Vermont hospitals facing IV fluid shortage

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BRATTLEBORO — More than three months after Hurricane Maria roared through Puerto Rico, Vermont hospitals are still feeling the effects. That's because the storm and its lingering impacts have severely hampered a key manufacturer of intravenous fluid bags, creating a nationwide shortage of a critical tool for mixing and delivering medications.

Doctors, pharmacists and medical administrators in Vermont have developed a variety of workarounds, including changing the way some drugs are delivered and leaning more on group-purchasing arrangements. But even as the shortage is showing signs of easing, hospital officials say they're still wrangling with supply problems from a hurricane that struck nearly 2,000 miles away.

"You lose millions of bags a week in supply to the United States, and that creates a shortage everywhere," said Mike Auger, pharmacy director at Northeastern Vermont Regional Hospital in St. Johnsbury.

Hurricane Maria devastated Puerto Rico when the storm made landfall Sept. 20, and recovery has been slow. A recent news report estimated that half of the island still has no power, more than 100 days after the storm.

A little-known side effect of the storm is its impact on the medical products industry. That industry has a "significant presence" in Puerto Rico, and the "disruption ... has had ramifications for patients both on the island and throughout the U.S.," the federal Food and Drug Administration said in a Nov. 17 announcement.

The FDA's concern has focused mostly on small saline IV fluid bags made by Baxter, an Illinois-based company with three facilities in Puerto Rico. Saline IV fluids have been "intermittently in shortage dating back to 2014," FDA Commissioner Scott Gottlieb said, but "the situation in Puerto Rico has greatly exacerbated this supply issue."

In a subsequent statement, Gottlieb also cited Baxter's disrupted production of amino acids for injection.

"This product is of critical need for patients, including children and infants, who are not able to eat and need to receive their nutrition intravenously," he said.

In an attempt to alleviate the issue, the FDA approved alternate suppliers of IV solution and also has been working with Baxter and other governmental officials to try and resolve production problems.

But it's a long-term project that will "require a sustained effort by industry, the agency and other partners as we work with manufacturers to return to production levels that adequately meet the needs of patients," Gottlieb has said.

The persistent IV fluid shortage has been felt across Vermont, from the state's smallest hospital, Grace Cottage in Townshend, to the largest, University of Vermont Medical Center in Burlington.

"We are definitely feeling the pinch from what happened from Hurricane Maria," said Wes McMillian, UVM Medical Center's pharmacy director.

McMillian said the storm "interrupted our normal supply chain" for saline and dextrose IV fluids, as well as for amino acids.

The hospital has not changed any bedside procedures but has modified its drug-compounding practices when necessary — for instance, using dextrose instead of saline if saline is in shorter supply.

UVM also has worked with other hospitals within its regional network to share supplies and has relied on a nationwide group-purchasing network called Vizient to help manage the shortage, said Charlie Miceli, chief supply chain officer.

"To have that collaboration has been super for us," Miceli said.

The strength-in-numbers approach also is part of the solution at Brattleboro Memorial Hospital. Purchasing Director Ernie Dowd said Brattleboro's membership in the New England Alliance for Health allows him to "share information and where possible make a deal with other hospitals to purchase something I need or offer them items I may have excess of."

Within the hospital, Dowd said staffers are managing IV fluid inventory by making sure heavily used products are "stocked as much as possible" in higher-use locations. For instance, the hospital might place more lactated Ringer's solution, used for fluid and electrolyte replenishment, in the emergency department on weekends.

But reallocation only goes so far. At many Vermont hospitals, conservation is the buzzword for IV fluids.

Grace Cottage is contracted to use Baxter IV products, but "we're very fortunate, where our supply team jumped on it and was very proactive," said Pharmacy Director John Kim.

"We were able to communicate with providers in our hospital to make sure we used those bags more conservatively and order as much as we can when the opportunity arises," Kim said.

At Northeastern Vermont Regional, Auger noted that IV fluids "make it really convenient" to deliver a variety of medications including antibiotics, pain relievers and cardiovascular drugs. But he said the hospital has seen supply reductions as severe as 80 or 90 percent. That's changed the way the hospital administers drugs in some cases in order to "conserve whatever bags we can get," Auger said.

Patients likely won't notice any difference, Auger stressed. And, "in terms of quality of care or safety, there are no safety risks with the strategies that we've employed here," he said. That was a common theme throughout the state, as health officials said they've been able to cope with the shortage without compromising care.

Vermont Department of Health spokesman Ben Truman said officials are aware of the supply shortage, and Commissioner Mark Levine "has received national briefings about it."

He added, though, that the department has received "no requests for assistance or intervention" from any hospitals or emergency medical services.

There are indications that the situation is improving. In an update issued Thursday, the FDA said all of Baxter's facilities in Puerto Rico have been reconnected to the power grid. Citing that and other developments, Gottlieb said he's "optimistic that supplies of IV saline and amino acids will increase over the next few weeks and the stress of the shortage will begin to abate."

That doesn't mean that supplies will flood the market quickly, however. At Southwestern Vermont Medical Center in Bennington, administrators have made purchasing and procedural changes to ensure that the shortage's impact is "very minimal," Pharmacy Director Rob Sherman said.

But Sherman also said he'd heard that it could take until the end of the first quarter of 2018 to get Baxter fully operational again.

Other hospitals also are taking a cautiously optimistic view of the situation.

"We're not out of the woods, but it's improved," UVM's Miceli said. "We still have to keep an eye on it and work very closely with our suppliers."

Mike Faher can be contacted at mfaher@vtdigger.org.

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