Supply-Chain Communication and Drug Reallocation

Experts provide insight into the initial logistical steps following a drug shortage, with a discussion on interdisciplinary communication and drug redistribution.

Troy Trygstad, PharmD, MBA, PhD: It sounds to me as if there are 2 categories of drug shortages that you’re experiencing regularly. Category 1 is the type of shortage that requires a lot of administrative work; you’re loading something new into your electronic health record and picking a list, and you’re having to switch out the physical location or find a new production source. There’s the active management going on behind the scenes that the frontline practitioners do not see. You have these drug shortages that are sentinel events in some ways, that have a major impact on care. How do you communicate to the institutions that have 20, 30, or 200,000 employees? What does that look like?

Richard Montgomery, RPh, MBA: At the local level, places came up with scoreboards and scorecards—whatever you want to call them. For critical medications that were in severe shortage or not available, they were marked “red.” “Yellow” means it’s tight and administration needs to be judicious, and “green” is noncritical. These posts are seen by nurses, physicians, and the pharmacy staff.

Troy Trydstad, PharmD, MBA, PhD: You're coming up with ways of communicating. You’re saying the facilities aren’t necessarily communicating, but you’re having to communicate out as proactively as possible. You feel as if you’re a little bit behind the 8 ball. This almost feels like a press secretary’s room. You get a piece of news that comes in, and you ask yourself: “How can I turn this over? What do I do? How do I polish this so it’s clearly communicated?”

Erin Fox, PharmD, BCPS, FASHP: It is a challenge because you have to make a plan without knowing all the steps that you’re going to need to take. You have to make a plan without complete information. Sometimes you make a plan, and you get a delivery the next day; that’s the best-case scenario. It’s hard to look at that and seem as if you’re not crying wolf. You need to have a good plan so that everyone is happy. It is a challenge to communicate with what is almost a moving target.

Troy Trygstad, PharmD, MBA, PhD: Sure.

Richard Montgomery, RPh, MBA: It also depends on the drug: Sometimes it’s a specialty like anesthesia or neuromuscular blockers that go short, and we have to send messages out to the people who administer it. This channel of news is focused. I don’t want to say it’s easy, but it’s easier than when we have to send messages regarding widely used drugs.

Erin Fox, PharmD, BCPS, FASHP: Good point: It’s easier to target communication toward specific providers. What makes it so challenging is the amount of basics that affect every area of the hospital. It is very hard to communicate to every provider who might need to know about a shortage like lidocaine [Lidoderm].

Troy Trygstad, PharmD, MBA, PhD: My heart is palpitating now. That’s a little inside pharmacy joke with the lidocaine. Walk me through the basics. You’re saying basic, everyday drugs are in short supply?

Erin Fox, PharmD, BCPS, FASHP: Yes.

Troy Trygstad, PharmD, MBA, PhD: Like?

Erin Fox, PharmD, BCPS, FASHP: Like diphenhydramine [Benadryl] injection, lidocaine, bupivacaine [Marcaine], sterile water, even some sizes of saline, basic antibiotics, cefazolin, and cefoxitin [Mefoxin]—really basic products that are used throughout an entire health system.

Troy Trygstad, PharmD, MBA, PhD: An interesting point you made earlier that’s fascinating to me is that, regarding your 48 hospitals across 9 states, some of them have specialty groups of emphasis that others may not; some might receive flu outbreaks sooner than others. Do you have a scenario for when one hospital conveys a portion of its supply to pharmacy, etc, across town?

Richard Montgomery, RPh, MBA: Yes, but we don’t cross state lines.

Troy Trygstad, PharmD, MBA, PhD: That’s a barrier.

Richard Montgomery, RPh, MBA: We just received a new permit in the state of Florida, so we’ll be able to transfer products earlier. If it’s mission crucial, yes, we will move product, especially if it’s a lifesaving drug. In the Orlando area, we also have a central distribution center where medication will come in and get pushed out to the hospitals, not all over the state of Florida, though.

Troy Trygstad, PharmD, MBA, PhD: But you might have a hospital that specializes in a procedure or a particular area, eg, organ system, and you have to target that messaging too.

Richard Montgomery, RPh, MBA: What we’ve done in those cases is work through another wholesaler to get it back to our wholesaler in the state of Florida. Legally, that’s the best way to do it.

Troy Trygstad, PharmD, MBA, PhD: How many pharmacists know what 503B is?

Erin Fox, PharmD, BCPS, FASHP: Many I believe would because it’s new.

Troy Trygstad, PharmD, MBA, PhD: In your world.

Erin Fox, PharmD, BCPS, FASHP: It’s a new category of compounders—true pharmacists who specialize in the community setting might not be as aware, but pharmacists who work in hospital settings are certainly aware.

Troy Trygstad, PharmD, MBA, PhD: Tell us about what this has to do with drug shortages.

Erin Fox, PharmD, BCPS, FASHP: There are companies that can register with the FDA to be a 503B compounder. They can make drugs that are in short supply once listed on the FDA drug-shortage list. Sometimes this helps hospitals, especially with long-term shortages. It’s not an immediate help, however. The reason why is because, once a hospital is in short supply of a drug, there’s a delay before it gets on the FDA drug-shortage list, and then there’s a delay for that company to ramp up their supply and produce the product. Hospitals often have to make 2 or 3 different plans. What’s your initial plan to get through until the 503B can supply you? They’re not always as timely. Hospitals have to juggle that as well. It can be a help for some organizations that use those companies, but it can also pose a challenge.

Troy Trygstad, PharmD, MBA, PhD: These are meant to be temporary fix solutions until the traditional manufacturing process can get started, completed, and into the supply chain.

Erin Fox, PharmD, BCPS, FASHP: Yes.