Before a shortage of potassium phosphate products hit the OhioHealth health system in March 2011, the member hospitals had been “acting in silos” to manage scarcities. However, things changed after they realized they only had a two-week supply of potassium phosphate and an indefinite shortage resolution date ahead of them.

As Lorrie Burns, PharmD, one of OhioHealth’s medication safety pharmacists, explained during a recent Institute for Safe Medication Practices (ISMP) webinar, the health system quickly moved to a collaborative and proactive approach.

“We didn’t know how long the shortage would last, so we developed a systemwide Shortage Response Team to meet weekly,” Dr. Burns recalled. The team, which is now part of OhioHealth’s drug shortage management strategy, includes pharmacy procurement coordinators, registered dieticians, clinical pharmacists and pharmacy managers.

“Our initial goal was to preserve phosphate products for neonatal TPN [total parenteral nutrition] and adults requiring custom TPN,” she said. To achieve that goal, the team developed a potassium phosphate conservation strategy. The strategy specified that, when appropriate, patients not in these two priority groups should be switched from IV to oral potassium phosphate for phosphate replenishment. For nonpriority patients requiring TPN, they recommended using a premixed TPN solution containing phosphate when appropriate. A health-system team of registered dieticians and pharmacists created an order set for substituting the premixed TPN products.

“Another very important thing we did was to have a smaller hospital transition the preparation of neonatal TPN to a larger hospital in the system so that we didn’t have two sites opening phosphate vials every day and potentially throwing away product,” Dr. Burns said.

Dr. Burns and her colleagues quickly disseminated details of the potassium phosphate shortage and the newly developed conservation strategy.

“It was very important that physicians and particularly front-line nurses be aware of what was happening and felt comfortable with the conservation strategy,” said Dr. Burns, noting the centralized communication approach also saved staff time and effort.

The strategy proved a success, she said, and “we had our changes in place within nine business days and were able to conserve our potassium phosphate stock until it was again made available.”

Lessons Learned

In addition to teaching the importance of working collaboratively, the potassium phosphate shortage highlighted the need for vigilant drug shortage monitoring as a way to head off crisis situations, Kelly Besco, PharmD, medication safety coordinator for OhioHealth Pharmacy Services in Dublin, Ohio, told webinar attendees. “Tracking wholesaler stock and our own internal inventory of shortage drugs allows us to be a bit more proactive so that we aren’t waiting until our supply reaches a critical state or until we aren’t able to obtain any product.”

Dr. Besco said the conservation process typically begins when wholesaler supply of a shortage drug is noted to be trending down. “Once we identify a current or predicted national and wholesaler shortage, we report it to our health-system Shortage Response Team, which is charged with directing our conservation efforts,” she said.

An individual hospital might volunteer to take the lead in developing a conservation strategy because it has the staff resources to do so or if it is particularly affected by the specific shortage, Dr. Besco noted. Building a conservation strategy begins with a look at each hospital’s internal product purchase history to get a snapshot of usage patterns.

If the usage patterns suggest inventory is likely to last until the predicted shortage resolution date, the team keeps an eye on stock. If the findings indicate supply may be depleted before the shortage resolution date, the team conducts a more detailed “deeper dive,” looking at the product’s use patterns, which indications it is most often prescribed for, whether order sets are used and who the most frequent prescribers are.

The deeper dive helps identify which substitutions can be made, whether and when drug administration routes can be switched, how supply can be centralized and what patient groups should be prioritized to receive the drug. The individual conservation steps can be triggered sequentially when stock drops below prespecified inventory thresholds. And the finalized conservation protocol is shared across the entire OhioHealth system but discretion as to when to implement the protocol is left up to individual sites based on their own patterns of use and existing inventory.

“It’s a challenge to carve out resources to perform the deeper dive,” Dr. Besco admitted, “but we’ve found students and pharmacy residents are very helpful in conducting these reviews.”

ISMP’s Take

At first glance, the OhioHealth approach might seem too involved for some institutions to emulate, said Allen Vaida, PharmD, ISMP’s executive vice president. However, “as you continue this approach with repeated shortages with even a small shortage management team, what may seem resource intensive becomes less so,” he said. Moreover, “the lessons learned from implementing the strategy with one product will help make it easier when another product is identified on shortage.” To ensure success, he stressed, “the team should be given the backing to implement the change that may be needed in the organization, whether it be a health system or an individual hospital.”

Drs. Burns, Besco and Vaida reported no relevant financial conflicts of interest.