Lessons learnt from medicines crunch amid coronavirus
As we stand in mid-June 2020 it is not yet clear if we have sidestepped the worst of the coronavirus pandemic. Our growing optimism suits the human condition, and is bolstered by the assumption that any future cases will benefit from the rapid preparations of the last few months, through which the threat of acute COVID-19 cases drove laser-focus on readying Australia’s healthcare system in response.
From the outset of this pivot, hospitals and the important roles of healthcare professionals have certainly been recognised, while an increased interest in some areas of health care such as personal protective equipment (PPE) and access to ventilators have burst onto the scene. However, other essential factors such as access to medicines have been slow to catch up.
Counterintuitively, when urgent decisions were made regarding expanding ICU beds and importing ventilators, the need for specific medicines that make patients unconscious and comfortable during intubation was not flagged. For our members, this has resulted in extreme concern as hospitals aimed to increase ICU bed capacity by up to 250%.
In the Australian medicines market, public and private hospitals were put under significant pressure as they ramped up their requirements for medicines such as propofol and neuromuscular blockers needed to treat thousands of additional patients. As only 2% of the international market for medicines, Australia does not command huge attention for key manufacturers that are mainly based in Asia and Europe — areas facing their own severe pandemic challenges.
Over recent decades, Australian hospitals have grown increasingly reliant on ‘just-in-time’ supply — often multiple orders weekly — of key medicines. As soon as larger orders to support a greater number of beds started to appear, manufacturers halted them.
To help clarify the implications for planned ICU bed capacity as national COVID-19 preparations continued, The Society of Hospital Pharmacists of Australia (SHPA) conducted a series of weekly online surveys to quantify information about medicine demand and supply.
An early disconnect was evident when SHPA members reported that 80% of propofol orders, a drug essential to the intubation of ICU patients, were not being supplied in full in mid-April, although this has since improved gradually. Other medicines, such as key neuromuscular blocker cisatracurium, remained difficult to obtain across the April/May period, with 63% of orders reported as either unable to be placed or on back order.
Regional, rural and remote hospitals faced a particularly difficult challenge as their orders were less likely to be provided in full, and interruptions to transport and logistics made delivery more uncertain. Given that 43% of the hospitals who advised they were treating COVID-19 patients were in regional, rural and remote locations, these combined challenges could have had a much worse impact.
While there is no reason to believe these shortages came to impact on care in any way, the fact they remained prevalent indicates greater efforts are needed to safeguard Australia’s medicine supply in case of a pandemic. The experience of preparing for a surge in COVID-19 patients also highlights the need for strategic medicine reserves to contain medicines for standard medical use, rather than only medicines for unusual events, such as vaccines. Greater information about strategic reserves at federal and jurisdictional levels, and how to access them if required, would also prove beneficial to hospitals, rather than seeking to address systemic problems on a unilateral basis.
The interruption to medicine supply was also felt in community pharmacy settings when the community swarmed pharmacies to get their frequently used medicines for asthma, heart disease and other chronic conditions. An unexpected spike in demand for hydroxychloroquine resulted in significant inconvenience for long-term patients with autoimmune conditions such as rheumatoid arthritis. These complications reflect the unusual policy and regulation environment for medicines in Australia, where the key paradigm for discussion of medicines is typically related to their trade terms.
As the immediate threat of COVID-19 appears to recede it is important to rebuff dismissive reflection; coronavirus was in no way ‘unprecedented’. Instead, we should use our shared recent experience as an opportunity to learn and build future preparedness plans that truly cover every contingency.
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