Health care workers, and anesthesia providers specifically, had likely never given much thought to supply chains until the start of the COVID-19 pandemic. As the world shut down, and we shifted our practices to emergency procedures, careful intubations, and ventilator management, our televisions were inundated with images of bare shelves in the supermarkets, with shoppers suddenly hoarding home essentials such as toilet paper and disinfectant wipes. Since that time, disruptions in the supply chain have affected consumer goods such as semiconductors, computer chips, and infant formula.

Medical devices and medications have experienced supply chain issues that existed before the tumult of the last several years. A national shortage of propofol occurred in 2010 that caused anesthesia providers to quickly shift to alternate induction agents. This shortage was attributed to two major problems. The first was manufacturer hesitancy to make drugs with high liability risk, following a court ruling that held Teva Pharmaceuticals liable for the inappropriate and unsanitary use of propofol, which led to an outbreak of hepatitis C (Am Health Drug Benefits 2013;6:171-5). The second was noncompliance with the FDA's good manufacturing practices, which led to closure of manufacturing facilities as well as quality assurance and regulatory issues (Am Health Drug Benefits 2013;6:171-5). A limited number of manufacturers further hampered supply availability, with only three companies (Teva Pharmaceuticals, Hospira, and APP Pharmaceuticals) making the drug in 2009 (N Engl J Med 2010;363:806-7).

It is also important to note the effect that pricing has on drug availability. With a narrow profit margin, there is little incentive for manufacturers to traverse a complex and costly regulatory process to gain approval. Consequently, fewer manufacturers are available to produce these medications, potentially leading to a price spike when there are only one or a few available in the market. Lower-priced generic drugs are therefore often found to be at elevated risk for shortages, resulting in cost increases (Value Health 2018;21:1286-90).

Procurement of both medications and medical devices is a complicated process that involves numerous stakeholders in both hospitals and outpatient surgical center settings. The health care supply chain often depends on the use of group purchasing organizations (GPOs), which are alliances of health care organizations that enable the creation of economies of scale, allowing for improved negotiation on rates, as well as other benefits such as value analysis, predictive analytics, process efficiency, and clinical/safety improvement (Health Care Manage Rev 2020;45:186-95). GPOs, however, may be controversial organizations, acknowledged for their benefits in cost efficiency, estimated to be tens of billions annually, but also drawing criticism for potentially contributing to drug shortages (JAMA 2019;321:1729; JAMA 2018;320:1859-60).

Nonetheless, health care systems remain susceptible to medical device and medication shortages for a variety of factors. The practice of anesthesiology is also uniquely positioned to feel the impacts of disruptions of the health care supply chain due to the varied use of equipment and drugs for daily practice. Recent shortages have affected anesthesia supplies of seemingly every form and shape. At University Hospital in Newark, New Jersey, clinicians in recent months have experienced backorders and shortages of forced air warmer blankets, fluid warming intravenous tubing, and carbon dioxide absorbent canisters for anesthesia workstations.

Each deficiency required different solutions. The shortage in forced air warmer blankets necessitated the use of alternate supplies, such as using a lower-body blanket on the upper body or using an under-body blanket when a practitioner would normally use another modality. As those supplies dwindled, the system purchased more Bair Hugger flex warming gowns and shifted their use more broadly, whereas they were previously limited to patients in our Enhanced Recovery After Surgery pathway. The disappearance of fluid warming I.V. tubing required the abandonment of an entire fluid warming system, necessitating the placement of a new device in each OR and completely different tubing that was more easily procured. The dearth of carbon dioxide absorbent canisters led the hospital to source the supplies from seven different merchants, many of which needed expedited approval as hospital vendors to ensure timely availability.

On one recent day, the following items were unavailable or in limited supply in the ORs at University Hospital: arterial line extension tubing, atropine syringes, continuous epidural kits, disposable videolaryngoscope blades, laser endotracheal tubes, bupivacaine for spinal injection, adult oxygen masks, flexible suction catheters, and supplies for intravenous rapid infusers. The government of Canada recently issued a warning via its health service to health care providers regarding a critical shortage of epidural catheters, which has also been covered by mainstream news outlets like CTV News and NBC's Today show (asamonitor.pub/3S6b3FQ; asamonitor.pub/3T34m93; asamonitor.pub/3MBhGiy). How did this predicament become a seemingly constant occurrence? The procurement of medical devices and medications depends on a global supply chain that faces numerous points of vulnerability from manufacturer to the end user.

“The practice of anesthesiology is also uniquely positioned to feel the impacts of disruptions of the health care supply chain due to the varied use of equipment and drugs for daily practice. Recent shortages have affected anesthesia supplies of seemingly every form and shape.”

Manufacturers face a number of potential risks to disruption of operations, including geographic concentration of factories, limited numbers of manufacturers, and scarcity of source materials (BMJ Qual Saf 2021;30:331-5). Unique vulnerabilities are also present throughout the remainder of the supply chain; for example, GPOs are susceptible to quality control and vetting of medical devices and timely negotiation with manufacturers to secure the health care required goods. Health care devices and medications then move from GPO to hospital system, where stresses include the need for accurate predictive forecasting, poor inventory management systems and unclear delineation of responsibility for ordering and monitoring supplies. When the supply chain reaches the anesthesiology department, concerns such as budget management and the stocking of rarely used items also become factors. Also, in recent years, the utilization of just-in-time inventory management systems has enabled a more cost-effective supply chain, reducing overstock and waste; but this approach requires a robust and reliable procurement system and leaves the end user, or health care provider, vulnerable when items are not immediately available for reorder (Anesth Analg 2000;91:337-43). The flow of goods throughout the supply chain are also affected by limitations on cross-border movement or regulatory compliance failures. See the Figure for additional vulnerabilities to supply chains.

Figure: Sample supply chain for health care systems including components and potential vulnerabilities for each node.

Figure: Sample supply chain for health care systems including components and potential vulnerabilities for each node.

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Anesthesiology departments and providers should take steps in conjunction with their respective internal supply managers and/or anesthesia technicians and health care system procurement systems to prepare contingencies for supply chain disruptions and to mitigate ongoing concerns for shortages. These steps may include improving communication between supply chain points for potential disruptions in supply, maintaining reserve inventory at facilities, backup plans to secure items from nearby health care facilities, and maintaining lists of alternate suppliers for certain essential devices or medications. See the Table for additional mitigation strategies.

Table: Considerations for health care leaders to attenuate potential risks to the supply chain affecting medical devices and drugs.

Table: Considerations for health care leaders to attenuate potential risks to the supply chain affecting medical devices and drugs.
Table: Considerations for health care leaders to attenuate potential risks to the supply chain affecting medical devices and drugs.

Although the health care supply chain remains an ongoing concern for facilities and providers, numerous steps can be taken to mitigate the risks to patient care. It is essential for anesthesia providers to be educated on this topic and for departmental leaders and stakeholders to assess individual needs and vulnerabilities to decrease their potential susceptibility to disruptions that can affect patient safety and clinical care.

George Tewfik, MD, MBA, FASA, Associate Professor and Director of Quality Assurance, Department of Anesthesiology, Rutgers-New Jersey Medical School, Newark, New Jersey.

George Tewfik, MD, MBA, FASA, Associate Professor and Director of Quality Assurance, Department of Anesthesiology, Rutgers-New Jersey Medical School, Newark, New Jersey.

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Samuel Mark Paschall, Chief Anesthesia Technician, University Hospital Newark, Newark, New Jersey.

Samuel Mark Paschall, Chief Anesthesia Technician, University Hospital Newark, Newark, New Jersey.

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