Running Dry: How Hospitalists Can Conquer the IV Fluid Crisis

Intravenous fluids are undeniably essential in modern medicine, acting as a critical conduit for delivering hydration, electrolytes, medications, and nutrition to patients. They are vital for resuscitation, maintenance, and replacement therapies. However, the increasing prevalence of IV fluid shortages is a growing concern for healthcare systems worldwide. This scarcity often disproportionately impacts essential fluids like sodium chloride (normal saline) and dextrose solutions, which are fundamental to a wide range of medical interventions. The consequences of these shortages are widespread, affecting patient care, disrupting hospital operations, and straining healthcare budgets. Recent events, such as the damage inflicted by Hurricane Helene on the Baxter manufacturing plant in North Carolina, have further exacerbated the situation. As a major supplier of IV fluids in the U.S., the significant reduction in Baxter’s production capacity triggered widespread shortages, serving as a stark reminder of the healthcare system’s vulnerability to supply chain disruptions. This underscores the urgent need for robust contingency plans to ensure continued access to these essential medical resources.¹

Underlying causes of the shortage

The current IV fluid shortage is a multifaceted problem with a complex web of contributing factors. Natural disasters, such as hurricanes and earthquakes, can severely disrupt manufacturing processes, especially considering the specialized nature of IV fluid production facilities. Furthermore, shortages of raw materials, including plastics for IV bags and sterile water, coupled with global supply chain delays, create bottlenecks in the production process. Increased demand during public health emergencies, such as pandemics or large-scale infectious outbreaks, can further strain the system. The concentration of IV fluid manufacturing in a limited number of companies and the stringent regulatory requirements for production adds further complexity to the issue, making it challenging to increase production quickly or diversify supply sources in response to shortages.

Challenges faced by hospitalists

Hospitalists, who are at the forefront of inpatient care, face unique challenges in the context of IV fluid shortages. The limited availability of IV fluids necessitates a more judicious approach to fluid management, requiring clinicians to dedicate more time and effort to patient assessments, exploring alternative therapies, and making frequent adjustments to treatment plans. In severe shortage situations, health professionals may be forced to make difficult ethical decisions regarding fluid rationing and the prioritization of patients based on individual needs and the likelihood of benefiting from the limited resources. Effectively communicating the rationale for fluid conservation measures to patients and their families can be challenging, requiring clear and empathetic communication to alleviate concerns and ensure understanding. Staying abreast of the latest fluid management guidelines and recommendations during a shortage demands continuous learning and adaptation to evolving best practices. Also, the use of alternative fluids and adjusted medication regimens, particularly in the context of fluid conservation, increases the risk of medication errors and potential adverse patient outcomes, necessitating heightened vigilance and careful monitoring. Effective communication and collaboration with the entire healthcare team, including nursing staff, pharmacists, and supply chain managers, are also crucial to ensure that fluid conservation efforts are consistently applied and understood across all levels of patient care.

Strategies for managing IV fluid shortages

Optimizing fluid management: Care providers must adopt a meticulous approach to fluid management, beginning with thorough patient assessments to accurately determine the type and volume of IV fluids required. This includes avoiding unnecessary or excessive fluid administration. Exploring and using alternative therapies when clinically appropriate is essential. This may involve oral rehydration solutions and enteral hydration. Minimizing waste using smaller IV fluid bags and avoiding the disposal of partially used bags is another important conservation strategy. Continuous monitoring of patients’ fluid status and electrolyte balance is crucial, with treatment plans adjusted as needed to ensure optimal hydration. Incorporating standardized order sets and protocols into daily workflows can streamline fluid management and facilitate conservation efforts.^2,3

Leveraging technology and clinical competency: Clinicians should utilize available technology to support fluid-management decisions. Electronic health record (EHR) systems can be used to implement alerts and reminders for appropriate fluid prescribing, alternative therapies, and conservation strategies. Integrating clinical decision support tools into EHR systems can provide real-time guidance and recommendations for fluid management. Staying informed about the latest guidelines, best practices, and research related to fluid management during shortages requires continuous learning and engagement in continuing medical education activities.^2,4

Enhancing patient and family education: Open and transparent communication with patients and their families is crucial. Healthcare providers should clearly explain the reasons for IV fluid conservation efforts and emphasize the importance of oral hydration for patients who can tolerate it. Addressing any questions or anxieties that patients may have regarding their treatment and fluid management plan with patience and empathy can help alleviate concerns and foster trust.

Focusing on patient-centered care: Patient-centered care remains paramount during IV fluid shortages. Attending physicians should actively engage patients in discussions about their fluid management plans, explaining the rationale behind conservation efforts and addressing their concerns. Using patient-reported outcome measures can help assess the effectiveness of fluid management strategies and tailor interventions accordingly.⁵

Promoting antimicrobial stewardship: Judicious antibiotic use is critical during IV fluid shortages. Hospitalists should adhere to evidence-based guidelines for antibiotic prescribing, including appropriate selection, dosage, and duration of therapy, to minimize the need for IV antibiotics and the associated fluid requirements. Transitioning patients to oral antibiotics as soon as clinically feasible is another key strategy to conserve IV fluids. Optimizing antibiotic dosing strategies to minimize the volume of IV fluids required for administration can further contribute to conservation efforts. To conserve IV fluids, consider IV push antibiotics when clinically appropriate. While pharmacists often manage this process, physicians should be aware of this strategy to help address IV fluid shortages.^2,6

Addressing specific patient populations: Vulnerable patient populations, such as pediatric, geriatric, and critically ill patients, require special consideration. Clinicians should develop specific protocols for managing fluid balance in these populations, considering their unique needs and risks.

Analyzing economic implications: The economic impact of IV fluid shortages should not be overlooked. Care providers should explore cost-effective strategies for managing fluid resources, such as using smaller IV fluid bags and minimizing waste. Advocating for institutional policies that allocate budgets for backup supplies or alternative fluids can help ensure preparedness for future shortages.

Ethical frameworks for fluid rationing: In severe shortage situations, ethical considerations become paramount. Hospitalists should be involved in developing clear ethical guidelines for rationing IV fluids and prioritizing patients based on factors such as severity of illness, likelihood of benefit, and availability of alternative treatments.

Interdisciplinary approaches: Effectively managing IV fluid shortages requires a collaborative interdisciplinary approach. Hospitalists should foster collaboration across departments, including pharmacy, supply chain management, and nursing, to enhance fluid management strategies and ensure a coordinated response.

Impact on hospital culture and resilience: IV fluid shortages highlight the need for a culture of innovation, cross-training, and improved emergency preparedness within hospitals. Healthcare practitioners can play a key role in advocating for better supply chain preparedness and contingency planning at the institutional level.⁷

Future of fluid management

Artificial intelligence (AI): AI has the potential to revolutionize fluid management. AI-powered tools can predict IV fluid needs based on patient demographics, medical history, and real-time data, allowing for proactive planning and resource allocation. These algorithms can identify patients at higher risk of fluid overload or dehydration, enabling early interventions to prevent complications. AI can also tailor fluid-management strategies to individual patient characteristics and risk factors, helping to ensure resources are used efficiently.

AI-powered inventory management systems can also forecast IV fluid demand based on historical usage trends, patient profiles, and supply chain data, thus optimizing ordering and preventing future shortages.^8-11

Telemedicine: Telemedicine provides a valuable platform for assessing and managing fluid needs, especially in stable patients or those in remote or resource-limited settings. Virtual monitoring can be conducted to evaluate patients’ hydration status and determine the appropriateness of oral hydration or alternative therapies. Continuous monitoring of vital signs, fluid balance, and even biomarkers could allow for real-time adjustments to fluid administration, optimizing patient outcomes. This reduces the need for IV fluid administration and can help preserve supplies for acute cases. Additionally, telemedicine allows clinicians to monitor patients’ responses to alternative therapies remotely, ensuring that fluid requirements are met without depleting critical IV resources.

Institutional responses to recent shortages

The recent IV fluid shortage crisis, exacerbated by events like Hurricane Helene, prompted a swift and coordinated response from various institutions:

• The FDA implemented temporary measures like compounding flexibilities, extended shelf-life for certain IV fluids, and facilitated importation to increase supply.¹²
• The Department of Health and Human Services (HHS) focused on information dissemination, collaboration with stakeholders, and supporting increased production.¹²
• Professional organizations like the American Society of Health-System Pharmacists, the Institute for Safe Medication Practices, and the United States Pharmacopeia provided guidance on conservation strategies, compounding practices, alternative therapies, and medication safety.
• State- and hospital-level emergency declarations, resource coordination, and hospital-level task forces were implemented to manage the crisis effectively.

These collective efforts highlight the importance of collaboration, proactive planning, and a multi-tiered approach in responding to public health emergencies like IV fluid shortages.

Conclusion

IV fluid shortages present a complex and evolving challenge for healthcare practitioners, demanding a multifaceted and adaptive approach to ensure the continuation of high-quality patient care. Hospitalists, with their central role in inpatient management, are uniquely positioned to lead the response to these shortages. By staying informed, optimizing fluid management strategies, promoting antimicrobial stewardship, educating patients, leveraging technology, harnessing the power of AI, advocating for system-level solutions, and fostering interdisciplinary collaboration, inpatient care providers can effectively navigate these challenges and ensure the best possible outcomes for their patients. While the issue of IV fluid shortages may persist, a proactive, collaborative, and innovative approach, informed by lessons learned from recent events and empowered by technological advancements, can help mitigate its impact and safeguard the delivery of optimal patient care.

*At the time we went to press, Baxter published a statement on its website saying it is increasing allocation levels for several IV product groups, effective November 26, 2024. The company will share details on planned, phased increases in allocations in mid-December and at year-end, to reach 100% allocation across several IV product codes by the end of 2024. 

**Update on Baxter’s website from 12/19/2024: Eight of the 10 manufacturing lines at the site (~85% of pre-hurricane capacity) have been restarted. The company expects to be producing at pre-hurricane levels across the plant early in the first quarter of 2025.

Dr. Patel

Dr. Patel is the chair of the inpatient clinical informatics council, the medical director of virtual medicine, and a hospitalist at Ballad Health System in Johnson City, Tenn. He is also chair of SHM’s Health Information Technology Special Interest Group.

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