Saline Shortage Prompts Conservation Efforts
Drug shortages have been a part of daily pharmacy practice for years, but the recent national shortage of 0.9% sodium chloride injection is garnering unusual attention.
"This is one that's really hitting every patient across the board," said Jennifer Brandt, clinical specialist pharmacist at MedStar Washington Hospital Center in Washington, D.C.
"There's rarely a patient that comes into the hospital that doesn't need i.v. fluids for a procedure, for surgery, for hydration," Brandt said. "With a lot of the other shortages, it's been a really narrow patient population that is affected."
Three out of four pharmacy directors who responded to a recent ASHP online survey said i.v. sodium chloride products are in short supply at their institutions. In all, 29% of respondents said they had insufficient supplies of the i.v. solutions to meet patient needs.
Conservation efforts reported by the survey respondents included using alternative products when appropriate, changing doses, prioritizing i.v. saline use in patients on the basis of clinical factors, and, rarely, delaying treatments.
Bona Benjamin, ASHP's director of medication-use quality improvement, said ASHP conducted the survey to assess the effects of the shortage on patient care and communicate the urgency of the problem to FDA and the health care community.
"We have also used this information to notify the Centers for Disease Control and Prevention of the potential for a public health risk and to update the assistant secretary for preparedness and response," Benjamin said. "We are in daily contact with the FDA drug shortage staff, who has said locating additional supplies is their priority issue right now."
FDA stated in January that the agency was working with Baxter Healthcare Corp., B. Braun Medical Inc., and Hospira Inc., to preserve the U.S. supply of sodium chloride injection. According to FDA, the shortage is related to an increased demand for i.v. saline solution that may be related, in part, to the treatment of patients with influenza.
Brandt said the shortage hasn't greatly affected her health system.
"We've been really lucky," she said. "MedStar, as a whole, has worked really hard to mitigate the shortage. And they tried to do that as early in the process as possible. So we were able to conserve what we had and use it wisely."
She said MedStar's saline conservation practices include using smaller-sized bags, oral replacement fluids, and alternative i.v. solutions, when appropriate. Information about the shortage and mitigation practices is communicated through e-mail, newsletters, and messages embedded in the computerized prescriber-order-entry system.
"We have 1500 prescribers and more than 2000 nurses, and getting the message across to all of them has been difficult," she said.
She said another important practice has been to reemphasize an existing policy to keep bags of i.v. saline hanging for 96 hours during administration to a patient instead of replacing them every 24 hours.
The Centers for Disease Control and Prevention (CDC) recommends changing infusion administration sets no sooner than 72–96 hours in patients who are not receiving i.v. blood, blood products, or fat emulsions.
That policy does not include an official recommendation for so-called hang times for i.v. fluids. But the Institute for Safe Medication Practices (ISMP), in response to the i.v. saline shortage, found that at least one study supports extending hang times beyond 24 hours, which ISMP said hospitals are now doing or considering.
William Greene, chief pharmaceutical officer for St. Jude Children's Research Hospital in Memphis, Tennessee, said his hospital has doubled i.v. bag hang times in response to the shortage.
He said the nursing staff, when told about the shortage, let him know that they were routinely discarding saline bags with substantial volume remaining in them.
"In a child, you might send up, say, 500 cc's or a liter of fluid, and you only use 200 or 250 cc's and throw away the rest," he said. "So the first step we did to improve our utilization and reduce our waste was simply to allow those fluids to continue to stay on and running for up to 48 hours."
Greene said the additional hang time applies only to "preprepared and low-risk fluids," not i.v. solutions that contain medications or are otherwise unsuitable for the extension.
He said no one could recall a valid clinical justification for the previous practice of changing i.v. bags after 24 hours, and the infection-control staff supported the doubling of the hang time.
Greene characterized the shortage as mostly administrative in nature and said it is having a moderate effect on the hospital. He said a dedicated purchaser for St. Jude networks with manufacturers and wholesalers to meet patients' needs, and the pharmacy staff hand count the hospital's supply of i.v. saline solutions at least three times per week to keep track of what's on hand.
"We're spending the time and effort to go and count, and that means that we're worried about it," Greene said.
He said St. Jude probably has less need for saline than, for example, hospitals that treat adults or burn victims.
Nevertheless, he said, the hospital is taking the shortage seriously. In addition to increasing hang times, saline conservation largely involves communicating with clinicians and asking them to select alternatives to i.v. saline, when appropriate.
"Our clinical pharmacists are engaged in a lot of nutrition-support and hydration decisions," Greene said. "They know when it's possible to select a different kind of hydration fluid."
Greene said clinicians at St. Jude are mindful, when considering dextrose-based i.v. solutions, of the need to avoid changes in osmolality that can cause serious neurologic problems, especially in small children.
John Armitstead, system director of pharmacy services for Lee Memorial Health System in Fort Myers and Cape Coral, Florida, said the shortage has led to greater-than-normal use of lactated Ringer's injection and a more moderate increase in the use of dextrose solutions.
Armitstead said dextrose solutions can be used safely in patients with diabetes, especially in conjunction with the blood glucose monitoring that hospital patients undergo.
"It sounds counterintuitive, but all you need to do is compensate for the calories that you're delivering," he said. "In a diabetic patient, it's preferred not to dominate the diet with carbohydrate calories, but dextrose solution contains small-to-moderate amounts of carbohydrates."
Armitstead said establishing and maintaining i.v. line access accounts for the vast majority of i.v. solution use at Lee Memorial, with far less going toward fluid replacement. He said the hospital uses alerts in the electronic health record system to remind prescribers about the shortage and ask them to select another fluid, if appropriate.
The multihospital system typically maintains a three- to four-week supply of i.v. saline and had about three weeks' worth on hand when news of the shortage broke, Armitstead said.
"Through our conservation, we projected that we'd turn that three-week supply into, in essence, a six-week supply," he said, adding that his group purchasing organization has been able to consistently supply the health system.
"We're still under conservation mode, but we never ran out and we don't expect that we will," Armitstead said in late February. "So we are not directly impacted in patient care needs situations."