Mask shortage straps pharmacists who need them to keep medicines pure

Reviewed by James Ives, M.Psych. (Editor)Mar 20 2020

Pharmacy staff who prepare IV drugs inside hospitals are the latest health care workers decrying a shortage of masks as they scramble to prepare medications for patients with everything from cancer to COVID-19.

The staffers wear surgical masks while preparing liquid medications injected into patients' veins to avoid breathing any droplets of saliva into the formulas, a crucial step in ensuring the medication remains sterile. Pharmacists are also in need of N95 masks to protect them as they counsel patients at hospitals — but tend to be behind front-line medical providers in line for protective gear.

The American Society of Health-System Pharmacists surveyed about 400 members about the shortages.

"I can tell you we had some very concerned members who indicated that they're in danger of running out," says Michael Ganio, a pharmacist and director of pharmacy practice and quality with the pharmacists’ group. "Over half said their institution has implemented a conservation plan. It's something that's very concerning."

Medications that require sterile preparation include those needed for treating COVID-19 patients, such as medications to calm, sedate or paralyze patients on a mechanical ventilator. Other such medications could supply IV nutrition or boost the blood pressure of patients who develop sepsis or shock.

Geriatric and pediatric patients are also frequent recipients of sterile compounded medications because they need doses tailored to their weight or have age-related health problems that require specially made medicine they can tolerate.

The survey of hospital pharmacists, released Thursday, found that 15% of them have already seen a "major or moderate" disruption in surgical mask supplies. That meant they went without masks or used alternatives with "mixed or poor" results.

Nearly 20% of them reported that mask prices were marked up compared with December 2019. And 70% of pharmacists said their organizations had already implemented plans to conserve masks.

To be sure, these conservation efforts are more optimal for pharmacists, who use masks to preserve a sterile environment, than they are for front-line COVID-19 clinicians working in a contaminated environment.

University of Utah Health Hospitals are still receiving masks. But pharmacists are reusing masks for sterile drug preparation to conserve them for other staff members and patients who need them during the outbreak, said Erin Fox, senior director of drug information and support services at the University of Utah Health Hospitals.

"That will allow more PPE [personal protective equipment] to be available for front-line emergency department folks that need it way more than we do," she said, adding that there's guidance on how to safely reuse masks.

A tornado that cut through Tennessee this month is making things even more complicated in the state, said Mark Sullivan, the executive director of pharmacy operations for Vanderbilt University Hospital and Clinics in Nashville. That's because it damaged a warehouse that held hospital supplies.

"We are able to get masks," he said. "Given the tornado and coronavirus situation, they are obviously in short supply in our area."

Vanderbilt University Hospital and Clinics are also following guidelines for conserving masks and other personal protective equipment, like gowns and gloves, as demand has spiked, Sullivan said.

"It's just a tough situation we’re all in, trying to make sure front-line folks have what they all need," he said. "And behind the scenes, we're just trying to make sure we have what we need to make safe products for patients."

Before coronavirus became a reality, pharmacists at NYU Langone Health used to change masks and gowns when they went out on break. Now, if that gear isn't soiled, they hang it up in a clean room and reuse it, said Arash Dabestani, the hospital's senior director of pharmacy. His team is also keeping all personal protective equipment in an electronically locked cabinet to control use.

For weeks, hospitals have been getting fewer masks than they ask for from their suppliers. Health care facilities were getting only 44% of the N95 masks and 82% of the surgical masks they ordered, according to a survey released March 2 by Premier, a group-purchasing organization that procures supplies for 4,000 U.S. hospitals and health systems.

Most of the masks sitting in hospitals are redirected to front-line staff who care for patients, said Soumi Saha, a pharmacist who is senior director of advocacy for Premier Inc.

Saha said many state laws require pharmacists to wear masks when mixing sterile compounds. Her fear, she said, is that if the mask shortage is dire enough, hospitals will move to an unregulated way to get those crucial medications to patients: bedside compounding.

That means that clinicians such as nurses would mix the medications right in the patient's room and put them straight into an IV, she said. She worries such a sudden shift means "we could start seeing a surge in unfortunate patient medication errors and patient harm."

Premier has asked the federal government to waive the state requirements on pharmacists wearing medical masks to mix compounds or allow them to use industrial masks or expired ones, Saha said.

For now, the choice is up to individual states, said Carmen Catizone, executive director of the National Association of Boards of Pharmacy. He said the national standards-setting organization that advises state boards, called USP, has urged states to make their own risk assessments when weighing whether to waive rules.

So far, California, Iowa and Connecticut have made moves to relax the rules for pharmacists' personal protective equipment.