Brother, Can You Spare an Ensure?

One constant reminder that we're still dealing with an active pandemic is the supply chain. This chain which appeared to work almost seamlessly to me prior to COVID19 now has plenty of gaps. From not getting in products quickly to not getting them in at all, it's a struggle to get the supplies that you need in healthcare. In our foodservice department, my director has had to go to many large box stores to get plastic silverware or food items such as graham crackers for our patients. While these items may seem like small potatoes, not having them causes significant frustration for patients and healthcare staff.

What's equally as bad or possibly even worse is not being able to get the enteral feeding formulas and oral supplements that we give our patients. I was used to being able to place an order online and have it delivered three days later, maybe four if I ordered right before the weekend. I took for granted that these items would arrive promptly. In fact, in two years, I only had to overnight items one time. Then came COVID19. Suddenly, my items are taking 50% longer to arrive, if they arrive at all.

What's a Dietitian to Do?

Every few weeks, I get an email from our supplier about the current items that are either not available or available in very limited supply. I'm not sure how high my hospital is on the priority list but I have to image we're fairly low since it can take items months to arrive. I think I'm still getting items I ordered in 2021 and it's a month into 2022 already.

So, someone doesn't get their protein supplement, big deal right? Well, it can be. When it comes to oral supplements, they're not one-size-fits all. For example, a renal oral supplement designed for a person with kidney disease may not have a substitute. A thickened supplement which we use for patients that have swallowing problems doesn't always have a substitute. Additionally, these examples are two populations which often don't eat well and likely need a supplement to maintain their nutrition status.

When it comes to our enteral formulas, the problem often gets worse. While there isn't a great deal of evidence for specialty formulas, they often work better for my patients. I know that there isn't evidence for a diabetic formula, but my uncontrolled or brittle patients with diabetes usually do a little better with this formula. Once again, you may be able to find a substitute but it's not always the best.

Managing Shortages: Practical Solutions

How exactly did we manage? Well, it's an ongoing challenge but we first started by cracking down on what we ordered. Does your patient really need three ensure a day or will they only be able to drink one every day? Trying to strategically manage our resources became a huge priority. We circled back to patients sooner to find out if they were actually taking what was being provided and discontinuing supplements they didn't like. We also developed a quick "cheat sheet" for the best substitution products. For example, one of our vanilla flavored protein supplements serves as a reasonable although suboptimal substitute when our renal supplement isn't available.

We also had to be proactive on our enteral formulas and switch patients to the formula that we had. This area was more problematic as, once again, the substitute wasn't always ideal. We managed without huge problems although frequently had concerns for our long-term enteral patients who were used to a certain formula.

Finally, I had to become much more proactive about keeping up with stock, ordering higher volumes, and communicating shortages to the foodservice staff. I planned to order at least a week in advance and started ordering about 30% more than our normal par levels to keep on track. For items out of stock, I talked to our supervisors and patient services manager weekly to provide updates on shortages and substitutions.

I hope we get back to pre-COVID19 supply chain function, but I doubt that will happen anytime soon. This may be our new normal. It's a fair amount more work but shows that, in the immortal words of Tim Gunn, we will make it work!