From: David Collette
To:
Sent: Thursday, January 11, 2018 4:11:13 PM
Subject: Narcotic and fluid shortages

As you have all heard, we are in an unprecedented time of shortages, especially fluids and narcotics. Here are a few points to note as we move forward:

• ORAL is the key word...converting patients to oral narcotics and fluids is essential to preserving our supply. We can argue about who we should "reserve" drugs for, but the key point is -- if we don't conserve, WE WILL RUN OUT!

• If the patient can possibly get by without the IV fluid, work with the prescriber to get it stopped. If it can't be stopped, pursue reducing the infusion to the lowest rate possible. Note: we will be suggesting banning all KVO drips as a first step to preserve fluids---think SALINE LOCK. If we run out of fluids, there will be no surgeries, very little chemo, no trauma or critical care, etc.

• IV narcotics should be switched to PO AS SOON AS THE PATIENT CAN TAKE PO - we will be pursuing official P&T and MEC approval for automatic conversion soon, but we need to start moving to PO NOW. Talk to the nurse, call the prescriber, whatever it takes to get these drugs switched to PO. Again, if we don't conserve, WE WILL RUN OUT...and, again, that means we will be able to treat very few patients.

• Please identify frequently-used order sets in your area(s) that contain IV narcotics, review the doses ordered, and note where the dose could be reduced to the next lower vial/syringe size. This needs to be done NOW and then sent to me. If we run out of injectable narcotics, all we will be able to use is oral!

• We will be promoting multi-modal analgesia to OR/anesthesia

• Berkley is identifying drugs that are made by PSP in piggybacks that could be stopped in order to prolong our supply. We have already identified thiamine, promethazine, and Vitamin C. After some time (a few days) to publicize the issue, they will no longer supply these drugs in IVPB form...they must be given IM, PO, or PR (as available) or not at all. If you see issues (such as patients with severe thrombocytopenia or those on therapeutic doses of anticoags getting IM doses), please let me know. Again, we cannot argue over who needs this drug or that drug...if we don't conserve, WE WILL RUN OUT!

If you have suggestions for other measures (including other drugs that are not curative and could be restricted to the non-IV route during the shortage), please let me know. Thanks for all you do and for helping us survive this crunch. Utilize students and residents as needed to accomplish our goal of significantly reducing our IV fluid and narcotic use...just notify the appropriate preceptor when you need to re-direct their efforts. Also, involve nursing as much as possible in the process...they are the ones who know the patient best and they are the ones that will get the loud complaints when patients' pain is not controlled.

If you have questions, please let me know. I have surgery scheduled for Jan 18 (foot) and plan to be back Jan 24. DAVID

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David R. Collette, Pharm.D., FASHP
Operations Manager, Professional Services
Huntsville Hospital Department of Pharmacy