Safe here in the Pacific Northwest, we watch increasingly devastating hurricanes slog the southeastern US. When Hurricane Helene unprecedentedly slammed western North Carolina in late September, we in Thurston County were significantly impacted.
It turns out that 60% of the nation’s intravenous (IV) fluid supply is manufactured by one large Baxter International facility there. The 2,500-employee plant shut down due to flooding from a breached levee and damage to their bridge access. On October 28, one line of IV fluid production resumed operation, with a second line due to start up soon. They anticipate resuming full production by the end of the year.
IV fluids are important for surgeries, transfusing blood products and medications, and providing fluid to those who cannot drink for various serious reasons.
When there is a shortage, mitigation measures must be implemented. This means using less fluids where possible and canceling non-urgent surgeries.
Healthcare facilities are granted an IV fluid allotment from the companies they purchase from, based on their use. When production stopped at this one key producer, the effect rippled nationwide.
Some 40% of the St. Peter’s IV fluids come from Baxter. The administration was acutely aware that the plant shutdown would have a substantial local impact.
Within a week of the event, they activated an Incident Command Structure led by Chief Medical Officer Melissa Grant, MD. Colonel Dr. Grant, an OB/GYN surgeon, came to Providence from the Army. Emergency response structures must be second nature to her as such a crisis is the stuff of wartime.
In addition, the Operating Room (OR) Governance Council, created in response to the COVID-19 crisis, was re-activated. Their job was to review and reschedule elective surgeries. Elective surgeries are important but non-urgent, including spine surgery, joint repairs, and more. Other surgeries, such as appendectomies, bowel obstructions, cancer surgeries, and others, are urgent, lifesaving, and must go on.
Ultimately, some 200 surgeries were rescheduled, most orthopedic, with individual consideration of each patient in collaboration with their surgeon. Over one month, or 20 operating room days, 10 surgeries per day could not be performed! Talk about impact. Patients needed to reschedule time off work, friends, and/or family to help with care and consider end-of-year deductibles and holidays. Surgeons and anesthesiologists cannot make up the lost time and income, nor can the hospital. Patients waiting to be scheduled will wait longer.
IV conservation measures to conserve IV fluids were implemented as well. Fasting before surgery and medical procedures was shortened to minimize the risk of dehydration and the need for IV fluids. Hospital patients who could tolerate fluids and pills by mouth were transitioned from IVs. Nursing Units were stocked with ample Gatorade, and nurses were asked to encourage patients to drink fluids to stay hydrated. Saline IV flushes before and after medication infusions and blood transfusions were held without adverse effects.
These actions were critical because, for a few weeks, St Peter’s received only 4% of their usual IV fluid allotment.
Olympia Orthopedics owns and operates its surgery center in West Olympia.
When Sylvia Johns, vice president of surgical services at Oly Ortho, heard that Hurricane Helene was predicted to hit North Carolina, she sensed the risk and anticipated the need to act quickly. She remembered when Hurricane Maria shut down the Baxter Plant in Puerto Rico in 2017. Immediately, she emailed the executive committee (composed of senior management and physician owners) who oversee operations, alerting them to an impending crisis. They responded quickly, granting her the authority to act. She promptly ordered as much IV fluid as their supplier would send and instituted conservation measures, too. All this was in place BEFORE the crisis hit.
Though Oly Ortho’s supplier is B.Braun (not Baxter), Baxter’s closure impacted the availability of all IV fluids nationally.
As a result, its surgery center schedule was minimally impacted. Johns participated daily with the local hospitals’ operating room committees regarding patients who could safely be rescheduled. Ultimately, 145 of Oly Ortho’s hospital cases were disrupted, most at St. Peter, with a few at MultiCare Capital Medical Center and Mason General.
I am personally grateful that my minor surgery proceeded last month, freeing me of numbness while typing this column!
Conservation measures made a difference, too. Instead of hanging IV bags for minor short procedures, IV access was obtained without "running fluid." When one IV bag ran out, the nurses asked if they should hang another.
The smaller organization’s agility to respond is notable. Staff share a history of working together and have built a culture of trust, mutual attentiveness, and granting authority to their leaders. This allowed for a rapid and near-immediate response.
Unfortunately, Providence's complex bureaucracy and size slowed the speed of its crisis reactivity. Despite its robust and thorough response, the delay caused them greater disruption. Time is of the essence in a crisis.
Olympia Ortho continues its full schedule and conservation measures. Its current IV allocation is nearly back to baseline.
St. Peter is now receiving 40% of its usual IV fluid allotment with the potential for additional shipments. All surgery cases have been rescheduled this year or early next based on patient and surgeon preference.
As Dr. Grant aptly and ‘punnily’ stated, "the situation remains fluid and optimistic!"
St. Peter and Olympia Ortho will review their responses to the situation to learn and plan for future crises, as they did after the COVID-19 pandemic. They told me they expect to implement safe conservation changes in the long term. Hopefully, hospitals, whose response speed is hampered by size and complexity, will systemize procedures, allowing faster responses in the future.
Both the St. Peter team and Ms. Johns from Oly Ortho expressed dismay at the absence of national planning and responsiveness to this crisis. They raised questions (so far without answers):
Sylvia Johns finds it shocking that we haven’t learned or instituted safety measures from prior natural disasters such as Hurricanes Katrina (2005) and Maria (2017).
This fall, the FDA extended expiration dates on IV fluid products to two years. How impactful was this policy? For context, Olympia Orthopedics essentially NEVER has to throw away expired IV fluids. They use what they order.
Washington State Hospital Association has three suggestions: “We are asking the federal government to act quickly to ensure adequate supply so that the effects on patient care do not get worse, stated WSHA CEO Cassie Sauer. “Specifically, WSHA and the American Hospital Association are asking the federal government to incentivize other manufacturers to ramp up production, allow importation from European Union countries and Canada, and allow hospitals to make their own solutions.”
This did not happen.
This is not the first, nor will this be the last, shortage of critical medical supplies and resources in our rich country.
Currently, there are shortages of many important medications, including chemotherapy. Such shortages result in patients stopping important treatment for a variety of diseases.
Medical devices, including external defibrillators and oxygenation devices, are also in short supply. Think life or death.
NO PLAN is what we have in the US.
There will be more storms. Some will be atmospheric, though many other potential disrupters exist in the critical medical supply chain.
Our local organizations worked together admirably, collaboratively, and as briskly as possible to avert the casualty of this IV shortage crisis. Though many patients needed to delay their surgeries, critical patients were cared for through it all. This bodes well for us here in JOLT country despite the lack of national leadership.
Debra L. Glasser, M.D., is a retired internal medicine physician in Olympia. Got a question for her? Write drdebra@theJOLTnews.com
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tattooednumbers
Thank you, Dr. Glasser and The Jolt, for highlighting this issue. While you note that “Though many patients needed to delay their surgeries, critical patients were cared for through it all. This bodes well for us here in JOLT country despite the lack of national leadership.”
Sadly, there continues to be a significant number of critical home health patients receiving IV fluids for numerous reasons - often immunocompromised or home bound, and treated outside of hospital infusion centers who have been placed at the very bottom of this priority list and continue to be rationed by local home health companies. These patients are not “being cared for through it all.”
Self advocacy and a tenacious primary care physician or specialist continues to be a patient’s best advocate these days. Many home health infusion patients are currently being told that they will continue to be rationed IV fluids until sometime in January.
Thanks for providing insight to this very important national AND local challenge.
Wednesday, November 20 Report this