Baptist Health Takes IV Fluid Management in Stride

As U.S. hospitals grapple with the need to conserve IV fluids, the pharmacy team at Kentucky-based Baptist Health has led efforts to safely reduce its IV fluid use by about 40%.

That level is well above what many other health systems have managed during the shortage, according to emerging data from Bainbridge Health and the National Infusion Collaborative, which tracks national IV use trends and practices (ASHP is a member of the collaborative).

“The data we look at across 500 hospitals in our network shows that there’s probably somewhere between a 10% and 15% decrease in fluid utilization, in aggregate,” said Sean O’Neill, chief clinical officer for Bainbridge Health. O’Neill said conservation strategies at high-performing organizations like Baptist Health could help other organizations that are struggling with the IV fluid shortage.

The shortage began in late September after Hurricane Helene flooded the North Cove, North Carolina, manufacturing facility where Baxter produces many of the company’s IV solutions.

Baxter is the main supplier of IV fluids for Baptist Health’s nine-hospital network, said Nilesh Desai, chief pharmacy officer for the health system. Desai said the Baxter products have been on a 40%–60% allocation since the storm.

Getting organized

Greg Fakelmann, system director for pharmacy clinical services for Baptist Health, said the initial response to the shortage was to make as many people as possible aware of the problem.

He said communication alerts related to the shortage were pushed out to the system’s electronic health record (EHR) and departmental dashboards, and clinicians were asked to minimize their fluid use as much as possible.

Baptist Health also up a systemwide web portal for updates and information sharing.

“Within that new website, we actually created an idea-sharing portal where anyone could go in if they came up with a good idea and offer it up for further vetting by the rest of the team,” Fakelmann said.

The pharmacy team had its own resource page where the staff could discuss and share messages and strategies before pushing them out systemwide. And Baptist Health also established a system command center for the shortage, overseen by the organization’s system vice president of quality, safety, and patient experience.

Fluid management strategies

One of the first EHR changes was to implement a stop time for IV fluid orders.

“Previously ... the provider could, if they chose, enter a duration in hours or in days,” Fakelmann said. “We removed the option for days and locked it down to just hours. And they had to specify how many hours they would like for those IV fluids to run.”

Along with the modified stop times, the health system added a practice alert to the EHR system. The alert, which triggers 24 hours after an IV fluid is ordered, reminds clinicians about the shortage and requires them to choose whether to continue, modify, or discontinue the order.

Fakelmann said if a clinician acknowledges the alert but opts to continue the IV fluids, the alert pops up again after 16 hours and requires another review.

Baptist Health also reviewed its policies for switching from IV to oral medications. Fakelmann said the health system implemented IV-to-oral therapeutic interchanges for seven commonly used antimicrobials and created EHR alerts for a dozen other medications identified for IV-to-oral conversion.

The pharmacy team also set up an EHR report and dynamic list of patients who are receiving continuous IV fluids. The report includes patient-specific data the pharmacy and nursing staff can review to determine whether it’s necessary to continue the infusion.

Patients who have taken oral medications or eaten a meal in the past 24 hours are potential targets for IV discontinuation, Fakelmann said.

The pharmacy department also began using the EHR system to track fluid-management interventions.

“Some of our hospital leaders were interested in understanding specifically what interventions pharmacy was recommending and how many,” Fakelmann said. “We created reports for the materials management team that helped analyze utilization. We established a guidance document for pharmacists to identify opportunities to discontinue maintenance IV fluids. That was one of those documents that we put on our pharmacy resource page and made available to everybody in the system.”

New opportunities

Sanchita Damania, system director of medication safety and regulatory for Baptist Health, said one of the “aha” moments of the shortage occurred when the pharmacy team reexamined longstanding IV flush volume practices. In some cases, she said, the medication administration policy called for a flush volume 40 mL when the recommended volume was 25 mL or less.

Damania said the health system hasn’t yet mandated a change to the lower flush volumes.

“That’s one of the things that we were looking to implement in the future as a standard of practice,” she said. And she said the hospital is also reassessing the routine placement and continuation of “keep vein open” IV lines that aren’t intended for immediate use.

Teamwork brings success

Fakelmann said the pharmacy staff hasn’t faced pushback from their nursing or medical colleagues about conserving IV fluids.

“A lot of the ideas that were coming through that idea-sharing portal seemed to be coming from nurses,” Fakelmann said. “They were proactively identifying patients that no longer needed IV fluids. And they were reaching out to the providers and pharmacists to see if they could get some of those orders removed.”

Desai said he’s pleased about the buy-in from the nurses, physicians, pharmacists, and other clinicians whose efforts are minimizing the effects of this serious shortage.

“Everybody is participating,” he said.

ASHP recently updated its fact sheet of suggestions for the management of small- and large-volume fluid shortages.