Northeast Ohio has been hit hard by a shortage of IV fluids since Hurricane Helene knocked out a major manufacturing site for one of the country's largest suppliers more than a month ago.
Many local hospitals rely on Baxter International for 80-85% of their fluids, which are essential for fixing electrolyte imbalances, supporting blood vessel volume and distributing medications in patients.
Hospitals including Cleveland Clinic, University Hospitals and MetroHealth in Cleveland, and Summa Health in Akron have said they’re conserving fluids.
Dr. Peter Pronovost, University Hospitals’ chief clinical transformation and quality officer, spoke with Ideastream's Taylor Wizner about how the health system has been managing the shortage — and when it might end.
What was happening inside UH when it became clear that the amount of IV fluid you expect from Baxter would decrease 40% of what you usually receive? You are a critical care doctor. What was going through your head?
The Friday after the news hit about the hurricane and the Baxter plant was down, our head of supply chain called us and said in our last shipment, we ordered 280 pallets of fluid. We got 25, so essentially 10%.
As a critical care physician, what went through my mind is to say we have to make sure we have sufficient fluids for resuscitation — so that's emergency surgeries and things like sepsis, because if we didn’t, people would be harmed.
Then, we got more fluid and we went into a phase to say, well, we don't know if we could keep doing elective surgery, but what would determine that is if we could conserve enough fluid again with safe and evidence-based practices to get that 40%. So that became our target.
We had enough supply in our storerooms that we had some time to learn if we could conserve that much, but we really didn't know. We hadn't done this exercise before, and (a 40% reduction) just seemed like a whole lot.
UH hasn’t canceled any surgeries and doesn’t plan to. How have you managed to do that, where other health systems across the country that have less reliance on Baxter fluids have had to cancel elective surgeries?
We knew the answer lied with our front-line clinicians and they had different strategies in different areas.
The innovations that the team came up with were just so interesting. One common one we saw, there's a number of procedures where patients get very little fluid, less than a liter. And so the teams innovated and said, ‘What if we had people drink before surgery?’ The evidence-based guidelines are you could drink up to two hours before surgery, but some of our earlier procedures were still having people not drink until after midnight, so they come in dehydrated.
We applied what was known — evidence-based practice that wasn't widely done. We would put what's called a Hep-Lock IV in them, which is an IV, but we didn't connect it to fluid. If people needed fluid, it was ready to give to them, but virtually everyone doesn't need it. They would hydrate again in the recovery room, and lo and behold, patients liked it better, didn't like the puffy feeling from fluid. It was a win for everybody.
Is there any concern that you are going to reach that sort of a scarcity of fluids? Baxter has said they are not going to be back to full capacity until next year.
We think about it every day and we manage it very disciplined every day. Right now, we have been getting — and they still predict that we will get — 60% (of our typical order). But as you know, it's dynamic.
That said, we built a really robust process to monitor it every day. Our clinicians go and look in the store rooms, or our staff, and add up how many different types of bags that are there. We have our quality teams go and observe if people are implementing these strategies, and if they're not, they give real time feedback and coaching. They also monitor that this is safe and there's no unintended consequences, and obviously we keep really close tabs on our supply chain.
Is there any anything you would recommend other health systems do to navigate this time of limited resources?
I think two things. One is make sure that you do the math, or you approach this as an optimization problem to the extent possible. Know your daily rate of different types of fluid, make sure you monitor that. Know what you're getting for your delivery so that you know how much you have to conserve per day to keep your operations unchanged while providing safe care. And some of it was just manual, or converting pallets to liters of different types of fluid. It's really key to have a good management system to how to do that.
And then the second part is the cultural thing. Honoring the wisdom of the frontline clinicians for their ideas and being vulnerable enough, or courageous enough, perhaps, to say we need your help and making sure that we listen to them.
