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Pharmaceutical Supply Chain Management before, during and after the inpatient CoVID 19 pandemic surge(s)
John Hrenko,. Gordon Hubbard. Jaime Levash. Margaret Stephan, Ifeoma Eche, Howard Seth Gold, Julius Yang, Christopher McCoy.
Department of Pharmacy, Division of Infectious Diseases, Division of Health Care Quality, Beth Israel Deaconess Medical Center
The Interventions
Introduction/Problem
In February of 2020, our group purchasing organization announced concerns for supply chain disruptions
given the reliance on active pharmaceutical ingredient (API) production from China. Conversely, none of
the wholesale distributors were experiencing any supply disruptions and that they anticipated none.
Historic experience with high acuity influenza surges (2009, 2017) and natural disasters (Hurricane
Maria) lent perspective to the potential impact of manufacturing and disproportionate demand leading to
shortages. However, the trajectory of this yet to be defined global pandemic left Pharmacy Operations
and Clinical Management without a clear direction for anticipatory purchasing or a watch and wait
approach.
After weeks, medications of concern affected were agents thought to treat CoVID-19 (e.g.
hydroxychloroquine, azithromycin), and agents to treat the symptoms of CoVID-19 (e.g. respiratory
medications-inhalers, nebulizers).
As the pandemic intensified, agents to address the influx of intensive care admissions (e.g.,
vasopressors, sedatives, intravenous opioids, neuromuscular blockers) became on short supply. The
shortage list continued to expand faster than any other time period across multiple categories threatening
to interrupt patient care.
Aim/Goal
To balance unclear and fast evolving demand with supply chain availability, fiscal responsibility, clinical
evidence, and avoiding a hoarding process, to avoid negative consequences in patients. There are no
available benchmarks for shortages other than avoiding stockouts, implementing therapeutic
substitutions and forestalling negative clinical outcomes.
The Team
John Hrenko, PharmD
Operations Supervisor
Gordon Hubbard
Purchasing Manage
Jamie Levash RN
Project Manager
Margaret Stephan MS
Chief Pharmacy Officer
Ifeoma Eche, PharmD
Clinical Manager
Howard Seth Gold, MD
Clinical Director
Julius Yang, MD
Clinical Director
Christopher McCoy, PharmD Clinical Manager
Department of Pharmacy
Department of Pharmacy
Health Care Quality
Department of Pharmacy
Department of Pharmacy
Health Care Quality, Infectious Diseases
Health Care Quality
Department of Pharmacy
Given the escalation and dynamic nature of supply chain disruptions daily huddles and communications were
enlisted,
Purchasing and Pharmacy Operations Administration continuously monitored supply chain announcements
from multiple sources, the group purchasing organization, manufacturers, wholesalers multiple times a day.
Purchasing sought out alternate suppliers and allocation methods to order/purchase items in high demand
continuously.
Pharmacy Operations used tactics including centralization of product supply, alternative route selection.
Clinical Pharmacy Managers worked with Infectious Diseases/Antimicrobial Stewardship to investigate and
reported out guidance relative to CoVID 19 therapeutics (e.g. high demand for azithromycin and
hydroxychloroquine). Alternate dosing strategies and algorithms for pain management, sedation and
neuromuscular blockade were created to standardize practice.
Invocation of the Drug Shortage Task Force including Health Care Quality was used to prioritize care, build
consensus with thought leaders and experts and devise algorithms and protocols.
A continuous modification of Provider Order Entry clinical decision support was designed and implemented to
guide best care and avoid shortages
Detailed interventions
Identify the key medications to
treat the complications of CoVID
19 infection.
• Dypsnea/Pneumonia
• Inhalers/nebs
• Antitussives
• Expectorants
• Sepsis
• Vasopressors
• Sedatives
• Antibiotics
• Analgesics
• Supportive meds
• Neuromucscular
Blockers
• Experimental CoVID tx
• Antibiotics
• Antivirals
Drugs completely out at the manufacturer and wholesaler level
Respiratory
Albuterol Inhaler
Albuterol Neb
Budesonide NEB
Epoprostenol IV
Ipratropium Bromide Inhaler
Ipratropium Bromide Neb
Tiotropium inhaler
Electrolytes
Calcium Gluconate IV
Magnesium Sulfate IV
Vasopressors
EPINEPHrine IV
NORepinephrine IV
Phenylephrine IV
Vasopressin IV
Intensive Care Unit Supportive
Artificial Tears
Chlorhexidine Gluconate PO
Sodium Bicarbonate IV
Sedatives
Dexmedetomidine IV
Ketamine IV
Midazolam IV
Propofol IV
Antibiotics
CefePIME IV
CefTAZidime IV
CefTRIAXone IV
Piperacillin-Tazobactam IV
Vancomycin IV
CoVID experimental therapeutics
Azithromycin IV
Azithromycin PO
Chloroquine PO
Cobicistat PO
Darunavir PO
Doxycycline PO
Doxycycline IV
Hydroxychloroquine PO
Lopinavir-Ritonavir PO
Neuromuscular Blockers
Cisatracurium Besylate IV
Etomidate IV
Rocuronium IV
Analgesics
Symptom Care
Benzonatate PO
GuaiFENesin PO
Fentanyl IV
HYDROmorphone IV
GuaiFENesin-Dextromethorphan PO
Ondansetron IV
For more information, contact:
Christopher McCoy, PharmD cmccoy@bidmc.Harvard.edu Clinical Manager, Infectious Diseases Pharmacy, Antimicrobial Stewardship
�Pharmaceutical Supply Chain Management before, during and after the inpatient CoVID 19 pandemic surge(s)
John Hrenko,. Gordon Hubbard. Jaime Levash. Margaret Stephan, Ifeoma Eche, Howard Seth Gold, Julius Yang, Christopher McCoy .
Department of Pharmacy, Division of Infectious Diseases, Division of Health Care Quality, Beth Israel Deaconess Medical Center
More Results/Progress to Date
Therapeutic specific
demand and utilization
during surge 1 & 2.
Introduction of a
Performance Manager View
Overarching Planning and Execution detailed for our team
Continuous
monitoring of
demand and
retrospective
lookbacks:
Antibiotic demand during the first surge of 3 months dwarfed antibiotic use for
years prior and patients with CoVID were 10x more likely to receive antibiotics.
Continuous shifts directed by our team were necessary to keep supply.
Tracking and movement of key meds
with grading of next phase readiness.
• Par levels needed to be adjusted to
the new normal for daily/monthly
utilization
• A safety stock to get through
national shortages was required
but had to balance fiscal
responsibility and good global
citizenship (e.g. no hoarding)
• Omnicell (floor supply) had to be
readjusted to meet new floor
demands and centralization.
For more information, contact:
Christopher McCoy, PharmD cmccoy@bidmc.Harvard.edu Clinical Manager, Infectious Diseases Pharmacy, Antimicrobial Stewardship
�Pharmaceutical Supply Chain Management before, during and after the inpatient CoVID 19 pandemic surge(s)
John Hrenko,. Gordon Hubbard. Jaime Levash. Margaret Stephan, Ifeoma Eche, Howard Seth Gold, Julius Yang, Christopher McCoy
Department of Pharmacy, Division of Infectious Diseases, Division of Health Care Quality, Beth Israel Deaconess Medical Center
More Results/Progress to Date
Situational awareness and community
building
Standard processes for ordering preparing
and administering meds all required
reframing across disciplines
Example of adjustment to steep demand
curves through therapeutic substitutions, in
this case from IV to PO for sedativeswithdrawal meds.
Example communications to all Hospital Staff
Early pandemic guidance suggested that all
items be disinfected to protect staff
In order to rein in the reflexive use of
agents thought to aid in treatment of the
infection given short supply and
prophylactic use.
Inhalers became in such short supply but critical
to care of all inpatients
For more information, contact:
Christopher McCoy, PharmD cmccoy@bidmc.Harvard.edu Clinical Manager, Infectious Diseases Pharmacy, Antimicrobial Stewardship
�Pharmaceutical Supply Chain Management before, during and after the inpatient CoVID 19 pandemic surge(s)
John Hrenko,. Gordon Hubbard. Jaime Levash. Margaret Stephan, Ifeoma Eche, Howard Seth Gold, Julius Yang, Christopher McCoy
Department of Pharmacy, Division of Infectious Diseases, Division of Health Care Quality, Beth Israel Deaconess Medical Center
More Results/Progress to Date
Drug substitutions were necessary but required
education and communication.
Drug Shortage Task Force Prioritization Schemes
Example communications and clinical therapeutic
summaries
Cisatracurium outages
Midazolam critical lows
Lessons Learned
Fentanyl Mitigation
Therapeutic demand and supply chain interruption is nearly impossible to predict during a global pandemic
Interdisciplinary involvement and broad communications are essential to keep available supply and ensure public health safety
Time required to address all the clinical decision making, inventory control and supply allocation is more than 50% of dedicated
time.
Next Steps
Utilize similar tactics for management of acute shortages early with engagement of therapeutic area leads, inventory tracking
and demand curves.
Apply modeling for network engagement and resource sharing.
Utilize global facing platforms like PowerBI through Performance Manager.
For more information, contact:
Christopher McCoy, PharmD cmccoy@bidmc.Harvard.edu Clinical Manager, Infectious Diseases Pharmacy, Antimicrobial Stewardship
�
Dublin Core
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Christopher McCoy (<a href="mailto:cmccoy@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">cmccoy@bidmc.harvard.edu</a>)
Project Team
John Hrenko
Gordon Hubbard
Jamie Levash
Margaret Stephan
Ifeoma Eche
Howard Seth Gold
Julius Yang
Christopher McCoy
Department
Any departments listed on the poster or identified in the spreadsheet.
Pharmacy
Healthcare Quality and Patient Safety
Infectious Diseases
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Pharmaceutical Supply Chain Management Before, During and After the Inpatient CoVID 19 Pandemic Surge(s)
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Format
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pdf
Effectiveness
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Safety