Drug Shortage Update- IV Fluids: The IV fluid shortage started with a national shortage of normal saline (NS). Subsequently, multiple other IV fluids were placed on allocation due to this national shortage, and many are now posted as national shortages. The following additions to the current adult action plan, involving automatic interchange of NS or 1/2NS to D51/2NS (certain exclusions apply), have been approved by the P&T Committee: 1) Remove the pre-checks on IV fluids on the adult Power plans/Care Sets except for those on the DKA plan and Severe Sepsis Bundle Orders. 2) Allow the pharmacy department to procure IV normal saline from Fresenius Kabi, USA who is temporarily distributing IV normal saline in the USA from its Norway manufacturing facility. On April 7, following Cerner Powerchart announcement and educational memo, the action regarding removal of pre-checks from the majority of Care Sets and Power Plans as described above was implemented. To date, the IV fluid shortage remains critical, and pharmacy is tracking system inventory on a weekly basis of the following fluids: NS, 1/2NS, LR, D5NS, D5W, and D51/2NS. Please refer to the front page of Methodist MD for weekly updates on the status of each IV fluid on shortage. Due to the critical nature of the IV maintenance fluids listed below, we ask that all clinicians critically review their patients receiving IV fluids. If not clinically indicated, encourage the prescriber to discontinue the IV fluid.

Policy Review: Unit Dose Repackaging Records and Procedures To ensure the standardization of medications that have been repackaged by pharmacy, the unit dose repackaging procedure was reviewed. Oral penicillins, lanthanum carbonate and gelcap formulations were added to the policy, which already contains oral solid chemotherapy, as preparations that will be repackaged manually. For hospitals who have gone live with bar-coding medication administration (currently only University), unit dose packaging labels will now contain barcodes specific to the medication dispensed. A record sheet is maintained for each drug that is repackaged. On the record sheet, pharmacists initials will be included for the finished product which includes independent double check by the pharmacist of the validation of the bar code.

April 2014

Special Interest Articles

Drug Shortage Update: IV Fluids Policy Review Core Measures Miscellaneous Drug Shortage Report Upcoming P&T Agenda Items Contributing Writer: Andrew Nishimoto, Pharm.D. Editors: Tifany Derheimer, Pharm.D., BCPS Kerry Cleveland, M.D., Chair, MLH P&T Committee References: LexiComp, www.fda.gov

All P&T decisions and actions described herein have been approved by the Medical Executive Committee

Next P&T Meeting: Thursday, May 1, 2014 12 Noon to 1 PM Upcoming P&T Agenda Items: TPN MUE, IV acetaminophen MUE, Hemostatic Product Class Review, Rituximab restrictions, Sliding Scale Insulin Protocols

Core Measures Rules: P&T approved the following Core Measures Rules to fire to physicians:

AMI Aspirin at discharge AMI Statin at discharge Stroke Antithrombotic at Discharge Stroke Statin at Discharge

The purpose of these rules is to determine whether the respective medications were prescribed and if not, if a reason for not doing so has been documented, and notify the user accordingly. If the above medications have not been prescribed, nor a reason documented appropriately, a message will display to the user and allow them to act accordingly.

Miscellaneous:

The following Order Sets, Power Plans, and Order Forms were approved: Cath Lab Intra Procedure Plan, Neuro Intra Procedure Plan, and Outpatient IVIG Order Form.

The following shortage plans for adults were approved: cefazolin and heparin premix. Fortunately, stock has not dropped to a critically low level to warrant implementation of these plans. If implementation is warranted in the future, educational memos will be prepared and distributed to staff.

Addendum to the override list: Strong Iodine Solution (Lugol’s Solution) was added to the override list for Interventional Radiology Omnicell.

Drug Shortage Report: In addition to the aforementioned IV fluids shortage, the following shortages remain critical with official action plans in place (adult plans): Calcium gluconate injection: Conservation to minimum amount in adult TPN solutions, with the intent to keep ionized calcium within low normal range (1 mmoles/L) Excel bags: Removed from EH carts in order to have supply available for chemotherapies that require admixing in Excel bags. Have procured amiodarone premix bags from PharMedium for use during the shortage, in order to conserve stock of the Excel bags, as amiodarone requires admixing in Excel. The premix from PharMedium is a different concentration than our standard- Pharmacy IS has corrected the Cerner sets and educational memos have been sent to nursing and pharmacy. Hydroxyzine injection: CPOE alert active driving prescribers to use diphenhydramine if clinically appropriate. Nitroglycerin drips: CPOE alert active, encouraging use of alternatives where clinically appropriate. Phosphate injection: Shortage plan in place. Recently have opened up use for sodium phosphate in TPN. For boluses, automatic interchanges to PO are in place if patient meets specific criteria. Utilize potassium phosphate for bolusing. See shortage plan for further details on pharmacy Sharepoint and on Methodist MD http://www.methodistmd.org/quality-and-patient-safety/pharmacy-and-therapeutics/drug-shortages.dot under IV potassium phosphate and sodium phosphate shortage memo. Vecuronium: OR has agreed to use rocuronium as an alternative during shortage. CPOE alert active for adult sites driving prescribers to use atracurium when ordered on the Neuromuscular Blocker Protocol or Hypothermia Protocol (Dr. Ice Protocol)