ATS Guidance: 10 Steps for Hospitals Facing Intravenous Fluid Shortages
In September of 2024 hurricane Helene became the deadliest inland hurricane on record in the United States causing widespread damage to multiple states. It made landfall on Sept. 26, 2024 as a category 4 hurricane and damaged the Baxter plant in Marion, N.C. causing a supply chain shortage of intravenous (IV) and peritoneal dialysis solutions. This plant produced 60 percent of the IV solutions used every day in the US. Two weeks later hurricane Milton made landfall as a category 3 near Siesta Key Florida causing the closure of B. Braun which produces about 20 percent of the nation’s supply of IV fluids.
These shortages and the effect on hospital supply lines have been widely reported. A letter from the Department of Health and Human Services has called upon providers and systems to implement product conservation strategies (1). On Oct. 7, 2024 the American Hospital Association addressed a letter to President Biden calling for declaration of a National Emergency and directing the FDA to allow hospitals and systems to produce their own sterile IV solutions (2). At the writing of this document this has yet to take place. This document gives guidance on how healthcare systems facings shortages of these fluids may conserve fluids and address the shortages.
In the event that your hospital or healthcare system is currently experiencing or is expected to experience critical shortages of IV fluids, electrolytes, or amino acids, here are 10 steps to consider adopting. Some of these have been previously published by the ATS (3).
- Convert patients to oral rehydration and oral medications as appropriate. Commercially available products include, but are not limited to, the following: Trioral TM, Oralyte, and Pedialyte. Institutions should consider formal intravenous to oral protocols. Common medications for IV to PO conversion include: antibiotics (e.g. azithromycin, beta-lactams, fluoroquinolones, metronidazole), antiepileptics (e.g. levetiracetam), proton-pump inhibitors, vitamins (e.g. thiamine [100 mg], folic acid).
https://www.thoracic.org/professionals/clinical-resources/disaster-related-resources/resources/IVF-shortage-IV-PO-policy.pdf - Reconfigure electronic health record to guide appropriate prescribing. Implement hard and soft blocks in the electronic medical records to guide providers towards selection of IVF based on availability.
- In areas that pre-spike fluids for cases consider using a “just-in-time” approach to eliminate waste.
- In areas that warm fluids, balance having enough against wasting fluids discarded due to time in warmer.
- Consider routine reassessment of need for IVF orders. Either enact a maximum allowed duration of IVF orders to be up to 24 hours and ask for a new order to extend duration or require new order for IVF when the current bag is depleted. The latter option is preferable to minimize waste. Additionally, be cognizant of discontinuing or switching to another product (e.g. 0.9% sodium chloride to dextrose 5% in sodium chloride 0.45%) before current infusion completed. Upon switching to alternative product, ensure remainder is utilized (if clinically appropriate) before starting of new IV fluid. Educate bedside nursing staff to keep unused IV fluids spiked and primed until expiration of product or tubing in the instance of therapy re-initiation.
- Use smaller bag sizes for low-rate continuous infusions when possible.
- Implement specific breakpoint criteria for utilization of intravenous electrolytes and preferentially use oral repletion of electrolyte. Recommend electrolyte replacement dosing based on serum electrolyte concentrations (e.g. serum phosphorus concentration of less than 1.6 mg/dL). Consider PO replacement whenever possible. Restrict IV electrolyte replacement to patients with life-threatening electrolyte abnormalities or those with strict NPO status. Utilize enteral replacement for electrolytes (e.g. potassium, phosphorus).
- Limit utilization of parenteral nutrition (PN). Initiation of PN should be based on assessed nutritional risk and status and duration of nothing by mouth (NPO) status. Early discontinuation upon tolerance of enteral tube feeds or solid oral diet.
- IV push of medication when possible and timely switch to PO antibiotics.
- Consider delay of elective surgeries to conserve supplies.
Based the supply chain supply and demand as well as your individual systems specific needs the order and scope of these specific interventions may change over time.
References/Additional Resources
- HHS Letter About Supply Chain
https://www.hhs.gov/about/news/2024/10/09/letter-health-care-leaders-stakeholders-impacts-hurricane-helene-secretary-becerra.html - AHA Letter to President Biden
https://www.aha.org/2024-10-07-aha-president-urging-administration-take-immediate-action-address-iv-solution-supply-shortage-result-helene - ATS Document: Fluid Shortages (Carlos, et al) 2017
https://www.thoracic.org/professionals/clinical-resources/disaster-related-resources/
Authors
W. Graham Carlos MD (wcarlos@iu.edu)
Indiana University;
Late Breaking Learning Committee
Charles S. Dela Cruz, MD, PhD (delacruz4@upmc.edu)
University of Pittsburg;
Late Breaking Learning Committee
Shazia Jamil MD
(sjamil@health.ucsd.edu)
Scripps Clinic and University of California San Diego;
Late Breaking Learning Committee
Reviewer: Michelle Gong, MD