The Day the D50 Dried Up

   In EMS, adversity is what we do. We're used to being dealt bad hands and spinning the proverbial stuff into Shinola. In that sense, it's not a surprise that an enterprising system could turn a sudden shortage of a needed drug into a positive for its patients and itself.

   In this case the drug was 50% dextrose solution for injection, which, as many services experienced, was in short supply following a spike in demand last year.

   The system was Oklahoma's Emergency Medical Services Authority (EMSA), which serves around 1.25 million residents in Oklahoma City, Tulsa and surrounding areas. How EMSA handled its D50 drying up can be a lesson for systems facing shortages anywhere.

   "Personally," says EMSA Medical Director Jeffrey Goodloe, MD, NREMT-P, "I think the drug shortage last year was one of the best things that ever happened to our system in terms of operational and financial efficiency."

Having vs. Using

   When the dextrose started to dwindle, EMSA leaders had to assess some things:

• What crews actually used;
• What units normally carried;
• What was kept in reserve.

   What units carried was 10 or more amps per ambulance, three per paramedic engine. What they used, well, that turned out to be a bit of a surprise.

   The belief was that crews were regularly seeing some diabetics who had chronic problems managing their blood sugar, and that some particularly bad-off patients required more than one amp of D50 on a single run. Neither turned out to be the case, Goodloe told attendees at the EMS State of the Sciences Conference in February. A review of run data showed that over six months, there had been but a single "power user," who had required seven amps in that half-year, and not a single patient who had required more than one amp on a call.

   "This really showed the power of data driving decisions, and not best guesses or hunches," says Goodloe. "We'd assumed we were using dextrose 50% for individual patients multiple times every few months, or had folks with episodes of such profound hypoglycemia that they required two-plus administrations in one patient encounter. What we found was, we don't have any power users in our system. The typical patient in a six-month time frame whom we were managing for diabetic complications, we only saw once in that six-month time frame."

   Knowing that, EMSA could adjust what it carried on units with confidence crews wouldn't be caught short. Leaders cut ambulance stocks from 10 amps to 4, freeing up hundreds of amps to add back to an inventory that had shrunk to less than a week's worth. "The supply room," says Goodloe, "went from not having enough to us having to find extra boxes to put it all in." They also placed an order for the drug whenever they could get it.

   And then EMSA turned the process to its other drugs. It will ultimately repeat it for every one its units carry. That's a long process and not yet complete, but eventually, all unit stocking and reserve inventory will be tied to demonstrated use.

   So far leaders have found some drugs, particularly those used a lot, were carried in appropriate quantities. But others, less frequently used, are proving to be overstocked.

   "In most situations, we're finding we can actually cut the amount of pharmaceuticals needed to resupply," says Goodloe. "On top of that, we can cut back on some of what's being carried, but not administered as much as we thought it was."

   It's a lot of data to analyze. EMSA gives pharmaceuticals on almost 30% of its runs, or around 45,000–50,000 calls a year. But major metropolitan systems replicating this procedure, Goodloe suggested at Eagles, could save up to a quarter million dollars. That's a lot of money that could be reinvested in patient care, people and other priorities.

The Lemonade-Making Machine

   One caution for systems moving ahead with this kind of review and recalibration: Be careful how it might come off to local lawmakers or media. "You have to be careful, when you talk about this way of saving money, that you don't erroneously broadcast that your system has been frivolous with its spending," says Goodloe. "We look at it as being smarter—we're looking at things in a different way. But you have to be careful as you move forward that your past practice isn't held against you."

   In fact, many systems only now have the readily available kinds of data to facilitate this kind of appraisal. EMSA's results are another good argument for getting it. No operational decision should be based on a hunch.

   As you crunch the numbers and make any adjustments, it's important to keep field troops in the loop as well. They have to know leaders aren't just squeezing the drugs for profit, but are making data-driven decisions that will make their operation leaner, but not endanger patients or make care harder.

   "The goal is to ultimately deliver the best clinical performance possible, and to professionally support the clinicians giving that care. And it takes real, hard dollars to do that," says Goodloe. "This is a way to help generate some of those dollars to drive that clinical ability through equipment, through training, and through recruitment and retention of qualified professionals. But you have to do it in a stepwise approach.

   "We just simply took a shortage of one medication and said, ‘You know, this is not a lemon coming our way. This is the proverbial opportunity to make lemonade.' So we basically designed a lemonade-making machine to look at all the pharmaceuticals and better appraise what we use, carry and supply. And when we do that, that's a pretty big cost savings to a large system."