MCH, ORMC still have to work around IV fluid shortage

Medical Center Hospital and Odessa Regional Medical Center still have to work around a shortage of IV bags that occurred after Hurricane Maria in fall 2017.

One of the major IV fluid supplies, Baxter, was devastated by Hurricane Maria in Puerto Rico and shut down, a news release said. Other suppliers were experiencing the same shortage due to manufacturing interruptions and increased demand, the release said.

According to the Puerto Rico web page that focuses on business and investment, half of the world’s leading pharmaceutical companies have operations on the island and 11 of the top 20 prescription medications sold in the U.S. are made in Puerto Rico due to the tax incentives offered.

MCH Emergency Management Coordinator Amanda Everett said several different manufacturers make those bags, but they didn’t see the hurricane coming or didn’t think it would cause as much damage as it did.

“Usually companies will ramp up prior to events like this to cover if the manufacturers go down, but that didn’t happen in this situation and we’re still having issues with getting the products out of Puerto Rico,” Everett said.

She added that she has heard things are up and running again, but the problem is getting the supply to the United States. Everett said the situation isn’t expected to ease until the third or fourth quarter of this year.

“It’s good practice during the summer to start … ordering a couple more boxes every time they put an order in … to kind of get a side cache going because every flu season we’re going to use more fluid than on a normal basis,” Everett said.

Everett said the shortage hit during a period when the hospital had already planned on using more fluids than normal, so most hospitals already had some fluids set aside.

MCH Pharmacy Director Charlene Dawson said the pharmacy usually goes through a palette of IV fluid about twice a week. For lactated ringers, another kind of IV fluid, it’s probably a palette a week.

“We had shortage issues already because we purchased most of our fluids through what was Hospira, bought by Pfizer and it’s now ICU Medical. They had some plants that the FDA shut down because they had mold growing in the vats where they put the IV fluids in to package them, so the shortage actually started long before the hurricane. That was just kind of the thing that pushed us over the edge so that no one was able to keep up with supply,” Dawson said.

Everett said it was first a problem with the actual fluid and now there is a problem with packaging the fluid.

“Whenever we get into bad situations in the hospital,” Everett said, “we start talking about strategies on how to conserve. There are situations when you can use a different kind of formula to give to a patient, if necessary. But there are some medications that don’t mix well with certain fluids. Sometimes you just have to have normal saline, or you just have to have lactated ringers for a specific medication.”

There are different ways to administer medications such as pushes, where it’s a much smaller dose and the nurse has to push it in slowly.

“It looks like a shot going into an IV, but it’s just a very slow push,” Everett said. “You can put medications into different sizes of bags. Some pharmacists have preferences on putting a certain medication in a 250 milliliter bag, but since we have shortages maybe they have to go in a 500 now. … You work with what you have.”

Dawson said a liter is about the same as a quart.

Everett added that the hospital has mutual aid agreements with other hospitals in their trauma service area that they can trade with, or borrow from and pay back later.

“It has helped other hospitals in the past. As of right now, we haven’t had to get to that point yet,” Everett said.

Dawson said MCH has a “very collaborative” relationship with ORMC and Midland Memorial Hospital.

On a separate matter, Dawson said the hospital also is having significant issues with shortages of drugs like morphine, Dilaudid and Demerol.

“It’s been this way for several years,” Dawson said. “It kind of waxes and wanes. Part of it is because manufacturing plants work off of a production schedule very similar to what a car manufacturing plant does. They set up a plant to make a drug for a period of time. They project what their sales volume is going to be for that period of time. They make that much. They stop, they retool (and then) they make something different.”

“If something unexpected happens and they run out of their initial projection, somebody didn’t guess then you just can’t go in and say we’re going to make more of that tomorrow. You have to adjust the production schedule. Typically what happens is we’re just out until they make it again. When they make it available again price is 4 to 20 times as expensive. You pay it because you don’t have a choice,” Dawson added.

Tim Mickle, director of pharmacy at Odessa Regional, said the way the process with IV fluids works is manufacturers make the product and move it to the wholesaler. That company moves it to the actual facility.

For instance, Mickle said, let’s say Cardinal Health is ORMC’s wholesaler. “They’re the distribution center we get our fluids from. The order is placed through the wholesaler. They have product ship to you. As they run out, they contact Baxter to get more,” he said.

“When there is a shortage, everyone wants to hoard product. Someone who uses 10 cases a week, they may order 200 cases and stack it up because they know down the road I’m not going to be able to get this so I’m going to buy everything I can,” Mickle said.

Unfortunately, when everyone does this it depletes the product, he added.

As things improve they’ll increase to 100 percent of allocation.

There is a certain standardization in healthcare, so when you can’t get what’s normally used, it changes everything.

“I think everyone’s having difficulties,” Mickle said. “Our main issues are plain IV fluids.”

“What we’ve done at ORMC is we switched to an IV push process where we use sterile water for injection, dilute the drug in that product and use that instead of sodium chloride and D5W (intravenous sugar solution).”

Asked if he had seen a situation like this before, Mickle said, like MCH, the hospital has struggled with drug shortages for five to 10 years.

The hospital also is trying to administer as much oral medication as possible for antibiotics and to stop it at the appropriate time.

“We meet every day to discuss patient care, antibiotic therapy and duration. Part of that discussion becomes can we transition into oral? Can we stop the antibiotic? …” Mickle said.

He said the inventory isn’t static.

“When Puerto Rico had the hurricanes and it wiped out the manufacturing process, there’s a certain amount of inventory that’s in their warehouses on the shelf within the distributors’ facilities. It takes a period of time for that to be utilized and used up, so for several weeks afterward you may not feel it but then it slowly takes place. But when they ramp up production will take the same slow process for product to get back into the inventory,” Mickle said.

He noted that it wasn’t necessarily the manufacturing building and the facilities that put a kink in things; it was the infrastructure on the island, such as damaged road and no electricity, which delayed production.

“It’s a good lesson in logistics and it’s also a part of not putting all your eggs in one basket,” Mickle said.

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