me wonder if I was making good life choices. As a manager, this made me feel like I’m competing with little babies for mom’s time and talents. How can we retain good employees when they’re in love with the competition? The truth is, we can’t. The kids always win, and they should.  We can only hope to join mom in loving these little, squishy sugarplums by giving her the support she needs to excel at home and then in the workplace.

Raise Benefits Awareness

They say, “a baby changes everything,” and this extends to the need for benefits and the enrollment period.  Benefits could be anything from financial planning, expanding insurance coverage and assigning beneficiaries, or simply knowing they have employee assistance for stress management. Having insurance coverage for breast pumps, lactation consultants and pelvic floor physical therapy is tangible proof of the company’s support for mothers of newborns. On-site childcare is an attractive benefit, too! Encourage expecting moms (and dads) to consult human resources and benefits management about what opportunities are available through your institution.

Support the Breastfeeding Journey

Time spent breastfeeding a child can equal as much time spent working a full-time job. The American Academy of Pediatrics (AAP) recommends exclusively breastfeeding for at least six months. Compare that to maternity leave, which can be as short at 6 weeks. That means new moms are working two jobs! Before she delivers, make her aware of lactation services which can include an on-site lactation consultant, time and space to express milk, and storage space for breastmilk. The AAP is an excellent resource for this, and they issued a news release in 2022 citing recommendations for corporate support of  breastfeeding:  American Academy of Pediatrics Calls for More Support for Breastfeeding Mothers Within Updated Policy Recommendations (aap.org)

Creative Scheduling & Cross-Training

Drug shortage mitigation proved to be a mere training ground when compared to navigating the workforce shortage, making employee retention seem more important than ever before.  Overall, what moms need from their employer is to be able to leave work to care for their child without judgement from management and coworkers. The workflow should be designed so mom can meet the needs of her sick child, or attend a school function, without added guilt of her workflow left unattended. Creativity is key when it comes to meeting the needs in the department while balancing employees’ needs outside the department. This may mean schedule changes, creating PRN staffing requirements, or expanding benefits to part-time employees. Cross-training employees ensures the needs of the department are met when special occasions arise during this precious season of life.

Moms have a reputation for being pretty remarkable creatures. Research has shown that mothers’ brains are equipped to be “more efficient, flexible, and responsive” as a result of changes occurring in the perinatal period.^1,2 That makes sense when we think of our cavewomen ancestors protecting their young, but these traits make valuable employees in today’s era, too. She may not be shooing away a sabertoothed tiger, but it can feel that way as she juggles the demands of work and home life. Working with employees as they venture through seasons of life, especially young motherhood, lets them know they are supported and valued at work, and creates a space for them to build a career.

These opinions are those of the author and not of Pharmacy Angle or USA Health.

Ref:

1 Kinsley, Craig Howard, and Kelly G. Lambert. “The Maternal Brain.” Scientific American, vol. 294, no. 1, 2006, pp. 72–79. JSTOR, http://www.jstor.org/stable/26061302.

2 Orchard, E.R., Voigt, K., Chopra, S. et al. The maternal brain is more flexible and responsive at rest: effective connectivity of the parental caregiving network in postpartum mothers. Sci Rep 13, 4719 (2023). https://doi.org/10.1038/s41598-023-31696-4.

VPL TrajectRx empowers outpatient pharmacies by giving them the cloud-based shipping, tracking and compliance solution they need to build cost-conscious, stronger, and smarter last-mile operations. Created for pharmacists by pharmacists, our clinically minded platform gets prescriptions out the door, tracks and traces them to their destination, communicates shipping updates to patients and staff, and compiles necessary reporting for proof of delivery. By minimizing distribution errors, enhancing operational efficiency, and reducing time spent on the phone, TrajectRx ensures a streamlined and effective pharmacy workflow.

Leonid Gokhman, PharmD, is a licensed, Epic Willow certified pharmacist who has more than 25 years of experience in the field of pharmacy. He has extensive experience in managing inpatient, ambulatory, and retail pharmacy operations, IT/informatics, value-added health economics, Formulary review/approval process, 340B Program, Medication Assistance Program, revenue cycle management, as well as managing both funded and unfunded patient markets.

For fifteen years, Dr. Gokhman has worked at the Harris Health System – a non-profit healthcare system located in Houston, Texas. For nine years, he’s managed the pharmacy business operations of the organization’s revenue cycle department. In his current role, he’s learned how crucial it is to have a pharmacist representation within the healthcare organization’s revenue cycle department.

Before his position, he said — much like the majority of pharmacists — he didn’t know much about the backend processes involved in medication billing, coding and reimbursements. As a frontline pharmacist, he was focused on his clinical work and patient care.

However, after learning about the inner workings of the revenue cycle processes, he’s developed a full understanding of the healthcare system’s frontend and backend processes. His knowledge and experience have allowed him to create and optimize all medication-related charging and billing processes.

This has ultimately contributed to more than doubling the organization’s cash collections, while saving millions of dollars through the 340B Program and medication assistance programs, and optimizing the organization’s Formulary.

Currently, he has three analysts working for him who are pharmacy technicians. He’s trained them to understand the system like he does. He shared a few examples of how being a pharmacist with knowledge about the revenue cycle can help your organization: 

Centralizing pharmacy services is a popular topic, as health systems explore avenues that can bring value to the organization. The first step to centralizing services is determining what functions can be performed from a central location and the value of each. This will be specific to each health system as regulatory requirements are different in each state, as are the services offered by health systems, the prescription volume/mix, and the geography. Services that a central pharmacy can provide include mail order/specialty pharmacy, call center, prior-authorization, patient assistance, self-distribution/warehousing, repackaging, kit/tray management, training, order verification, and medication reconciliation.

Once a decision is made on the services, the next step is defining how each of the functions will be performed.  Traveling around to the multitude of Central Pharmacies throughout the country you will see varying levels of automation versus manual processes. It is important to know about staffing limitations and address those through automation during this design phase. Automation vendors are expensive, long-term partners so this is a key decision point.  Due diligence is needed, so leverage relationships with other health systems, GPOs, wholesalers, and potentially consultants, depending on the aptitude of your internal team.  It is worthwhile to look outside of typical pharmacy vendors for technology solutions, as many of the activities performed from a central pharmacy are warehouse activities.

Another long-term decision is the floorplan of the central pharmacy. Even after the recent shift to move employees to work-from-home, most central pharmacies wish they had more space. There will be attempts to reduce square footage in favor of budget.  If a compromise needs to be made on square footage, look to what employees could move to remote/hybrid, but be steadfast in your requirements for the operations and storage areas within the facility. Remember to define the footprint based off current opportunities AND potential future growth.  It is much less expensive to plan for a potential 2^nd floor upfront, rather than rip up concrete and replace support beams in the future.

Once the general floorplan is defined there will be a decision to buy existing property, build from scratch, or join existing property, which typically means co-locating with Supply Chain and/or Lab.  If you are joining an existing centralized Supply Chain many of the vendor decisions may already be made (Warehouse Management Software, courier vendor, shipping software, etc.).  If it’s a new build there will be a lot more decisions, but more freedom in design. Your ROI will be impacted by the location, and ability to tap into existing services.

Data is crucial in defining the revenue, costs, and savings available to the health system to support the business plan, as those will be the metrics that determine the viability of the facility. The goal is an autonomous pharmacy with 0 medication errors, 0 medication waste, and no manual intervention until medication is delivered to the patient. An autonomous pharmacy allows 100% of the pharmacists’ time spent on clinical activities, with 100% visibility into inventory levels system-wide, and 100% regulatory compliance. Lean on the wealth of data available through your EHR, dispensing software, automation software, and financial software to communicate the ROI of your proposed services. Be bold in your request of vendors, as much of the industry is inefficient today and is ripe for automation.

At this point, if your business plan supports a central pharmacy, be prepared for the multitude and magnitude of decisions that need to be made. Details matter, and there will be a lot of details.  If you’ve built a custom home, you can appreciate the minutiae of building something from scratch.  Defining every data/power drop, whether employees get a laptop or desktop, the number of monitors for an employee, furniture, signage, and all the way down to the location of each trash can.  Do not underestimate the resource commitment from Pharmacy for the sheer volume of decisions that need to be made, the new technologies and software integration development needed, and the hiring required to open a new facility. Building out a new facility and team will demand significant resources, while the day-to-day functions of pharmacy will still need to be tended to.

Staffing a new facility is a challenge given the pharmacist and pharmacy technician shortage. Pharmacy will staff positions outside of the pharmacy department as well (Security, IT, Environmental Services, etc.). Lean on the leaders of those departments within your health system.  Much of your time will be spent on interviewing and onboarding, which will all need to be timed out with a go-live date that is a moving target.  Plan a calendar block for the interviews and create interview teams to tackle hiring as your team grows. This is another key focal point, because culture matters and as an organization scales you want to ensure your environment is a desirable workplace that can attract the top talent in a competitive market.

Go-live is likely a phased implementation, as it is typically too much to take on day one. Plan out your phases as many of the resources may overlap, or some of the functions may be required to go-live at the same time.  With the knowledge you’ve gained with your implementation, share with other health systems. We are all in this together to provide first-class care for patients and to support the viability of the health systems in our community.

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Drug shortages are becoming a pervasive global issue.  In the United States alone, there were 309 active drug shortages at the end of the second quarter of 2023 — the most in nearly a decade and close to the all-time high of 320 shortages, according to a report by the American Society of Health-System Pharmacists. Causes of these shortages are varied and complex, ranging from manufacturing and quality issues to unexpected demand surges, posing significant risks to public health. However, the responsible use of evolving technology, especially Artificial Intelligence (AI), can be a valuable asset in addressing the drug shortage crisis. The National Artificial Intelligence Act of 2020 defines AI as “a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Here are a few ways in which healthcare systems can utilize AI-driven approaches to mitigate the impact of drug shortages.

AI-Driven Forecasting and Inventory Management: One of the most significant ways AI can combat drug shortages lies in its ability to forecast shortages before they occur. Conventional methods of demand forecasting rely on manual analysis and decision making and often fall short in capturing dynamic factors influencing supply and demand. In contrast, AI algorithms swiftly analyze diverse data sources such as historical shortage data, production capacity, regulatory trends, and market dynamics, achieving high accuracy in predicting potential shortages. By capitalizing on these predictions, healthcare systems can take proactive measures to mitigate shortages, such as increasing production capacity or securing alternative suppliers. Furthermore, AI-powered epidemiological models can forecast changes in disease prevalence and treatment demand, enabling healthcare systems to anticipate shifts in medication requirements and adjust procurement strategies accordingly.

Supply Chain Optimization: Pharmaceutical supply chains are complex and are notoriously susceptible to disruptions. However, AI’s data analysis prowess holds promise in optimizing the pharmaceutical supply network. Through predictive analytics and machine learning algorithms, AI can identify vulnerabilities in the supply chain, anticipate disruptions, and recommend strategic interventions to minimize risks, preventing shortages from happening in the first place.

Production Optimization/Quality Control: Manufacturing quality issues and production inefficiencies are major reasons for drug shortages. AI can enhance production processes within pharmaceutical manufacturing facilities, minimizing drug shortages. By analyzing production data in real-time, AI can identify inefficiencies, optimize manufacturing workflows, and reduce waste. Furthermore, AI-driven quality control systems can enhance the reliability and safety of pharmaceutical products by detecting defects, anomalies, or deviations from specifications in real-time, minimizing the likelihood of production delays due to regulatory compliance issues.

Alternative Therapies/Enhanced Clinical Decision Support: AI can support clinical decision-making in managing drug shortages. Though still in its early stages, AI-driven clinical decision support systems (CDSS) can analyze patient data, treatment guidelines, and drug availability information to recommend alternative therapies or dosing regimens when preferred medications are unavailable. By integrating clinical expertise with real-time data analytics, AI-driven CDSS can empower healthcare providers to navigate complex treatment scenarios and optimize patient outcomes amidst drug shortages.

Overall, AI presents a promising path forward in addressing the persistent issue of drug shortages. By integrating AI-based tools, healthcare systems can not only predict and prevent shortages but also optimize supply chains, streamline production, and support informed clinical decision-making. While challenges remain, responsible implementation can ensure that AI’s potential in tackling drug shortages is fully realized, achieving better patient outcomes and improving the global public health. 

Lifepoint Health is a leading healthcare provider that serves patients, clinicians, communities, and partner organizations across the healthcare continuum. The company has a growing diversified healthcare delivery network comprised of 60 community hospital campuses, more than 60 rehabilitation and behavioral health hospitals, and 250 additional sites of care, including managed acute rehabilitation units, outpatient centers, and post-acute care facilities.

Historically, the process for managing expired drug waste was not clear for this complex organization, and corporate oversight proved inefficient in providing guidance or standardization across the enterprise. Poor data visibility from the reverse distributor was the primary hurdle to oversight.  Lifepoint Health worked with its reverse distributor to improve data analytics tools to help improve outcomes for its 60 acute care community-based hospitals.

With potentially millions of dollars in annual expired waste costs, enterprise-wide level oversight of expired drug waste is necessary and is dependent on clear visibility into actual expired drug volume and cost data to effect change.

Methods

The first step was to improve the expired drug waste data collection process and data visibility. Lifepoint’s Pharmacy Operations lead worked with the reverse distributor’s team to develop a quarterly report worksheet that provided accurate detailed expired waste data per facility per quarter.  The report consisted of the following information: 

• Division-level aggregated data
• Facility-level totals and line-item data
• Creditworthy Return Benchmarking Data:
  • National
  • Corporate
  • Division
  • Facility
• Non-creditworthy expired returns Reason Codes
• Hazardous waste codes

Secondly, a PowerPoint Summary Report was developed for specific facilities. Due to the considerable number of hospitals, inclusion criteria were developed to determine which hospitals would receive a quarterly PowerPoint Summary Report and which would not.

Summary Reports are described below:

• PowerPoint Content
• Creditworthy returns, non-creditworthy returns, and total expired drug waste cost per facility
• Total expired drug line items and % of Division Total expired waste line items
• Non-creditworthy return totals per reason code
• RCRA U and P listed HD Returns (if applicable)
• Raw return data for non-creditworthy non-controlled drugs for top 150–200-line items.
• Actions to decrease expired drug waste, guidance on what to include in reverse distributor returns and what not to return.

The PowerPoint template was completed with data from the reverse distributor’s quarterly report for each eligible hospital and emailed to the Director of Pharmacy and Division Director of Pharmacy Operations with requests to review the report for opportunities for improvement regarding expired drug waste management.

Results

The reports and recommendations provided to the Directors of Pharmacy resulted in a 4% decrease in expired drug waste volumes, a 9.1% increase in creditworthy returns, and a 16.4% decrease in cost reduction from 2020-2022.

Conclusion

The creation of a reverse distributor quarterly detailed Expired Drug Review Report was key to central oversight of expired drug waste for Lifepoint Health’s acute care hospitals. The reports allowed for timely analytics and process improvement recommendations.