A severe flu season is increasing the need for intravenous fluids for patients in the central San Joaquin Valley at a time when they are in short supply.
The demand for IVs has outstripped their availability for several years because a limited number of manufacturers produce them. But the shortage became critical over the past five months after Hurricane Maria cut power to major manufacturing plants in Puerto Rico.
Patients likely haven’t noticed the shortage, but hospitals and medical practices have had to adopt strategies to conserve dwindling inventories, such as giving patients more pills and fewer drugs through IV tubes.
So far, hospitals have been able to avert worst-case scenarios: limits to admissions and delays of elective surgeries – but “it’s a very fluid, dynamic situation,” said Dr. Thomas Utecht, corporate chief medical officer at Community Medical Centers, which operates Community Regional Medical Center and Fresno Heart & Surgical in Fresno and Clovis Community Medical Center.
However, a surge of flu patients in hospital emergency rooms and intensive care units over the past month is making the situation more dire. “It’s added an increased stress point to the system,” Utecht said.
Scott Gottlieb, commissioner of the federal Food and Drug Administration, said in a statement Tuesday that the agency is working to get the Puerto Rico factories up to full operation, and is working with manufacturers to import IV fluid products from countries outside the United States, most recently from a Baxter International Inc. plant in Brazil. The FDA also is considering a request by pharmacists to extend expiration dates on products.
“Despite these steps,” Gottlieb said, “it may still take more time for new product supply to diffuse across the marketplace and have a noticeable impact on product availability.”
Hospitals and health care providers need both small bags used to mix medications and larger bags to deliver fluids. The bags in short supply contain an IV saline (salt-based) solution.
“Suppliers are not telling us day-to-day or week-to-week when we are getting our next fluids,” Utecht said. The shortage has required hospital staff to assess IV fluid supplies twice a day, he said. Doctors are encouraged to prescribe oral medications whenever possible instead of using IV fluids to deliver drugs. And doctors are closely watching patients to see when they safely can be switched from an IV to take fluids or medications by mouth.
Dr. Jessica Mason, an emergency department physician at Community Regional, said the shortage of IV fluids is especially noticed in the administration of antibiotics. “So if there’s a medication I can give in pill form and it works just as well in pill form, I give it in pill form.”
She also is ordering more medications be given through injections, when possible.
Doctors at Saint Agnes Medical Center in northeast Fresno are giving lower doses of medications that can be directly injected instead of medications that normally take longer to drip from an IV bag.
“The shortage is significant,” said Dr. Walter E. Egerton, chief medical officer at Saint Agnes. “Supply shipments are unpredictable so we are managing the supplies we receive in the most efficient manner possible.”
Kaweah Delta Health Care District in Visalia is managing its supply of IV bags, but the potential for secondary shortages of syringes and empty bags are of concern, said Rheta Sandoval, inpatient pharmacy manager. More syringes are being used to draw up a small amount of fluid to administer a drug, bypassing the need for a full IV bag. And empty IV bags are being used to mix medications that normally would arrive pre-mixed in full IV fluid bags.
FDA Commissioner Gottlieb said the agency is aware of diminished supplies of empty bags and is identifying steps it can take to help.
The FDA’s assertion that hospitals should see an improvement in the shortage of IV fluid bags in coming weeks and months is welcome news.
So far, Valley Children’s Hospital has an adequate supply of IV bags, but the hospital monitors the supply daily, said David Hodge, vice president of ancillary services.
Patients are not noticing the shortage of IV bags, and that’s the important thing, he said. “It has not affected our ability to deliver patient care.”
But the IV bag shortage has caused concern at more than hospitals. “It was pretty scary for a while,” said Matt Paliughi, a pharmacist at California Oncology in Fresno.
“It was scary for a while,” Paliughi said. “It’s medically necessary for these people to have their chemotherapy – to stay on track for that.”
The office has been able to avoid treatment delays or sending patients to hospitals for care by eliminating some excess usage of bags, he said.
Right now, Paliughi said, the oncology practice has an allotment of IV fluids, and it looks like the national shortage should be resolving in the next couple of months. But hospitals could be the first to benefit when manufacturing returns to normal, he said. “My understanding is hospitals might have a little more priority – more buying power.”