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Hospital Management of Shortages Following Natural Disasters


Case study:

Intravenous bags of saline solutions have been in short supply since Hurricane Maria slammed into Puerto Rico in September and knocked out power to several IV bag manufacturing plants, including those owned by Baxter International, a leading producer of IV saline solution. What should hospitals do to manage the shortage?


erin fox, pharmDHealth systems across the country have been dealing with limited supplies of 50 ml and 100 ml IV bags since Hurricane Maria made landfall in Puerto Rico. Erin Fox, PharmD, BCPS, FASHP, the senior director of drug information service at University of Utah Health Care, said her hospital is trying to operate with 40% to 50% of its typical supply.

“That’s a really big drop,” said Dr. Fox. “Small bags are used for nearly every hospitalized patient—we’re used to using thousands per day. That’s why it’s been so difficult to manage the shortage.”

The increased costs associated with the shortage have been “unbelievable,” according to Dr. Fox. She said dealing with the shortage is taking up everyone’s time, but, at the end of the day, patients are still getting the medications they need because the hospital’s pharmacy acted quickly when supplies first started to dwindle and implemented several strategies to manage the limited supplies on a daily basis.

They first received buy-in from the health system’s leadership and supply chain managers to sequester IV bags in the pharmacy department, so pharmacists could allocate the bags to where they’re needed most. The pharmacists decided 50cc and 100cc bags of saline, which are used throughout the hospital for a variety of clinical applications, would be dedicated to the administration of medications. They also purchased as many pre-mixed medications as possible, explored which medications could be administered using 250cc bags, and moved medications to direct IV-push administration when it was clinically appropriate and safe to do so.

The majority of the increased workload has occurred in the hospital’s informatics department, which constantly changes medication order sets and adjusts the concentrations of smart IV pumps. “We make changes every few days to conserve supplies,” said Dr. Fox. “We’ve spent thousands of hours managing the shortage.”

Until saline solution flows at pre-Maria levels, the U.S. Food and Drug Administration (FDA) encourages hospitals to consider clinical recommendations for managing shortage of IV fluids released by the American Society of Health-System Pharmacists (ASHP) and the University of Utah (

FDA Commissioner Scott Gottlieb, MD, said in a statement on Jan. 4 that Baxter’s manufacturing plants in Puerto Rico have been reconnected to the commercial power grid and supplies of saline solution should begin to increase over the next few months.

“That’s a long time to go,” said Dr. Fox. “At any given time, we have 4 to 8 days of bags on hand. It’s scary.”

Dan Cook

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