EMTs and paramedics administer numerous drugs, like epinephrine for anaphylaxis, albuterol for asthma, and nitroglycerine for chest pain, to treat life-threatening medical conditions and relieve patient pain. The administration of those drugs is governed by scope of practice rules or statutes and medical director-approved protocols.
The decisions of which drug formulations or brands to purchase, where to purchase drugs from and what volume of drugs to purchase are likely collaborative decisions made between the EMS agency operation’s director and medical director. Making those decisions requires the input of field providers and the analysis of patient care data. Here are the important questions to answer when purchasing EMS drugs.
Which drugs can a medical first responder, EMT or paramedic administer?
The drugs administered by medical first responders, EMTs and paramedics are determined by the providers’ state scope of practice. A paramedic in Wisconsin might have a larger formulary than a paramedic in Texas. An EMT in Pennsylvania may have two choices to treat hypoglycemia – oral dextrose or Glucagon – compared to an EMT in a neighboring state who may only have a single choice.
A state EMS authority or regional EMS authority likely maintains a drug formulary, which is the list of approved drugs for EMS providers in the authority’s jurisdiction. Depending on the state or region, the drugs on the list are reviewed and updated regularly
Who selects the drugs an EMS provider can administer?
An EMS agency’s medical director is responsible for authorizing drug administration through protocols, and authorizing certified and trained providers to practice under the medical director’s license. Administration of a specific drug is matched to a patient care protocol. A specific protocol is applied based on the patient assessment, which identifies:
- Associated signs and symptoms of the illness or injury
- Pertinent negatives of the illness or injury
- Contraindications for the drug
- Indications for the drug
For example, nitroglycerin is indicated for a patient with chest pain, a systolic blood pressure great then 90 mm Hg, and no recent use of a phosphodiesterase inhibitors, like Viagra. If a contraindication exists, such as a systolic blood pressure of 76 mm Hg, nitroglycerin is contraindicated and not administered.
Drug information, either in line with specific protocols or as an appendix, is available for each drug providers are authorized to administer. The common medication information is:
- Concentration
- Administration routes
- Initial dose
- Repeat dose, if applicable
Who collaborates with the medical director to select a drug for the EMS formulary?
A team approach is used to evaluate the drugs already on the formulary, as well as selecting drugs to add to or remove from the formulary. Use a multidisciplinary team, including these representatives, to make formulary changes:
- Medical director
- Operations director
- Intensive care or emergency medicine pharmacist
- Educator or training officer
- Field supervisor
- Field staff
The multidisciplinary team, through a structured research and discussion process, could:
- Identify the preferred benzodiazepine for a patient having a seizure
- Update an ingested poison protocol to remove activated charcoal
- Evaluate the delivery of bag-valve mask ventilations while naloxone is prepared for administration
- Create a plan for when the agency would allow administration of expired medications
What are triggers to adjust the EMS drug list?
An EMS agency’s drug list, usually as part of an annual or every-other-year protocol review, can be adjusted for several reasons. The top reason to adjust a drug list is the availability of new evidence about a drug’s efficacy published in a peer-reviewed medical journal. Evidence-based medicine can also inform decisions to remove a drug from a formulary or narrow its indications for use.
Research: For example, in the last decade, the efficacy of tranexamic acid has been researched in the combat casualty care provided to soldiers with severe hemorrhage in Iraq and Afghanistan. The research on TXA has led to increased interest in administering the drug as part of civilian trauma care.
Ketamine is another drug that has seen an expanded list of indications in the last decade. Some paramedics now have protocols to administer ketamine for pain management, sedation for behavioral emergency or as an amnesiac for airway procedures.
There have also been significant changes to the medication types, doses and frequency of additional doses included in the advanced cardiac life support algorithms. A long-time paramedic has seen antiarrhythmic choices expand and contract in the last 20 years.
Price and availability changes: A drug’s price and availability can also play role in its purchase and use. Drugs, like nearly any other product, obey the laws of supply and demand. If supply is limited through changes in manufacturing, quality problems or even natural disaster, not only is the drug’s price likely to go up, but EMS services and their medical directors are likely to go searching for new vendors of the same drug, alternative concentrations of the drug, alternative administration routes for the drug, or entirely new medications to administer instead of the drug which is in short supply.
A nationwide shortage of EpiPens, used to treat anaphylaxis, led many EMS agencies to search for alternatives to the expensive auto-injector. Many operations directors and medical directors developed injection protocols and trained personnel in how to draw 1:1,000 epinephrine from an ampoule and administer 0.3 mg with a syringe. Several pharmaceutical vendors responded to the EpiPen shortage and newly revised protocols for anaphylaxis treatment by selling epinephrine injection kits.
Increased use: Narcotics overdoses have dramatically increased as the opioid epidemic has worsened in the last 10 years. As the epidemic rages, EMS agencies, as well as police and fire departments, have determined that naloxone can be administered by basic life support providers through intramuscular injection or intranasal spray. Pharmaceutical companies have responded with new devices and kits to meet the increased demand for easy-to-administer naloxone.
Mitigate drug diversion risk: EMS agencies are at risk of staff who divert or steal drugs, especially narcotics, for personal use or illicit sale. A drug formulary might be adjusted to mitigate risks of drugs being diverted from the EMS agency. Some of those actions might include purchasing:
- A smaller volume of the drug
- A lower concentration of the drug
- Medications with less diversion risk
- Drugs with increased tamper-resistant packaging
Risk mitigation needs to be balanced with the ongoing need to treat a patient’s acute pain from traumatic injury. Purchasing actions are one-leg in a three-legged stool, which also includes monitoring and secure storage to mitigate the risk of diversion.
How is an EMS drug inventory managed?
EMS agency drug purchasing is complicated by factors that are unique to the prehospital care environment. Unlike an emergency department or intensive care unit, an EMS agency needs to:
- Store drugs in multiple places – stations, ambulances, quick response vehicles, fire apparatus and first-in bags.
- Frequently move drugs from the ambulance to the patient’s side and back to the vehicle.
- Protect drugs from severe fluctuations in ambient temperature.
- Make drugs available to providers who may not actually administer the drug during their shift.
- Monitor a drug’s expiration date through regular rig or vehicle checks.
A drug with a short shelf-life, infrequent indications for use, high price and narrow temperature range for safe storage isn’t likely to be adopted by EMS. The ideal EMS drug is:
- Easy to store
- Impervious to extreme temperatures
- Cheap to purchase
- Convenient to re-order
Read more about EMS inventory management.
What’s the role of quality improvement in EMS drug purchasing?
An EMS agency’s quality improvement program needs to include data collection and analysis of drug administration. Use data from electronic patient care reports to inform ongoing protocol updates and topics to cover in continuing education programs. These are a few of the data points that might be relevant to drug administration and purchasing:
- Frequency of drug administration
- Adherence to protocol for drug administration
- Difficulties encountered administering a drug
- Adverse patient reactions to the drug
- Education needed to safely prepare and administer a drug
Make sure to include the volume and cost of drugs that expire before administration in the quality improvement program. Unused inventory can represent a major expense for an EMS agency. Use inventory control and purchasing methods to limit drug supply to meet regulatory requirements and the likely amount to be administered in upcoming shifts, weeks or months.
Drug usage statistics from a quality improvement program can be compared to purchase records to monitor for irregularities, increasing administration or declining use. Drug use stats may signal:
- Change in a drug’s shelf life
- Excess waste in the field
- Diversion or theft
- Worsening influenza or opioid epidemic
How are EMS drugs procured?
Select an EMS drug vendor that is best suited to the agency’s patient volume, provider scope of practice and the emergencies most frequently encountered. An EMS agency serving a winter vacation destination in the mountains is likely to regularly administer pain medications for musculoskeletal injuries. An EMS agency serving an industrial community with lots of older citizens is more likely to frequently treat the chronic diseases of aging like diabetes, heart failure and COPD.
Drugs are purchased by EMS agencies in several ways:
- Single distributor: Individual agency purchasing from an EMS distributor
- Group purchasing: Multiple agencies participating in a regional or group purchasing contract from a single vendor
- Membership pricing: A cooperative, representing dozens or hundreds of agencies, negotiating pricing for drugs on behalf of its members
Some agencies enter into agreements to resupply drugs through the hospital systems patients are transported to. The EMS agency leverages the volume pricing the hospital obtains and shifts the burden of inventory management and purchasing to the hospital pharmacy.
What is the medical director required to sign?
The EMS agency medical director needs to sign a physician authorization to purchase. Many vendors will make an electronic version of this form available for ease of use. Purchasing controlled substances also requires completion of Drug Enforcement Administration paperwork, specifically DEA form 222.
The Protecting Patient Access to Emergency Medications Act of 2017 amended the Controlled Substances Act of 1970 to include DEA registration for EMS agencies, approved uses of standing orders, and requirements for the maintenance and administration of controlled substances used by EMS agencies. Every EMS medical director and operations director needs to understand and comply with PPEMA requirements for EMS use of controlled substances. Changes were made in these areas:
- DEA registration for EMS agencies
- Use of standing orders for controlled substances administration
- Storage of controlled substances in the registered location, unregistered locations and EMS vehicles
- Restocking EMS vehicles at hospitals with controlled substances
- Maintenance of controlled substances records to meet the requirements of the Controlled Substances Act
- EMS agency liability for proper use, maintenance, reporting and security of controlled substances rather than the EMS medical director
How can an EMS agency prepare for a drug shortage?
Make sure to understand the purchasing options available to your agency before you face a drug shortage, demand surge or vendor change. Here are five important questions to answer before a drug shortage:
- What is your vendor’s policy for communicating to customers about drug shortages?
- How will your vendor work on your behalf to find drugs during a shortage?
- How will neighboring agencies assist one another if a drug becomes scarce?
- Will your state make emergency modifications to the amount of a drug that EMS is required to stock if there is a shortage?
- Will your agency medical director or state medical director authorize EMS providers to administer expired medications?
Why are relationships important to EMS drug buying?
Relationships always matter. Regardless of the product, nature of the purchasing relationship or the supply and demand, these things always influence a purchasing decision:
- Price of the product or service
- Ease of purchasing
- Customer service
- Customer references
Compare prices during annual budgeting or monthly repurchasing. Know the options available to your agency and make sure to check with references about customer service, delivery expediency and billing practices before picking a new drug supplier. Jumping from vendor to vendor might save an EMS agency a few dollars in the short run, but building a long-term relationship with a vendor you know and trust is critical to ensuring product is available and your agency is insulated, to some degree, against wild price and inventory fluctuations.
What are your suggestions for purchasing EMS drugs? What types of purchasing arrangements have worked well for your service? Leave a comment below or email products@ems1.com with your feedback.
