A national shortage of IV fluid bags has Triangle hospitals scrambling to keep patients medicated through a patchwork of improvisations and workarounds that are more expensive, time-consuming and could increase the risk of medical error.
Local hospital executives say the nation is in the midst of one of the most severe medical product shortages they have experienced in their careers, and it comes as flu cases are on the rise.
The shortage of bags results from Hurricane Maria’s devastation of Puerto Rico, where the industry’s leading manufacturer, Baxter International, operates three manufacturing plants. The storm knocked out power and disrupted production of sterilized bags that are typically pre-filled with saline or dextrose and used to administer antibiotics, anti-nausea drugs and other medications.
The shortage is exacerbated by a sharp increase in flu cases nationwide, sending patients to hospitals where they often require IV drip medications. According to the Centers for Disease Control and Prevention, 46 states are reporting widespread flu activity, comparable to the peak of the 2014-2015 season, which was the most severe flu season in recent years.
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“On any given day you don’t know if you’re going to receive your deliveries or not,” said Erin Fox, senior director of drug information at the University of Utah, which tracks national drug shortages for the American Society of Health-System Pharmacists. “Some hospitals have just a few days of supply. With drug shortages and workarounds, the incidence of errors increases.”
Baxter, based in Deerfield, Illinois, operates a 2,000-employee plant in Marion, about 220 miles west of Raleigh, that makes larger IV bags, up to 1,000 milliliters in size, that are used to hydrate hospitalized patients. The larger bags are also in short supply as a raft of flu cases has increased hospitalizations around the country, but they are not at the critical shortage levels of the smaller bags used for medications.
A large hospital can use thousands of the bags daily. And multi-hospital systems require many thousands of bags a day.
Duke University Health System receives its IV bags from Baxter and is currently rationed for about half its normal supply of IV bags, said Kuldip Patel, associate chief of Duke’s pharmacy office. To contend with the shortage the system has assigned about 15 people to the task of ordering, monitoring and managing the bags. Duke has nearly run out of 100-milliliter bags in recent weeks and has moved the bags around its hospitals – Duke Regional, Duke Raleigh and Duke University – to make sure there were enough to go around.
“We are spending a tremendous amount of resources on this one topic,” Patel said.
The primary challenge for the hospitals is constantly monitoring supply, mixing medical solutions on site, ordering premixed and frozen solutions at a much higher cost from alternative suppliers, and assigning nurses to handle manual injections and other staff for processing.
Mark Lyons, executive director of integrated pharmacy supply chain at UNC Health Care, said that medical staff at its 13 hospitals follows published safety guidelines when administering medications manually.
Duke, UNC and WakeMed Health & Hospitals in Raleigh said that various combinations of juggling has allowed them to provide medical services without disruption so that they don’t have to postpone elective procedures.
In a statement, Baxter said all three of its manufacturing sites in Puerto Rico are now connected to the electric grid – the last site hooked up in late December – with diesel generators in place for intermittent power disruptions. Baxter has also received approval from the Food and Drug Administration to import IV bags from Baxter sites in six countries, including Mexico. The company expects to return to normal supply levels in the coming weeks.
Last week FDA Commissioner Scott Gottlieb said the agency expects the shortage of IV saline fluids to improve in early 2018, but noted that “the production situation in Puerto Rico remains fragile.”
Local hospital officials say that many patients are affected by the shortage, but the patients themselves may not be aware because they’re getting the medication by pill or manual infusions.
However, the problem has not completely escaped the attention of patients.
Sarah Thompson said her 12-year-old son, Edward, has complained that the manual infusion of an anti-nausea drug is unpleasant, and last week he specifically requested an IV drip, which wasn’t available because of the bag shortage. Edward receives the anti-nausea medication before his chemotherapy treatments at UNC cancer care center in Chapel Hill.
“He feels the difference,” Thompson said. “It gives him a funny feeling in the head when they push it in, kind of light-headed.”
The pump-actuated IV drip can take from 15 to 30 minutes, she said, while a nurse administering the medication manually would typically take about 5 minutes.
“I was really surprised he doesn’t like it that much,” she said. “There is that much of a difference.”
UNC Health Care spokesman Alan Wolf said the system’s goal is to keep the bag shortage invisible to patients.
“UNC Health Care has contingency plans in place, and teams of people working daily behind the scenes to find new sources for some supplies, implement conservation measures and use alternative medical products when possible,” Wolf said by email. “As part of that, those teams work hard to ensure that patients don’t notice issues like this.”