IV Fluids
Sonya Collins
When Hurricane Helene damaged Baxter International’s North Cove, NC, manufacturing facility last fall, an I.V. fluid shortage ensued. For many health systems, it may have felt all too similar to the shortage they faced after Hurricane Maria damaged Baxter’s Puerto Rico plant in 2017. I.V. fluid production is once again approaching pre-hurricane levels. But the shortage, along with the reality of increasingly frequent superstorms and other disruptions to the supply chain, such as global pandemics, has motivated health systems to reconsider their ongoing use of I.V. fluids and implement practice changes.
“During the shortage, we tried to locate any ‘leakage.’ Where were we reflexively using I.V. fluids when we didn’t need to?” said Delia Allen, PharmD, manager of medication use policy at St. Jude Children’s Research Hospital in Memphis, TN. “Some of the steps that we implement during shortages are just really good patient care and can continue on even after a shortage.”
Lessons from past disasters
In fact, some shortage mitigation strategies implemented at St. Jude after Hurricane Maria in Puerto Rico, such as extended hang times, were still in practice when Hurricane Helene barreled through North Carolina. The hospital brought back other strategies introduced after Maria that had been retired, as Allen and coauthor David Aguero, PharmD, director of medication systems and informatics at St. Jude, described in a commentary published December 9, 2024, in The American Journal of Pediatric Pharmacology.
The children’s hospital moved to standardize to-keep-open rates to the smallest effective rate and volume; limited outpatient I.V. hydration orders to a maximum dispense of 24 hours; changed some dispensing orders for small volume chemotherapy; and reminded staff to use oral medications whenever possible.
The latter tactic, Allen said, should remain in practice even outside of an acute shortage. “That’s just good patient care,” Allen said. “When patients have a working digestive system, we want to keep it working, so we want them to use their gut, and that’s continued on after the shortage.”
Default to oral administration
MedStar Health, too, will push to administer medications and hydration orally whenever possible as part of a new “fluid stewardship” initiative, according to an American Society of Health-System Pharmacists report.
The health system has revised over 300 order sets and 2,500 I.V.-related order sentences, including many that default to oral hydration over I.V. administration.
These changes underscore a need for health systems to reevaluate many of the scenarios in which patients automatically receive I.V. fluids, simply because they already have a central line for example, even though the fluids are neither necessary nor evidence-based in that given instance.
Push (and pushback) for I.V. push
The shortage has also led some hospitals and health systems to switch to I.V. push whenever possible. But this particular mitigation strategy comes with pushback as it disrupts nursing workflow.
“You have to stand there and slowly push, which can take a lot more nursing effort,” Allen said. But more effort does not necessarily mean it is not the right strategy.
“Sometimes we do things in health care, even in pediatrics, just because they are easier, not because they are necessary.”
Shine a light on fluid waste
The I.V. fluid shortage has brought to light a great deal of waste. A growing body of literature provides evidence that health systems are using more I.V. fluid than patients need and that there are straightforward ways to reduce or eliminate such waste.
The American Thoracic Society is among several professional societies that have released new guidance that addresses some of this waste. Among the waste-limiting strategies are:
- In areas that pre-spike fluids for cases, consider using a “just-in-time” approach.
- In areas that warm fluids, balance having enough against wasting fluids discarded due to time in the warmer.
- Enact a maximum allowed duration of 24 hours for I.V. fluid orders and ask for a new order to extend duration.
- Require a new order for I.V. fluids when the current bag is depleted.
- Whenever clinically appropriate, ensure the remainder of a bag of I.V. fluid is used before starting a new one.
- Educate bedside nursing staff to keep unused I.V. fluids spiked and primed until expiration of the product or tubing in case of therapy reinitiation.
The American Society for Health-System Pharmacists has also published recommendations for short- and long-term practice and policy changes on its website.
Though the most recent shortage is now nearly over, health systems may see increasing evidence of a need to change their I.V. fluid practices long-term.
“It’s only a matter of time until the next shortage,” Allen said, “unless there is some sort of large-scale change.” ■