Hospitals Strategize on Saline as Supply Stays Low After Maria

Marcia Frellick

December 04, 2017

Hospitals are finding creative strategies in the wake of a severe shortage of IV saline that has persisted more than 2 months after Hurricane Maria pounded Puerto Rico, which produces most of the saline used in the United States.

Hospitals have experienced IV saline shortages previously, but the damage to major manufacturers caused by the September 16 hurricane greatly exacerbated the problem.

Vivian Johnson, vice president of pharmacy services for Parkland Health and Hospital System in Dallas, Texas, told Medscape Medical News that one of the largest suppliers, Baxter, notified Parkland in late September and early October about the production problems.

Parkland then adopted a number of strategies, including administering IV drugs in syringes rather than minibags, seeking products from alternative suppliers, considering changing from IV to oral products when possible, and using larger volume IV bags to administer smaller volumes, because the smaller-volume bags are the ones in short supply.

"Parkland has a standing multidisciplinary team that reviews and manages responses to shortages on a daily basis," she said. "Although Parkland was impacted by the saline shortage, we have been able to successfully change practice without negatively impacting patient care."

Deborah Cowan, director of pharmacy at Angel Medical Center, a small hospital in Franklin, North Carolina, told Medscape Medical News the six hospitals in her system have been working together to find solutions for minimizing the use of the small-volume bags.

"We spent a lot of time going through the medications that we typically either mix in the small volumes or that the nurses prepare in those small volumes to see which could be safely given by IV push to the patients," she said.

Using IV push has disadvantages, including the fact that it takes more nursing time, which diverts nurses from providing other care, and can add risk for patients.

"You gotta do what you gotta do when you don't have IV bags," Cowan said.

Cowan said the first relief came this week when they received four cases of 100 mL saline IV bags from Baxter (one of two small-bag sizes).

The drug they had the greatest shortage of, she said, was potassium chloride premixed in small IV bags, and they received two cases of that Thursday.

"Really Low on Options"

Craig Frost, RPh, MBA, FACHE, vice president of clinical pharmacy for Catholic Health Initiatives, which includes more than 100 hospitals in the Denver, Colorado region, said they also are experiencing a shortage of IV solutions and nutritional solutions across the board, primarily the small-bag versions.

He said they are using IV pushes as well and are centralizing stock to the pharmacy to better manage the inventory rather than having decisions made in decentralized patient-care areas.

He explained that there are only three manufacturers of the saline for the US market, and two of them have had production problems. IV solutions are inexpensive to make but are expensive to ship and manage, which explains why there are so few manufacturers, he said.

"We're really low on options," he said. "When one has a problem, the whole supply portfolio of all hospitals is affected, and we have two that had a problem."

He says he sees indicators that production will be up next year, but he said he thinks it will be 3 to 6 months to have significant relief at his health system.

Because Catholic Health Initiatives is larger than some systems, they can share resources among facilities, he acknowledged.

"We haven't canceled any elective surgeries or postponed care for anybody yet, but that certainly is a possibility," he said.

FDA on the Case

On Thursday, US Food and Drug Administration (FDA) Commissioner Scott Gottlieb, MD, said in a statement that some major medical product manufacturers in Puerto Rico are stabilizing production, but until the power grid is again reliable, production levels will remain below baseline.

He said that the FDA has been working with suppliers and predicts the IV saline shortage "will improve by the end of 2017."

Yet, drug shortages, particularly amino acids for injection, remain a serious concern, a problem also exacerbated by Hurricane Maria, Dr Gottlieb noted. About 10% of the drugs prescribed in the United States are made in Puerto Rico, according to the FDA. Lists of drug shortages that are either in process or have resolved are available online from the FDA.

"This product is of critical need for patients, including children and infants, who are not able to eat and need to receive their nutrition intravenously," he said.

To help relieve the shortage, the FDA has worked with Baxter to temporarily import amino acids for pediatric and adult formulations of IV amino acids from Baxter facilities in the United Kingdom and Italy.

The FDA is working with some of the largest manufacturers serving the US market to increase supplies.

"We continue to work closely with federal and Puerto Rican authorities to address the needs of manufacturers on the island for power and other resources.... We're monitoring approximately 90 medical products manufactured on Puerto Rico (which includes biologics, devices, and drugs) that are important to patients," Dr Gottlieb said.

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