After Hurricane Helene struck Baxter's site in North Cove facility in Marion, N.C. — the nation's main manufacturer of intravenous and peritoneal dialysis solutions — several healthcare organizations have shared conservation and drug shortage mitigation tips.
The site has been temporarily closed since Sept. 29. Baxter said it plans to resume operations at the plant by end of year but is unsure when supply will rebound to normal levels, according to an Oct. 14 post on its website.
Here are 20 recommendations from the FDA, CDC, Vizient, the American Society of Health-System Pharmacists, the American College of Radiology, the National Home Infusion Association, the End Drug Shortages Alliance, the Emergency Care Research Institute, the American Society of Anesthesiologists and the American Society of Nephrology.
Editor's note: The recommendations are not listed in a specific order.
Operational suggestions
1. Establish a multidisciplinary team to create conservation and stewardship strategies. Communicate any changes with affected staff and patients.
2. Where clinically appropriate, transition patients to an oral equivalent. On Oct. 15, the ECRI published a data set of hundreds of functional equivalents and alternative products to Baxter's IV and irrigation solutions currently in shortage.
3. Make a schedule to regularly assess restrictions and adjust plans in response to current and future supply strains.
4. Obtain systemwide estimates of available IV and PD inventory. Communicate often with neighboring health systems, wholesalers, group purchasing organizations and distribution partners about available supply.
5. Consider changes in the EHR system to allow several options for compatible diluents. Also evaluate the possibility of using EHR alerts or forced functions when a drug is compatible with only one diluent.
Clinical recommendations
6. At every shift change and bag change, evaluate the clinical need to continue IV replacement and assess the need to start "keep vein open" orders.
7. Where clinically appropriate, consider catheter locks with flushes, discontinue infusions as soon as possible, and avoid stopping and restarting IV fluids during transitions of care.
8. Evaluate total fluid requirements for surgeries and transition to oral fluids within 24 hours after surgery.
9. Use smaller bags for slow infusion rates.
10. Avoid opening and "pre-spiking" bags in anticipation of a surgery, according to the ASHP. The ASA recommends limiting the use of pre-spiked fluid bags in nonemergency areas to limit IV fluid waste.
11. If the bag is spiked immediately before administration, consider extending hang times for IV solutions.
12. When compounding nonsterile presentations, review sterile water guidelines. Compound parenteral nutrition presentations in a single, central location to decrease inventory waste.
13. With small volume shortages, consider using single-flush syringes. Also consider administering medications via intravenous or subcutaneous injection if an oral route is not feasible.
14. With large volume shortages, decrease the unit stock of large volume bags or only stock in critical care, procedure and emergency care areas.
15. The Institute of Safe Medication Practices recommends never using IV solutions when they are in containers meant for infusion to obtain flush solutions, diluents or other products for more than one patient. When small volume packages are required but not available, aliquots of fluids drawn into syringes may allow a bag of fluid to be used on multiple patients if syringe pumps can be used, the ASHP said.
16. Radiologists are recommended to reduce test/patency flush to 20 milliliters, minimize or eliminate saline chasers in computed tomography, and reduce chasers for magnetic resonance to 10 milliliters.
17. Anesthesiologists are advised to use microbiome tubing and/or mini-drip fluid administration sets. Also, instead of continuous fluid administration, saline locks could be used for some minor procedures.
Other tips and resources
18. Report suspected nontraditional distributors engaging in price gouging and illegal activity.
19. Overall, prioritize bag sparing over solution sparing, the American Society of Nephrology recommended.
20. Click here to read 10 recommended steps the American Thoracic Society shared after the 2017 Hurricane Maria caused a widespread IV supply shortage.