Choosing a Post-Shortage Solution and Preventive Budgeting

Experts consider back-up plans following a drug shortage, if the primary action plan is insufficient, and attune the budgeting process for preventing future drug shortages.

Troy Trygstad, PharmD, MBA, PhD: Can you think of any instances when there was a drug shortage and the plan in place didn’t work? Do you then go to plan B, C, or D? Is it a flexible sort of scenario? Do these decisions have to be made in real time?

Richard Montgomery, RPh, MBA: It’s like a balloon: you squeeze one end, and the other end blows up.

Troy Trygstad, PharmD, MBA, PhD: So put pressure on the whole system.

Richard Montgomery, RPh, MBA: Drugs within that category start getting squeezed. They might be third- or forth-tier selections, however, which float up now to number 1 when there are shortages. And nobody is making enough to fill up the first and second choices, so you’re scrambling a lot. It happens with antibiotics frequently, when things are in demand and you have to try to replenish the stock. I’ll speak on my own opinion: sometimes pharmacists are hoarders and will grab what they can get, which doesn’t help with shortages. When the shortage is relieved, you’re stuck with excess inventory; this goes back to your comment on waste. It’s dependent on the situation, but it gets tricky.

Erin Fox, PharmD, BCPS, FASHP: We can think of maybe 4 good plans, but we choose the one that’s going to be the least amount of informatics work. I will tell you right now, that on our system, we haven’t been able to use our usual bicarb drips because we don’t have the manpower to redo all of those order templates and sets to make those changes. It was a good thing because, even though we felt confident about our sterile water and sodium bicarb, we eventually ran short. It ended up being a good thing that we didn’t have the informatics time to do that. In so many cases, however, the amount of labor and the amount of informatics changes dictate the plan that you make.

Richard Montgomery, RPh, MBA: You’re a little hesitant to make the change because you were just short for 6 weeks and now, they’re telling you they’re back up to speed. This is where it gets kind of tricky.

Troy Trygstad, PharmD, MBA, PhD: So it’s budget season and you’re making the case for more people, resources, forecasting software—whatever it might be. What’s your best pitch to get more resources to buffer the effects of drug shortages?

Richard Montgomery, RPh, MBA: We did service-line budgeting. We knew how many cases we were expecting, and we said, “OK, these drugs affect this service line. These drugs have been short. This is what our plan is for this.” Labor is always the tricky part. We spend 80% of our budget on drugs and 20% on labor—yet senior officials focus on labor first and drugs second. So making that connection between labor and drugs is the hard part.

Troy Trygstad, PharmD, MBA, PhD: Interesting. So, Erin, it’s budget season, you need an extra FTE [full-time equivalent] worker to perform for the health system and the patients. How are you making that case?

Erin Fox, PharmD, BCPS, FASHP: That’s a tough one because I lost an FTE last year. We try to focus on the efforts that we’ve made. We try to highlight our prevention efforts. It is hard to talk about the work that we do that goes unnoticed. We had to change many order sets. We had to pull this many people off line to make a clinical plan. Luckily, we do have support of our medical staff who hear from colleagues—maybe at their other facilities where they don’t have product—who know that we do, and they will ask me how this happened. I say, “Well, it’s because you worked with us to restrict the use, and so that’s why we still have some.” Maybe that organization will then be able to make a restriction plan as well. It’s a tough proposition, especially when you also have to spend additional money on drugs: you might have to buy a more expensive product; you might have to buy things off contract; you might have to buy imported product that’s more expensive. And so we have those costs as well. But, overall, we show we haven’t had to delay any surgeries. We haven’t had to deny patients care.