By: Nadia Awad, Pharm.D.
It seems like nowadays, every ED drug and its mother is on a manufacturer shortage. Epinephrine? Check. Etomidate? Check. Succinylcholine? Check. Sodium bicarbonate? Check. Some are on shortage for only a short period of time and may seem like that they were never gone to begin with, while others may be on a critical long-term shortage for various reasons. Pharmacists and pharmacy buyers alike are literally pulling their hair out trying to keep up with the shortages and determine which alternative agents would be appropriate to keep in stock and utilize in the meantime.
On a Friday last month, when I was doing my regular residency duties down in the ED, we got word that both the rabies vaccine and immune globulin were on shortage due to the increase in demand in both products since the summer months as well as a manufacturing delay. The only indication that both products could be obtained from the manufacturer would be for the purposes of post-exposure prophylaxis, and an order form would have to be signed by the ED attending physician that indicates the number of patients (possibly) exposed to rabies, weight of the patients, the number of vials of immune globulin needed, and the total number of vaccines anticipated to complete the full course of treatment. This form would be sent directly to the manufacturer in order for both products to be shipped to us.
When we heard this, the dayshift ED pharmacist, my residency program director, and I quickly did a count of the current inventory of vaccines and immune globulin at our hospital, and we determined that we had enough to at least last us through the weekend. We then drafted an institutional protocol within an hour to define the conditions and steps necessary for our pharmacists in dispensing both the vaccine and immune globulin. The protocol that we have developed is outlined below:
• ED attending physician enters an order for the rabies vaccine and immune globulin for a patient requiring post-exposure prophylaxis into our computer system.
• Upon verification of the order by the pharmacist, both the assistant pharmacy director and pharmacy buyer are to be notified of the name of the patient and ordering physician regarding the request for rabies vaccine and immune globulin.
• The pharmacist who verified the order is to complete the order form with all the patient information and have it signed by the ED attending physician.
• The order form is forwarded to the pharmacy buyer so that both products are ordered for the next business day.
• The first dose of the rabies vaccine is provided to the patient in the emergency department from the current pharmacy inventory.
• Once all subsequent doses of vaccine and immune globulin for the patient have arrived, that supply is sequestered for that individual patient.
• The pharmacist is to document their initials along with the name of the patient, name of the ED attending physician, and the date and time that vaccine and immune globulin are dispensed in the "Rabies Vaccine and Immune Globulin Dispensing Log" in the appropriate columns demarcating the days of therapy (days 0, 3, 7, and 14 for the rabies vaccine and days 0, 3, or 7 for rabies immune globulin).
• A physical inventory of both the immune globulin and vaccine on hand will be maintained by the pharmacist each time a dose of rabies vaccine and/or immune globulin is provided to an individual patient and record the amount in the area provided on the log.
Of course, there will be situations where a patient may require a shorter or longer course of therapy for post-exposure prophylaxis, and we indicated that that would need to be documented in the dispensing log as well to account for this.
We provided email communication to the ED attending physicians, physician assistants, and residents regarding the shortage to just give them a heads up about the shortage. In addition, we provided the protocol to the assistant director of the pharmacy and pharmacy buyer so that they knew how we would go about handling the shortage. We also provided a brief summary and a copy of the protocol to our pharmacists in our weekly departmental email bulletin.
So far, things have gone pretty smoothly and we have had not had any issues (knock on wood). I just cannot wait until we can go back to the days where we will no longer have to deal with the shortage. But that would make life less interesting, wouldn’t it?