Shortage of Epinephrine Prefilled Syringes: System Supports for Use of Epinephrine Ampoules

CONCERN IDENTIFIED

Paramedics use standardized algorithms, treatment protocols, and medication kits to facilitate the rapid provision of critical care in a prehospital environment.^2-4 There is an increased potential for error when a product’s appearance is different than expected or its intended use changes.

Epinephrine is commonly stocked by paramedicine services in 2 formats: 0.1 mg/mL (1:10,000 or 1 mg/10 mL) in a 10 mL ready-to-use prefilled syringe intended for intravenous (IV) use during resuscitation following cardiac arrest; and 1 mg/mL (1:1,000) in a 1 mL ampoule intended for intramuscular (IM) use to treat patients with anaphylaxis.⁴ During a supply shortage of the prefilled syringes, epinephrine from ampoules can be substituted for use during resuscitation but it must be diluted prior to use (i.e., draw up 1 mL from the 1 mg/mL ampoule and mix with 9 mL of normal saline in a 10 mL syringe to create the 0.1 mg/mL concentration).

Although both formats contain the same total amount of medication (i.e., 1 mg of epinephrine), there may be confusion related to the difference in volume, concentration, and packaging, which may increase the risk of error and delay in treatment.

PROACTIVE SYSTEM RESPONSE CREATED AND SHARED

In response to the recurrent short supply of prefilled syringes of epinephrine, a regional paramedic service created a special operations team to consider strategies to ensure safe medication delivery while still adhering to medication administration guidelines and protocols. The team implemented an innovative approach to out-of-hospital management of cardiac arrest: a dilution kit for restocking purposes whenever the prefilled syringes were not available because of a supply shortage. The dilution kit, packaged in a resealable plastic bag, contained 4 each of the following items: 10 mL syringes, 10 mL vials of normal saline, vial access cannulas, and blunt fill needles (Figure 1). Ideally, the epinephrine ampoules would be bundled together with the dilution components; in this circumstance, and in consultation with end-users, it was decided that the epinephrine ampoules be kept in their usual storage container to protect against breakage.

FIGURE 1. Components of a dilution kit for use when epinephrine prefilled syringes are unavailable.

The logistics section of the paramedic service was instructed to stock both the paramedic response bags and the ambulance cabinets with the dilution kit (Figure 2) whenever there was a shortage of the prefilled syringes. The prepared dilution kit was placed in the same location inside the bag or cabinet as the prefilled syringes would have been. In addition, a 1-page information leaflet explaining the shortage of prefilled syringes, describing the dilution kit and its components, and providing instructions on how to use the dilution kit in combination with an epinephrine ampoule in place of a prefilled syringe, was provided to staff as part of the customary daily briefing. These briefing notes were emailed to staff and were posted on a bulletin board in the common area at work.

FIGURE 2. Components of a dilution kit for use when epinephrine prefilled syringes are unavailable.

Bundling the necessary components and storing the dilution kit where staff would typically access prefilled epinephrine syringes served as a visual cue that dose preparation was required. The team later identified a future improvement opportunity to add a label on the bag listing the kit contents and the instructions for use.

CONCLUSION

Throughout the 6 months that the above strategy was in place to address a shortage of epinephrine 0.1 mg/mL (1:10,000) 10 mL prefilled syringes, there were no reports of medication incidents attributable to the improper use of epinephrine 1 mg/mL (1:1,000) 1 mL ampoules for the management of cardiac arrest. The approach to prepare a dilution kit containing the necessary components and to incorporate it into usual restocking procedures minimized workflow disruption while improving medication safety. System-focused solutions like this one are key to managing medication shortages that result from inconsistent delivery or supply.