NAEMSP: Pharmacist in the House

At the end of 2015, the Los Angeles County Fire Department got some challenging news: The pharmacy director at L.A. County/USC Medical Center, the department’s largest hospital supplier of controlled substances, announced it wasn’t going to supply them any longer. With the liability of medical directors being held personally accountable in cases of diversion, providing a supply to distribute across the department’s 76 paramedic squads and 3,000-square-mile jurisdiction wasn’t worth the risk.

More than just requiring a new supplier, the decision provided an inflection point for L.A. County Fire to reexamine its whole pharmaceutical-procurement process. “The system was so broken,” medical director Clayton Kazan, MD, told viewers of the National Association of EMS Physician’s annual conference Thursday, “that it made us reconsider the whole process from the beginning.”

The result—bringing the department’s pharmacy operations in-house—was the subject of Kazan’s talk, “The Fire Department Pharmacy: Navigating Drug Shortages, Improving Patient Safety, and Reducing Waste.”

Up to that point getting drugs was a less-than-efficient process for the department. Providers documented their use on ePCRs and two additional forms, and needs were relayed to a division drug-supply coordinator. The coordinator would send a driver to the pharmacy, where the pharmacist would verify and dispense what was needed. The driver would then take that back to various stations and restock, once units were in quarters. Then all the forms were updated.  

The “completely convoluted” process in some cases took as long as 10 days. Worse, the delays began to influence patient care, with medics getting tightfisted knowing restocking could be difficult. “We believe people were not getting morphine when they probably should have,” said Kazan.

Uncontrolled substances, meanwhile, were a buffet: Stations could order what they wanted from county hospitals based on perceived need rather than data. They took the packaging they got—glucagon, for example, not a cheap drug, only came in boxes of 10. If a station only needed two, it still ended up with 10. Stations also tended to order liberally for worst-case scenarios.

Better Care and Better Pain Management

The optimal solution appeared to be an automated dispensing system such as those used by hospitals—but California’s pharmacy board said fire departments couldn’t use them, because their stations weren’t healthcare facilities. The only way around that was changing the law, so with some help from state Sen. Ed Hernandez, a bill was shepherded through the legislature in 2017.

There was still federal law to contend with, though. Per the feds, moving 5% or more of received controlled substances out of a central location to stations would make the department a wholesaler/dealer—a designation hospitals could avoid because their distribution was generally all from the same address. The DEA said the department needed separate licenses for each station—so it got those too.

(The Protecting Patient Access to Emergency Medications Act of 2017 resolved many of these challenges for EMS systems, Kazan noted. EMS support for the bill was driven by late NAEMT medical director Craig Manifold, DO.)

To manage things centrally, the department created a pharmacy section in its EMS bureau headquarters. It distributed 24 Pyxis CII drug safes, one per battalion, one for air operations, and one extra to a battalion in a zone bifurcated by a mountain range. The safes are biometrically accessed, requiring fingerprints from two members, and remotely monitored. Restocks are compared to ePCR records, which wasn’t possible before. Waste is managed on scene and double-signed.

The benefits quickly became clear: In 3½ years and more than 20,000 transactions since the change, just three vials of morphine have been unaccounted for. And medics no longer feel such a need to preserve: Morphine administrations have risen by 18%, and midazolam by 31% (though regulations around that also loosened a bit). “It’s better patient care and better pain management,” said Kazan.

New Approaches

The new dispensing didn’t solve all the department’s drug problems, however. In the middle of this process, L.A. County Fire also faced an epinephrine shortage. Its supply came from county hospitals, but EMS wasn’t always those hospitals’ highest priority, and some were bleeding the department with inflated charges. Worse, moving to push-dose epi as pressor using hospital concentrations required double dilutions—obviously a great risk for error.

The bigger solution was moving to an in-house emergency pharmacist to help manage epi supplies and the whole litany of drug issues internally.

That pharmacist, Linh Vuong-Shaffer, PharmD, centralized ordering processes to run through her office—no more direct hospital-to-station transactions. Stations began reporting their epi stocks and expiration. Par levels were cut from 10 mg to 5 mg based on new literature. Use was tracked through ePCR data, and stock rotated from slower stations to those more likely to use it.

While still ordering from county hospitals, the department also worked to develop relationships with distributors and manufacturer Pfizer. Expired epi was repackaged per FDA regulations and sent to squads with the most cardiac arrests. As a result, L.A. County Fire maintained its epi stock even as departments around it went dry.

The successful management of that shortage fueled new approaches as scarcity continued over the years with a range of additional EMS drugs, including morphine, fentanyl, and lidocaine. The department took a universal approach, looking at 18 months of noncontrolled drug use to determine stations’ average utilization. Once that was determined, each station got a baseline stock of four months’ worth (a generous amount intended to accommodate L.A.’s many natural disasters). Each station now tracks use in a database, and the pharmacy keeps a 1–2-month supply of everything for the whole department on hand.

Leaders also recognized there was value in waste: Where previously they’d given expired meds to paramedic schools to train with, they instead signed contracts with reverse distributors to buy them back. It’s for pennies on the dollar, but “in a department our size, those pennies really add up,” said Kazan.

The bottom-line benefit to all this: In fiscal 2017, L.A. County Fire spent around $900,000 on pharmaceuticals and lost more than $300,000 worth to expiration and waste. By FY19 it spent just $700,000 and lost barely $100,000, and also made back $70,000 in credits from its reverse distributors.

Vuong-Shaffer and her colleagues—who now include another pharmacist, a tech, and a student to assist—also led to some other improvements. They noted, for instance, that epi isn’t supposed to be subjected to light, but crews were removing doses from their original boxes and keeping them in drug boxes, frequently exposing them, so they revamped that. And now with COVID vaccinations a priority, they’re bringing expertise to ordering, storing, cold chain, and documentation. Getting all the needed approvals is difficult, Kazan noted, and there are no better experts at navigating that and managing vaccine integrity than pharmacists.

“Pharmacists,” he said, “are the subject matter experts.”

John Erich is the senior editor of EMS World.