Anesthesiologists Face Increasing, More Routine, Equipment Shortages

In July and August 2022, an increasing number of anesthesiologists began to notice potential and actual shortages of their preferred epidural kits. Although most anesthesiologists did not have to find substitutes for their kits, a significant number of anesthesiologists nonetheless sounded the alarm that this equipment shortage could affect, to some extent, the quality of care they delivered. Epidural kits were just one of many products and equipment that anesthesiologists experienced in short supply in 2022.

Equipment shortages were more of an issue for anesthesiologists, manufacturers, and federal stakeholders during the COVID-19 pandemic. In March and April 2020, anesthesiologists and their groups, as well as hospitals and other front-line health care workers, experienced acute shortages of personal protective equipment (PPE) and many other supplies brought upon by a perfect storm of a pandemic, outdated regulatory barriers, and manufacturing challenges. To assuage the shortage, the Centers for Medicare & Medicaid Services (CMS), the National Institute for Occupational Safety and Health (NIOSH), and the Food and Drug Administration (FDA) relaxed certain requirements for reusing PPE, notably N95 respirators, but stopped short of issuing guidance on reusing other equipment like reprocessing single-use laryngoscopes. The FDA expedited substitute product approvals and was more liberal in its emergency use authorization protocols. COVID-19 also forced federal authorities to rethink the Strategic National Stockpile and enhance the role that the Administration for Strategic Preparedness and Response (ASPR) and other lesser-known federal agencies had in health care.

Unfortunately, since the start of the COVID-19 pandemic, equipment shortages have become more common. At first, it may have been caused by an increase in elective surgeries that were previously delayed because of COVID-19 precautions. Restarting manufacturing products, untangling a supply chain, and ensuring appropriate regulation with regard to stopping the spread of COVID-19 across global ports all contributed to delays and shortages. Hospital finances and changes to how equipment is ordered and procured also affected the drugs, equipment, and supplies that anesthesiologists use. Although access to PPE improved, other equipment seemed to be in chronic short, or limited supply in anesthesia locations.

In August 2022, ASA launched an equipment shortages survey that asked members to identify the severity of the equipment shortages they were experiencing. The survey was broken into several categories that included anesthesia breathing circuits, central line kits, endotracheal tubes, epidural kits or catheters, I.V. or A-Line catheters, laryngoscope or videolaryngoscope blades, PPE, syringes or needles, and tape or other dressings. Respondents were asked to rank each product on a scale of 1 to 5, with 1 indicating there was no shortage at their facility and a 5 indicating that the product was not available. Although not a scientific survey, at that time, 44% of respondents noted dire shortages in epidural kits, mostly in having to find substitutes for the products they previously used. Fifteen percent of respondents noted short supplies of syringes and needles, while 11% identified I.V. and A-Line catheters as a significant concern.

How anesthesiologists responded to these shortages once again demonstrated the intrinsic role that anesthesiologists play in ensuring patient safety and patient access to anesthesia care and perioperative services. The vast majority of equipment shortages were reported in the in-patient setting, with some shortages found at ambulatory and hospital outpatient locations. By far, anesthesiologists were asked by their hospital administrators to use substitutions or different vendors and then, if substitutes were not available, to prioritize, repurpose, and ration equipment (if necessary). Less than 1% of respondents indicated they postponed a surgery or procedure because of equipment shortages.

The survey also asked respondents if they understood why their product was not available. About 60% of respondents were not given a reason by their purchasing departments or vendors. For the other 40% of respondents, the answers included “back order,” “demand outstrips supply,” “dependent on foreign production,” “distributor issue,” “government regulation,” “incomplete kits,” “manufacturer issue,” “microchip shortage,” “discontinued,” “raw material shortage,” “supply chain issue,” and “unusable equipment.” Unfortunately, each of these responses appears to be correct.

ASA has contacted several manufacturers, hospitals, and physician workgroups to understand the contingencies affecting anesthesia equipment availability. Each product or equipment that an anesthesiologist uses to deliver patient care relies upon an intricate manufacturing system; oftentimes one that relies on a global supply chain. For instance, the Russian invasion of Ukraine and Russia’s cutting of energy supplies to European countries will likely affect how manufacturers in those countries can refine raw materials and produce medical equipment for facilities and anesthesiologists throughout the world. A 2021 winter storm in Texas sidelined resin plants for weeks and continues to limit the amount of resins available that are used to produce plastics found in equipment that anesthesiologists commonly use. Even a short work stoppage at a manufacturing plant can hinder production for weeks, if not months. Manufacturers often fear that changes to equipment, equipment packaging, and other features may require reassessment and approval from the FDA. In short, most equipment shortages have multiple antecedents, and a simple solution or labeling as “supply chain issues” may not fully encapsulate why certain products and equipment are unavailable or in short supply.

Anesthesiologists are not the only specialty working through supply issues. ASA has worked with the American Academy of Otolaryngology-Head and Neck Surgery and American College of Surgeons to bring attention to shortages in tracheostomy tubes for pediatric and adult patients. We have also reached out to FDA supply chain project leads and experts on certain shortages affecting anesthesiologists. Unfortunately, the FDA and other federal agencies may be aware of a shortage but have limited authority in what they can do to assuage the shortage, identify substitute equipment, or engage with the manufacturer. Outside of a very narrow COVID-19 reporting requirement, manufacturers have no obligation to notify the FDA or other entity on current or potential future shortages.

Predicting future equipment shortages is not easy, and anesthesiologists will regrettably need to contend with equipment shortages for the foreseeable future. The ASA Committee on Equipment and Facilities continues to track equipment shortages. To be more effective, the committee invites ASA members to report equipment shortages to the ASA Department of Quality and Regulatory Affairs at qra@asahq.org.