Boston Hospital May Have a Solution to IV Bag Shortage

Tara Haelle

March 22, 2018

In the midst of a US shortage of intravenous (IV) fluids, oral hydration is a low-cost, evidence-based solution hospitals can implement to treat adults with mild rehydration, write a group of international emergency care physicians at Brigham and Women's Hospital in an article published March 21 in the New England Journal of Medicine.

"We started the oral rehydration solution protocol in the emergency department, but it was quickly adopted throughout the hospital because the IV shortage affects all departments," said senior author Stephanie Kayden, MD, MPH, chief of the Division of International Emergency Medicine and Humanitarian Programs at Brigham and Women's Hospital in Boston, Massachusetts. "This has become part of our standard practice in the hospital, and I hope it will stay that way. In many ways, the oral rehydration is a better solution for patient care."

"Most of the IV fluid used in the United States is produced by only three manufacturers, so availability is vulnerable to even small fluctuations in supply," write Andrés Patiño, MD, and colleagues. Conversely, oral rehydration relies on inexpensive and readily available supplies. Moreover, oral rehydration can reduce emergency department admissions and lengths of stay, the authors note.

As 44% of IV fluid bags used in the United States are manufactured in Puerto Rico, Hurricane Maria's destruction on the island in September 2017 intensified a preexisting IV fluid shortage, expanding it from 50- and 100-mL bags to include 500- and 1000-mL bags. Brigham and Women's emergency department used 8519 liters of IV fluids, almost 30% of the hospital's total consumption, from September 2017 through January 2018. Therefore, the hospital asked a group of emergency physicians with international humanitarian experience to develop a solution.

"This is a protocol for people with mild dehydration from diarrhea, vomiting, morning sickness and similar problems, not for people who have major electrolyte imbalances, such as kidney disease," Kayden told Medscape Medical News.

Oral rehydration should not replace IV fluids in patients with moderate or severe dehydration or in those unable to take liquids orally, such as patients requiring bowel surgery, but it is ideal for patients with pharyngitis, gastroenteritis, and upper respiratory tract infections. "It's not for all patients, but it would definitely work in all hospitals. It's actually easy to do and can be very broadly applied," Kayden said.

Nearly 6 decades of research supports oral rehydration therapy, which can reduce diarrheal illness mortality by 93% and decrease the cholera case fatality rate from 30% to 1%, the authors note.

The Oral Rehydration Protocol

The Brigham and Women's protocol involves patient consumption of 500 to 1000 mL oral fluids, which is adequate to ensure the patient can continue rehydrating at home, along with pain relief, antipyretics, and antiemetics as needed. Patients choose from water, dilute juice, an artificially flavored oral electrolyte solution, or dilute sports drinks; only the latter two are offered if clinicians suspect electrolyte imbalance.

After receiving a straw, a 30-mL medicine cup, and 1000 mL of the liquid chosen, the patient is instructed to drink 30 mL every 3 to 5 minutes. The patient or a family member should time the sips with a cellphone and track progress on a log sheet. Clinicians should mark lines at every 250 mL on the pitcher to indicate volume targets (how much remains).

Ideally, patients should consume half the fluid within 50 to 80 minutes, and all of it by between 1 hour and 40 minutes and 2 hours and 40 minutes. A 20-minute delay in drinking is recommended for patients who vomit. A provider should regularly stop by to offer encouragement, provide additional antiemetics or pain control as needed, and switch out drinks if the patient does not like the first one.

"As with IV strategies, clinical judgment must be used when choosing oral hydration in patients with coexisting conditions such as renal disease, diabetes, or heart failure," the authors write.

Benefits of Oral Rehydration

Implementation began with hospital leadership emailing all providers to explain the IV fluid shortage and describe the new protocol. The team also posted in the emergency department, and faculty and residents received additional training and reminders.

A preliminary examination of the hospital's IV fluid use revealed about a 30% reduction in volume just 1 week after implementing the protocol hospital-wide. Two weeks later, 15% fewer patients had IV fluid orders.

There are patient-related benefits as well. For patients with mild dehydration from vomiting, oral rehydration lets clinicians determine whether the patient can really keep fluids down, Kayden explained.

Patients' participation in their care is another benefit IV fluids cannot provide. "By getting the patient involved in tracking like that, it lets them be involved in their care and knowing why they're doing it," Kayden said. Their families can similarly become invested when helping the patient log fluid intake.

That involvement also promotes patient education, potentially reducing a patient's future emergency department visits for mild dehydration.

"By showing them how to mix up the fluid and how we're having them take it in, it helps to educate them about what they can do at home to help themselves without even coming into the hospital next time," Kayden told Medscape Medical News. "It's really a win-win for everyone involved."

Ensuring Smooth Implementation

Oral rehydration can take longer than using IV fluids and requires the patient's participation but eliminates the pain of inserting an IV catheter. The authors note the potential for expanding oral rehydration if the IV fluid shortage worsens, but they recommend continuing oral rehydration for mild dehydration regardless of IV fluid supply in the future.

"A change is hard no matter what, so buy-in is going to be very key," Kayden said regarding other hospitals' adoption of this protocol. She added that hospitals should not underestimate the time needed for implementation. "There needs to be a lot of messaging and a lot of education. It's something relatively new to have the patient or family be so involved in the care, and I think the newest and possibly hardest part was to get folks to interact in that way."

But given that the strategy came from countries with limited resources, oral rehydration requires little: water, electrolyte powder, or juice and log sheets.

"This oral rehydration protocol wasn't really driven by costs. It was driven by doing what's in the best interest of our patients," Kayden said. High-income countries likely had not used this strategy previously because the ease and familiarity of IV fluids had become the custom, she said.

"It's easy enough in a Western setting, when you have lots of access to put in the bag, walk away, and know it's been done," Kayden said. "We have a culture that supports use of IV fluids even though the data show that, in many cases, oral rehydration and IV rehydration are equivalent in benefit."

This protocol focused only on adults because Brigham and Women's connects to a children's hospital that takes all pediatric patients. But oral rehydration is already standard practice in pediatrics, Kayden said, because clinicians try to prevent pain, such as the IV catheter insertion, as much as possible. The bulk of literature on pediatric oral hydration comes from the West, but most evidence for oral rehydration in adults comes from global health science, particularly in countries with limited resources.

"This is a really excellent example of how global health science not only has helped us weather the IV fluid shortage but actually helps us to improve patient care in the United States," Kayden said. "A lot of people assume global health is about Western doctors helping in low income countries, and this is one of those examples where what we learned there helps improve our lives here."

The authors have disclosed no relevant financial relationships.

N Engl J Med. Published online March 21, 2018. Abstract

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