Admin & Clinical Operations Supply Chain Disruptions: Why It’s Happening and What Can Be Done

Supply Chain Disruptions: Why It’s Happening and What Can Be Done

By Max Kravitz, MD, MBA; Meagan Hunt, MD; Derrick Huang, MD; and Megan Davis, MD, MBA, on behalf of the SAEM ED Administration and Clinical Operations Committee

A supply chain is the network of all stages that it takes to deliver a finished product to a consumer. These include raw materials, conversion to inputs, production of end products, and delivery of those end products. Many health care products utilize a complex global supply chain with many stages before our usage, and these networks are vulnerable to disruption at all stages. These vulnerabilities have existed for some time, but COVID-19 and the associated lockdowns have stressed supply chains and unveiled weaknesses.

Supply chain disruptions have impacted the lives of emergency physicians at home and work. From the infant formula shortage to the IV lorazepam shortage, it seems something is always in short supply. At the time of this writing, many emergency medicine physicians still face a shortage of iodinated contrast. The iodinated contrast shortage has been particularly challenging because it has forced many emergency physicians to alter their typical diagnostic evaluation of numerous life-threatening diseases. Instead of a contrast CT scan, emergency medicine physicians may be asked to order a V/Q scan to evaluate for pulmonary embolism or ultrasound for appendicitis workup. This article discusses supply chains, why some disruptions occur, what steps institutions should take to address shortages, and what should and should not be expected of emergency medicine physicians when shortages occur.

Iodinated Contrast Shortage

In the case of the iodinated contrast shortage, the Shanghai COVID-19 outbreak in April 2022 resulted in a two-month shutdown of the city due to China's strict zero-tolerance COVID-19 policy. This caused a global shortage of iodinated contrast media produced by GE Healthcare, which produces much of its contrast media in Shanghai-based facilities. Many health care systems in the United States utilize GE Healthcare as their preferred supplier for iodinated contrast, partly to save money through

“…the iodinated contrast shortage brought to light both vulnerabilities in the health care system and solutions to address them.”

preferred vendor contracting. Therefore, the Shanghai lockdown has had a devastating impact on the iodinated contrast supply of these health care systems.

Although China lifted its Shanghai lockdown on June 1, 2022, the future remains unpredictable due to China's continued zero-tolerance COVID-19 policy, the persistence of COVID-19 variants, and the threat of future pandemics, highlighting the necessity of constant innovation in the health care field. This shortage has been problematic for emergency medicine physicians as iodinated contrast is a staple in evaluating many common diagnoses, including stroke, aortic dissection, and pulmonary embolism.

Solutions to Supply Chain Disruptions

Notably, the iodinated contrast shortage brought to light both vulnerabilities in the health care system and solutions to address them. For example, the need for supply chain redundancy was demonstrated by several Boston hospitals. Boston Medical Center, which purchases contrast dye by Bracco Imaging SpA in Italy, was largely unaffected by the iodinated contrast shortage. On the other hand, MassGeneral Brigham has its iodinated contrast supplied by GE Healthcare, and they had to conserve contrast. This suggests that having redundancy in suppliers, and their respective supply chains, can ameliorate shortage issues with any one supplier. Other solutions implemented during this supply shortage are: repackaging contrast dye in smaller amounts, postponing nonemergent outpatient imaging studies that require contrast, triaging the use of contrast dye for the most ill patients, and switching from fixed to weight-based dosing of contrast media.

When considering potential solutions to supply chain challenges, we advocate choosing solutions that support our teams rather than those that demand more time and resources exclusively from emergency medicine. In our specialty, we are trained to solve any problem as quickly as possible in any potential circumstance. We take pride in our ability to do this without sufficient resources, and our institutions, administrations, and teams know this. If the COVID-19 pandemic has taught us anything, it is that proudly hurdling every obstacle thrown at us alone is exhausting and ultimately unsustainable for our teams. Before we ask them to make one more change, we must make sure that we call on all resources available to us, not just ourselves.

Every institution has at least one individual, likely a team, to manage supply chain issues. Request transparency to your entire institution if there is a shortage of a particular item. Nurses, residents, and attendings should not spend their time on shift addressing why their department does not have an essential item if the reason for its absence is that the institution is unable to obtain it. Emergency physicians should demand notification of upcoming shortages as soon as a shortage is anticipated. Early warning allows for multidisciplinary collaboration on solutions and reduces conflict during clinical care that can impact both patient care and staff experience. We are grateful for experts in supply chain management that diversify and broaden our number of suppliers, communicate inevitable challenges as early as possible, and respond to requests for transparency. We implore emergency medicine administrators to tap into this resource and amplify awareness and utilization of these resources.

Other solutions might include using EMR tools and other departments, such as clinical pharmacy, to develop automated solutions that can be communicated and implemented when these shortages arise. Not enough of a particular form of lidocaine? Your clinical pharmacy team can change the order preferences in your EMR or respond at the point of order verification in the EMR to replace the order with the readily available alternative. While this might not eliminate our annoyance at a change to our clinical practice, it will certainly be a superior solution to our nurse trying to pull the ordered medication and requesting our involvement to change the order to what we have available.

Once a shortage is identified, the responsibility for remaining informed and reducing use is shared. These reductions impact our team much differently when paired with transparency, shared institutional awareness, and support. Emergency medicine administrators have an opportunity to gain support for these requests for personal action and for themselves when they partner with all impacted departments and those responsible for managing supply chain issues. Emergency medicine physicians will continue to practice extreme ownership of our patients and our clinical care. For the good of our teams, we must also request assistance and partnership from others when a problem that is not ours to own, in this case supply chain shortages, threatens patient care and staff experience.

ABOUT THE AUTHORS

Dr. Kravitz is chief resident at Beth Israel Deaconess Medical Center Harvard Affiliated Emergency Medicine Residency.

Dr. Hunt, an assistant professor of emergency medicine at Wake Forest University School of Medicine, serves as medical director for the Adult Emergency Department at Atrium Health Wake Forest Baptist Medical Center.

Dr. Huang is the PGY3 Chief Emergency Medicine Resident at Ocala Regional Medical Center in Florida.

Dr. Davis is a second-year emergency medicine resident at Emory University.