IV Fluid Shortage Paves the Way for Clinical Change

The leadership team at MedStar Health has turned the recent national IV fluid shortage into an evidence-based opportunity to reduce the use of these products to about half of pre-shortage levels.

“This whole process has identified, for us, fluid stewardship,” said Bonnie Levin, vice president of pharmacy services for the 10-hospital system that serves Washington, D.C., Maryland, and Virginia. “We already do antibiotic stewardship; we do opioid stewardship. Now we’re doing fluid stewardship, and that is a permanent clinical practice.”

The fluid-conservation practices grew, in part, from a consensus among clinical leaders that overuse of perioperative IV fluids had become routine throughout the health system, said Chief Medical Officer Stephen R.T. Evans. He said the shortage presented “an opportunity to dial that back to what is clinically important and relevant.”

To accomplish this, the health system reimagined IV fluid use in the context of Enhanced Recovery After Surgery (ERAS) care pathways.

Fluid management is a cornerstone of the ERAS pathways, which were developed to hasten the recovery process after major surgery. The pathways re-examine traditional perioperative practices, replacing them with evidence-based practices when appropriate, according to the ERAS Society.

Evans said MedStar began adopting ERAS protocols just before the COVID-19 pandemic, but that crisis mostly halted the ERAS rollout. The IV fluid shortage reinvigorated ERAS implementation as part of a broader focus on fluid conservation.

At the height of the shortage, MedStar cut its IV fluid use by about 70%. Evans said IV fluid use in mid-January remained at about half of the pre-shortage levels.

“We did not have to scale back any of our surgeries,” he said. “All of our ERAS protocols are pretty well embedded. Our outcomes continue to be outstanding. And we have a team finalizing what are now standards of practice.”

Making it happen

Baxter announced Sept. 29, 2024, that it had halted production at a key IV fluid manufacturing facility that had been damaged by Hurricane Helene. The company quickly reduced allocations of many IV products, precipitating a sudden national shortage.

“I think people recognized it was an emergency,” Levin said. “They were reading about the hurricane in the papers, they understood that 60% of our IV fluids were lost in the United States. And so we had to make some changes, or else we would not be able to serve our patients.”

She said MedStar’s pharmacy staff immediately reached out to colleagues across the country to share ideas for fluid conservation and talk about practice guidelines. In addition, Levin and other MedStar leaders sought input from the health system’s heaviest IV users.

“We got on a call with the leads of the emergency department, anesthesia, and critical care,” Levin said. “And we asked, ‘What would you do if we didn’t have any IV fluids?’ And they started throwing out ideas.”

In many cases, the evidence-backed clinical consensus favored oral hydration over routine IV fluid use.

On the night of Oct. 5, 2024, the hospital’s information technology (IT) team revised 300 order sets and more than 2,500 IV-related order sentences. Levin said the changes included converting IV fluid orders to oral hydration, reducing the duration or rate of IV fluid administration, and eliminating IV hydration altogether.

Although the practice changes were driven by clinical considerations, Evans said there is probably a financial upside to shifting appropriate patients from IV to oral hydration.

“If we’re using half the amount of IV fluids, there is a financial impact in that,” he said. “These are expensive resources. Trying to use best evidence models for their use — where do you use them and how you use them, as well — is important.”

Collaboration and consensus

Evans attributed MedStar’s successful management of the IV fluid shortage to a combination of effective staff communications, an agile IT team, engaged clinicians, and “muscle memory” from the COVID-19 crisis. He said there was broad consensus among the clinical staff that permanently revamping fluid management was the right thing to do.

The supply chain team quickly pushed out oral hydration fluids to meet the heightened demand throughout the health system, working with the nursing staff to implement the new hydration practices. Close collaboration of clinical, pharmacy, and supply chain leadership resulted in rapid consensus and implementation.

“We did this not just in our hospitals but also in our ambulatory sites, across all of our ambulatory service centers, in our endoscopy suites, across the entire platform,” Evans said. “You cannot do this without having close alignment with your pharmacists, and you cannot do this without close alignment with your nurses.”

Levin noted that although this shortage was sudden and severe, her team knew how to handle it from a pharmacy perspective.

“We’ve been managing drug shortages for years,” she said. “It’s just become part of as usual for us.”