An Opportunity for Anesthesia to Lead

The severe shortage of sodium chloride 0.9% IV bags and other saline bags due in large part to the devastation wrought by Hurricane Maria on pharmaceutical plants in Puerto Rico offers one of the more unsettling recent examples.  (The commonwealth manufactures more pharmaceuticals for the United States than any of the 50 states or any foreign country.)

To help address the shortage, on January 24, the Food and Drug Administration (FDA) extended the shelf life of certain IV solutions made by Baxter Healthcare beyond the manufacturer’s labeled expiration date.  In a statement, the FDA said it expects the shortage will improve in the coming weeks and months and is working with manufacturers to import product into the U.S. from their foreign facilities.  (A comprehensive fact sheet on strategies for dealing with shortages of small-volume parenteral solutions is available from the ASHP.)

Drug shortages tend to hit anesthesia especially hard. In October 2017, the FDA announced a nationwide shortage of many injectable forms of fentanyl citrate, a shortage that persists.  A 2014 GAO study found that central nervous system drugs accounted for 17 percent of all drug shortages and that the shortages of these drugs were routine.  A 2012 survey by the American Society of Anesthesiologists (ASA) found that 97.6 percent of responding anesthesiologists were experiencing at least one anesthesia-related drug shortage. 

Anesthesia providers have used some innovative approaches to help prevent or reduce the impact of drug shortages in the past at their institutions.  Duke University Hospital (Durham, NC) formed a multidisciplinary perioperative drug shortage response team to address shortages of neuromuscular blocking agents such as succinylcholine in their operating rooms.

When a shortage is deemed critical, the coordinator of the Center for Medication Policy convenes a task force to discuss whether the shortage can be managed best by pharmacy alone or by a multidisciplinary group that includes anesthesiologists, nurse anesthetists, surgeons and OR nurses.

The team also uses data from its anesthesia information management system (AIMS) to identify trends and patterns in medication usage in the perioperative setting and develop strategies to repackage bulk medications into smaller unit doses whenever possible.  The approach allows the hospital to conserve inventory, reduce waste and extend the availability of difficult to obtain medications.

Anesthesia providers might also take a cue from pharmacist Trac Pham, RPh, of Advocate Health Care, who outlined strategies that have worked at his health system:

  • Use inventory control specialists whose responsibilities revolve around identifying red flags such as back orders and partial fulfillments. Empower frontline employees to identify these potential shortages.
  • Assess current inventory when a potential shortage has been identified—a step many hospitals fail to take. How much is sitting on the shelf today?  What is the hospital’s utilization rate?  How long is the current supply going to last?
  • Collaborate with supply chain and pharmacy to evaluate potential shortages, identify alternative therapies, prioritize patients who should receive the affected drug and modify clinical plans.
  • Develop a process that allows executives, clinicians and employees to communicate in a timely manner with each other to navigate drug shortages.
  • To ensure uninterrupted care, update the health information management system promptly to reflect alternative drugs when there is a shortage. 

For more information, also see the ASHP Guidelines on Managing Drug Product Shortages in Hospitals and Health Systems, American Journal of Health-System Pharmacy, 2009; 66:1399-405.

Death of Hospitals ( the exodus of surgical volumes)

Are you ready to be unreasonable this year? Or would you rather continue to bet on the healthcare status quo, that is, on a hospital-centric system? Or, is being “unreasonable” actually more reasonable?

George Bernard Shaw stated that “the reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.” Clearly in the “unreasonable” corner. Franz Kafka stated “in man’s struggle against the world, bet on the world.” Clearly in the “stick with the big boys” camp. Or, is it?

For the past twenty years, the reasonable approach has been for physicians to become more tightly aligned with hospitals. That’s where the money was and that’s where the power was. So much so, that physicians were barred from expanded and new Medicare certified hospital ownership.

But then fast forward to today. The hospital-centric financial and power structures are weakening.

Yes, it’s true that not all hospitals are dead, but most are slowly dying. Over time, what we know as hospitals today will be few and far between. That’s the theme of Mark’s book,The Impending Death of Hospitals (get a complimentary copy digitally, or a hard copy, on Amazon), and it’s being played out in the popular press on a very regular basis.

Witness the recently announced merger of CVS and Anthem in a bid to grab power away from hospitals. Or, the recently announced merger talks between Ascension Health and Providence St. Joseph Health that would create the largest U.S. hospital chain — each fears it cannot continue to exist alone.

What many, if not most, think is the reasonable, the safe, the traditional, approach is to continue to bet on the large players. That’s the bet being taken by the huge percentage of physicians employed by hospitals. But hospitals have bloated infrastructures and are sitting ducks for government intervention, whether by way of tax policy or via the tangled web of the government-hospital complex in which one “partner” is more equal than the other.

What to do? Deer in headlights? Reasoned thought? Unreasonable thought?

What clues, what proof, what evidence can we use to find our way?

In addition to closed hospitals, shrunken hospitals, down-sized new facilities, and bedless hospitals, there are other trail markers to the future. Payors are pushing radiology procedures out of hospitals to freestanding imaging facilities. Payors are pushing surgical procedures to ASCs. Hospital employment is becoming dangerous because if (when?) the system fails there will be no supported practice left to salvage. Hospital contracts in a world in which hospitals have declining case volume becomes problematic at best, disastrous at most.

Yet another famous writer, F. Scott Fitzgerald, stated that “the test of a first rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”

We’re smart, so let’s listen to Scott: Keep one foot in the hospital-centric world while taking affirmative steps toward one in which hospitals will be minor players. But it’s not enough just to hold ideas. Ideas must be implemented for them to be of much value.

For the past several years, I’ve been betting big on independent physician ventures. From surgery centers, to imaging facilities, to significant sized practice ventures. Yet, at the same time, I’ve been working with both large and small(ish) hospital based groups, and on physician-hospital joint ventures. That work will continue.

At the same time, in 2018, we’ll intensify a major push into expanded, physician-led ventures, with an emphasis on re-creating, on the physician-controlled level, integrated systems. As hospitals downsize and shift to the outpatient world to become more like ASCs, physician-owned ventures can become more like what hospital systems used to be, without the overhead, without the administrative bloat, and without the baggage.

Blog from Mark Weiss