Clinicians need help in order to conserve drugs in this time of shortage

Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity

- W. Edwards Deming (10th of Deming's 14 principles of management)

I love it when 2 ideas smush together in a chocolate-and-peanut-butter way.

It happened for me this weekend.

On Friday, I had a great time at BCPSQC's Quality Forum.  In addition to attending some stimulating breakout sessions, I met Dr. Keith White, BCPSQC's Clinical Lead for Medication Reconciliation.  As he explained his work, he told me about the challenges that family physicians have in ensuring antibiotic use for patients with respiratory infections.

Most patients seeing their family physician about flu and cold symptoms have a virus, and antibiotics are not useful (and may be harmful).  Despite public education campaigns, some patients may still have an expectation that they will be prescribed antibiotics.   Public health organizations have exhorted physicians not to prescribe antibiotics in these situations, so as to reduce the risk of side effects and the development of antibiotic-resistant bacteria.

Dr. White explained to me that it's not sufficient to encourage this behaviour in family physicians; we need to provide the tools to help them.  He suggests using "scripts", or rehearsed responses, that address common concerns patients raise, such as "The last time I felt this way, the doctor gave me antibiotics", or "What's the big deal? It's just an antibiotic."

When prepared with responses to "frequently asked questions", physicians can confidently address common concerns and misconceptions that patients may have about antibiotic use in viral infections.  But, we can't expect that they will magically have these answers at their fingertips.  An initiative to curb inappropriate antibiotic use should include providing this resource to physicians, and showing them how to use it.

Make it easier for them to do the right thing.

That was the chocolate.  Here's the peanut butter:

Drug shortages have been in the news, and on the minds of health professionals across Canada.  Because of production problems at a manufacturing plant that supplies most of our country's injectable drugs, physicians are being asked to conserve supplies and consider using alternative medications via other administration routes.

Late last week, our health region circulated a memo asking nurses and physicians to "immediately change to oral equivalent medication to conserve the injectable drug supplies...".  Medications affected include common pain-killers such as morphine, as well as other commonly used drugs such as heparin.

All clinicians will recognize the importance of making these changes, where appropriate and safe for our patients.  We realize that we need to conserve injectable drugs so that they are available for situations where there is not good substitute.  But, good intentions may not be enough.  Perhaps federal, provincial and regional administrations should take Dr. White's advice and make it easier for clinicians to make these changes.

Specialists become comfortable and familiar with a fairly small palette of medications.  We know the dosage, side effects and indications.  We may occasionally use an alternate form (say, if our patient is allergic to the more commonly used drug), but don't necessarily have the same level of comfort.  It would be very helpful to receive specific suggestions on which drugs could be appropriately substituted, along with equivalent dosages (especially for narcotics!) and any special considerations or side-effects.

We already have some confusion in our urology department about whether we can continue to use injectable heparin in postoperative patients (to prevent harmful blood clot formation).  Surely, we can't be the only surgical department in the country with this issue!

Don't expect that busy clinicians are going to research each medication change.  We may just default to status quo, and continue using the same medications - via the same administration routes - that we're familiar with.

But, administrators can help us.

I suggest supplying each clinician with specific recommendations/options for substituting drugs and administration routes.  Give us the bare-bones information, but also a way to drill down if we want to explore in more depth.  A website would be good; an iPhone app would be better. (Seriously, this is an important problem; throw some resources at it.)  Ideally, we'd have national experts create specific guidelines that can either be sent directly to clinicians, or sent to health authorities to distribute after they review them for local relevance.

This needs to happen by the start of business on Tuesday, March 13.  

Yes, I realize I'm dreaming to think a national initiative could be mounted in 24 hours.  So, instead, let's see it happen in each health region.  This is an urgent situation.  Patient care is and will be affected.  The shortage may continue indefinitely.  The sooner we start making appropriate choices for drug use, the more medication we'll be able to conserve for patients who really need it.

It's a fairly short list of medications.  I imagine a hospital pharmacist could come up with a recommendation summary in one working day, and circulate it to clinicians by email.  Post it in all care areas where these drugs are commonly used.  Put a copy of it on the front of all inpatient charts.

Don't worry about making it perfect the first time around.  As long as it gives safe information, the first version doesn't have to be comprehensive.  Ask for feedback and we'll let you know what other information we need.

Make it easy for us to do the right thing.

Then, give us some feedback.  Report each ward's medication use before and after this intervention.  (N.B. Use charts, not data tables.  We like pictures!) We'll be curious to know how we're doing.  As this is an unusual situation, I doubt that there are published benchmarks for the conversion of injectable to oral administration routes.  But we can do internal comparisons (for example, between surgical units), to get a rough idea whether or not we're being diligent in making the requested changes.  "High-performing" units will be a source of ideas for their colleagues. But, this will work only if we know how everyone is performing.

Most importantly, make it clear to all clinicians that appropriate medication is never to be rationed to patients.  If the alternate drug or administration route is not suitable or effective, then our patients must receive the standard drug according to established practice.

Our health region memo goes on to say "If this voluntary conservation method does not maintain minimum supplies, stricter measures will be employed."  That sounds sensible and prudent to me, but let's make sure it doesn't come to that.

Don't just tell us what we should do.  Show us how to do it, and help us along the way.

Make it easy for us to do the right thing.