Responding to the IV Fluid Shortage Crisis: A Community Discussion

As a result of severe flooding in North Carolina from Hurricane Helene in late September 2024, one of the largest suppliers of intravenous (IV) fluids in the US was forced to shut down, causing a strain on the national inventory of these vital supplies. Owned by Baxter International, the plant produced critical products like saline and sterile water for injection. For several weeks, infusion centers, hospitals, and dialysis centers sought creative solutions around this shortage.

Thoughts From the ACCCeXchange

Given the severity of the shortage, this topic quickly appeared in the ACCCeXchange, a community forum made up of members of the Association of Cancer Care Centers (ACCC), wherein individuals can pose questions and respond to one another in threads. In early October, one member asked how infusion centers are responding to the IV fluid shortage crisis and what strategies other members are using to conserve fluids.

Members were quick to add to the discourse with a variety of solutions, including:

• Changing infusion premedications to oral agents
• Changing infusion of premedications from IV piggyback to IV push
• Compounding drugs in 5% dextrose in water versus 0.9% sodium chloride if one stock is better
• Using saline flushes to push volume through instead of hanging secondary fluids for flushing
• Limiting orders and total daily treatments for inpatients
• Holding daily team meetings to determine whether treatments can be pushed further out
• Delaying elective surgeries
• Using smaller volume hydration bags and oral hydration, when appropriate
• Operating with the warning to not open or spike bags unless 100% sure of use
• Switching patients on rituximab, trastuzumab, or pertuzumab from the IV formulation to the injectable formulation when possible.

The high volume of responses led to an official webinar and discussion of the topic on October 30, 2024. Members were encouraged to attend and share their personal experiences and those of their programs.

Providers Come Together to Share Challenges and Solutions

Meagan O’Neill, executive director of ACCC, opened the webinar by asking members how the shortage has impacted patient care. One participant shared that though his center hadn’t been significantly impacted up to that point, the shortage has highlighted the need for leaders to have critical conversations about how they will respond when their inventory is depleted. “One thing we’ve started with is an incident command and an emergency management philosophy, and that’s been helpful here,” he stated.

Another attendee added that of all the types of drug shortages to experience, IV fluid is the most disruptive, “since it hampers our ability to administer certain products.” He also emphasized that because the Baxter plant supplies 60% of the US inventory, the crisis is of a greater magnitude. “And of course we know that there’s a protracted process to get back up and running, and there are various quality steps and assessments [to be completed] before we can start seeing that product be released out to the batch,” he said.

Shifting to strategies for addressing the shortage, a nurse manager at a regional cancer center in Vermont said that her center began changing premedications that were in bags to IV push or oral formulations. A clinical coordinator added that nurses at her center were concerned about hand-flushing nonhazardous drugs at a slow enough rate to avoid adverse effects. “One of our nurses came up with the idea to use a hemostat to clamp the drug to the y port and connect a 10-cc saline flush—because we have plenty of those—and program it for 10 mL,” she explained. “We do 2 of those, and we’re able to flush the remaining 20 mL of saline that are in the line in 12 minutes without risking adverse effects.”

Another attendee discussed the importance of conservation strategies based on the size of an organization and the structure of its emergency management policies. “One aspect to look at is how much you’re using per line item, then forecasting to determine opportunities you may have to switch to different bag sizes,” he suggested. “Having information about what you have in stock and your upcoming allocation is key, so you can plan ahead.”

Prioritizing Communication With Patients and Caregivers

On the topic of patient and caregiver communication, one participant explained that she has been preemptively telling her nurses and patients what to expect, “because if they see us hand-flushing or doing something different than normal, I want them to know why we’re doing it.” She also spoke to the importance of educating patients who get more routine fluids and telling them to increase their oral intake as much as possible. A director of infusion services echoed the need to educate patients about hydrating themselves at home as they were getting infusions. “We worked with clinic providers, preoperative staff, and pharmacy workers to create a 3-tiered approach,” she explained. “We also worked closely with providers and talked with their patients if we were potentially going to adjust their routes or dosage.”

Implementing Lessons Learned From Previous Shortages

When asked about lessons learned from past shortages, one attendee said, “Unfortunately, it's a sign of the times that we're actually getting too good at mobilizing these responses to supply chain issues across the health care industry. Specifically in a cancer program, the relationship between the pharmacy and nursing departments is key to responding to situations like this, because there are a lot of great, creative solutions that come up when you get those 2 groups together.”

Others commented on the role government interventions should play in the future to mitigate the impact of natural disasters or pandemics. One participant spoke to the advocacy work of pharmacy professional organizations around drug shortages. “There is a need for some significant change in the pharmaceutical industry, because we're just setting ourselves up to repeat this over and over,” he argued. “The main theme being thrown out is increased transparency: having better numbers of what is made in each plant and where [those plants are] located around the globe so that we can react quickly if there's a natural disaster.” He also advocated for better communication with companies about available products, their location in the market, and other matters such as strategic reserves of fluids or other critical essential medications.

Another attendee posed a question about increasing industry oversight for the sake of patient care during shortages. “We need to have more transparency and better access, because this has happened before, right?” she said. “We've gone on this pathway where one company has a monopoly. Is that where the government starts to play a role? We have free enterprise, but when we start thinking about the patients and what we have to deliver to them, should we have that kind of open market?”

ACCC will continue to monitor this and other shortages and provide updates accordingly. For more guidance regarding extending expiration dates, read Baxter's announcement. To join in the conversation and share what is happening at your cancer program, please visit ACCCeXchange.