Humans have a tendency to take things for granted until they experience a shortage or interruption in supply. Who thinks about the electrical grid until their lights won’t turn on? Or about the water flowing from the faucet until it comes out discolored, or not at all? This common pattern of thinking extends to our daily practice as anesthesiologists as well. Do you often think about how the endotracheal tube made its way into the anesthesia cart from the manufacturer? Who made the decision to buy this particular brand, in this amount, and in these particular sizes? Did it just magically appear here?
Although materials shortages are rarely on our mind until a crisis presents itself, it seems that every day there are seismic disruptions in national supply chains that can easily trickle down and affect daily anesthetic care. In late February 2023, for example, Akorn Operating Co. – one of only two domestic producers of liquid albuterol – suddenly ceased its operations (asamonitor.pub/40D5nrg). Nephron Pharmaceuticals, the only remaining supplier, reported that its albuterol formulation was on back order, though it hopes to return to normal levels in the spring. In January 2023, it was reported that numerous shortages are also affecting local anesthetics, with Pfizer, Fresenius Kabi, Eugia, and Hikma Pharmaceuticals reporting bupivacaine shortages, and Amphastar Pharmaceuticals, Pfizer, and Fresenius Kabi reporting lidocaine backorders (asamonitor.pub/3Hiky2b).
Whose job is it to ensure that an anesthesiology department has the local anesthetic they need for regional anesthesia or neuraxial blockade, or a critical respiratory medication? Decisions about supply chains are made by a variety of personnel and can differ greatly between health care facilities. Supply chain management is often the purview of materials management or a procurement department in a large institution or hospital system. With divisions in labor common, however, there can be confusion regarding ownership of ensuring that a vital piece of equipment or a medication is available when needed. For example, while the pharmacy may be responsible for ordering and stocking all medications in one institution, in another, they may only be responsible for controlled medications, such as opiates and benzodiazepines. The onus of responsibility to order and stock emergency medications, paralytics, induction agents, and inhaled anesthetics may fall upon other personnel like anesthesia technicians.
Anesthesia technicians are integral members of the anesthesia team and often are responsible for essential components of the perioperative supply chain. There are three main categories: certified anesthesia technologists (CerATT), certified anesthesia technicians (CerAT), and noncertified anesthesia technicians. According to their collective professional society, the American Society of Anesthesia Technologists and Technicians (ASATT), their main goal is to “assist licensed anesthesia providers in the acquisition, preparation and application of the equipment and supplies required for the administration of anesthesia” (asamonitor.pub/3HBs091). In addition to being invaluable members of the care team by assisting in the maintenance and preparation of OR equipment, anesthesia technicians are trained in supply chain and materials management. They may be directly responsible for equipment and medication acquisition, or they may work in tandem with a facility’s pharmacy, procurement, or materials managers to complete this crucial task.
Nonetheless, despite their incredible value to the successful and efficient deployment of anesthesia resources, the anesthesia technician field suffers from a dearth of training and certification programs, though the numbers are rapidly improving. In 2019, according to the ASATT, there were only three nationally accredited CerATT programs, but that number has increased to 11 in 2023. The anesthesia technician field has shown tremendous demand, with double-digit growth in recent years, including a 19% year-over-year increase in the number of certified technologists in 2021 (asamonitor.pub/41WetAh). The ASATT has approximately 1,600 members nationally, and due to the huge demand for credentialed providers, the organization has developed a Practical Experience Pathway to allow for certification of experienced technicians.
With a complicated and convoluted process in place for ordering medications and equipment, it is vital for anesthesiology leaders to identify the personnel involved in procurement and sourcing for perioperative supplies (Figure). When this process involves anesthesia technicians, one should determine which supplies these care team members are responsible for. At our home institution, University Hospital in Newark, New Jersey, anesthesia technicians are responsible for ordering and stocking medications, with the exception of controlled substances, in all locations. This includes all emergency medications, such as cardiovascular agents, as well as local anesthetics, intravenous fluids, etc. They are responsible for determining the thresholds for reordering based on usage, sourcing of medications, and refilling medications in anesthesia workstations in the ORs, anesthesia carts for remote locations, and the perioperative central supply room. Controlled medications are refilled separately and tracked by the pharmacy. This kind of division causes confusion, especially late at night when an anesthesiologist is looking for a medication that has already run out. Calling the pharmacy to replace a vasopressor is futile; conversely, the anesthesia techs cannot refill controlled medications.
The division of labor is often also confusing when it comes to durable and disposable anesthesia equipment. At University Hospital, anesthesia technicians order equipment such as fiberoptic bronchoscopes and videolaryngoscopy handles, but disposable items such as endotracheal tubes and intravenous angiocatheters are ordered by materials management and restocked by their representatives. Things get even more complicated when discussing shortages or items that are on backorder. While most items ordered have to be assessed by a value analysis committee (to ensure the financial and patient safety benefit of a medical device) and purchased through a group purchasing organization (GPO), anesthesia technicians at our home institution can circumvent the traditional procurement process in an emergent situation by seeking emergency authorization to purchase critical items directly from suppliers.
A rapidly changing landscape with respect to availability of medications and equipment requires novel approaches to ensure uninterrupted patient care of the highest caliber in the OR. Critical to that success is for anesthesia leaders to ensure accountability and clear lines of communication regarding equipment and medications. It should be clearly delineated which health care workers monitor and reorder each medication or piece of equipment. Though it is preferable to have as much of that responsibility “in-house” with their departmental anesthesia technicians, a shortage in certified techs may cause out-sourcing to administrators, materials managers, etc. Without a centralized figure, such as the anesthesia technician who can coordinate procurement and monitor for shortages (for items ordered either within their own department or by another hospital or health care facility department), anesthesiology departments should identify an equipment “champion” or coordinator to ensure uninterrupted supply.
Anesthesiologists and anesthesia providers should be empowered to notify anesthesia technicians or the anesthesia “champion” regarding critical supply shortages or the need for additional supplies or medications. If, for example, a new type of surgery or a new surgeon will require a special endotracheal tube (such as a laser tube), the chain of command regarding this decision should allow for a timely and frictionless procurement. When formulations of medications change, and there is an increased risk posed by confusing vials due to similarities in their labelling, there should be a clear notification system in place to ensure safe medication handling by frontline clinicians. This may include sending out an email with pictures of the medications or creating flyers that are posted in clinical sites or public locations to inform anesthesiologists of the problematic changes. When backup equipment or medications are deployed due to shortages, anesthesiologists should also be informed to prevent frontline confusion at the patient’s bedside. For example, if the institution’s regional anesthesia or epidural kit normally comes with all required instruments for a procedure (ultrasound probe cover, local anesthetic, etc.), but emergency kits do not include these items, patient care may be compromised without timely communication.
With no end in sight to regular disruptions in supply chains for medications and medical equipment, anesthesiologists and anesthesiology departments should be empowered to anticipate potential shortages, identify relevant stakeholders at their home institutions, and communicate effectively to all clinicians regarding acute changes. Effective leadership, and ownership of the process, is essential to weathering the storm caused by critical shortages with minimal to no deleterious sequelae to patient safety and perioperative efficiency.