The recent Hurricane Helene disrupted the production and supply of IV fluids — a reminder of our nation’s fragile health care supply chain. In this conversation, Michael Schiller, executive director of the Association for Health Care Resource & Materials Management (AHRMM), and Michael Ganio, senior director of pharmacy practice and quality with the American Society of Health-System Pharmacists (ASHP), discuss the need to create a conservation plan for critical patient supplies that could be threatened by a disaster.

Tom Haederle

The nation's hospitals and health systems are still adjusting to the disruption in the production and supply of vital intravenous or IV fluids that many patients depend on, as Hurricane Helene damaged the plant that is the leading producer of these fluids. It's still undetermined when full production capacity will be resumed. In the meantime, we are reminded of the fragile supply chain that delivers many of the essentials of patient care and the need for a plan if things go awry.

Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, we learn more about the need to create a conservation plan for not only IV fluids, but for every critical patient resource that could be threatened by a disaster, natural or otherwise. Host Michael Schiller is executive director of the Association of Health Care Resource and Materials Management (AHRMM), a part of the American Hospital Association, and he's joined in this discussion by Michael Ganio, senior director of pharmacy practice and quality with the American Society of Health-System Pharmacists (ASHP).

Tom Haederle

Now to Mike Schiller.

Michael Schiller

Michael, it's great to have you here with us today. Let's talk a little bit about some of the weather patterns here that are affecting the health care supply chain. There's certainly a lot of factors that are affecting the health care supply chain, at least certainly in this post-pandemic environment. But as of late, we've had a couple of hurricanes that have really disrupted our IV supply chain and our IV solution supply chain.

Michael Schiller

And this is a great reminder. Not that we need these, but that these storms can certainly jeopardize the availability of the critical patient supplies that we need on a day-to-day basis. From a conservation strategy standpoint, Michael, what advice would you share with our listeners today?

Michael Ganio

Well, I think one, understanding the severity of the shortage, that's the first thing that needs to be done. Take inventory of your stock and understand how many days supply you have on hand. I think most organizations have done that. But an adequate conservation plan really goes further. And where can we cut back on use? And these large volume fluids are a little unique because in some hospitals, pharmacy manages some of the supply.

Michael Ganio

And in other hospitals pharmacy isn't, they're a little more hands off with things that go directly to nursing units. So I think the, you know, the thing caregivers need to keep in mind as they develop their own plans is where are these solutions coming in to the hospital? How are they being used? How can they be conserved?

Michael Ganio

And as you noted, this is not the first time this has happened. And whether it's major storms, which we all know are expected to continue as the Gulf stays warm and there's other threats to the supply chain. You know, we have put out conservation strategies. This is the third time now we've done this — the second time for large volume fluids, and we've done it once for small volume fluids.

Michael Ganio

So it's really important that caregivers have a framework for conservation of really any critical resource. And there are a lot of resources out there to do that. But in this instance, for the fluids, it's important to recognize where all those fluids are in the health system.

Michael Schiller

You know, you talked about utilization and understanding your utilization. That reminds me of a term that we used during the Covid pandemic: burn rate.

Michael Ganio

Yes.

Michael Schiller

And, I don't know about you, but this situation sure seems a bit Covid-esque to me, with what we're what we're going through. So you talked a bit about, conservation strategies. Can we dig into that a little bit more and share with us what the basic elements of a sound plan for the management and conservation of fluid shortages would look like?

Michael Ganio

Yeah. First, again, understanding where utilization is and then I recommend kind of a tiered approach to something like this. You know, you have your worst case scenario where maybe you're canceling some of those elective procedures, but then you have less invasive and less clinically disruptive strategies. And that may be alternative sources. With pharmacy, we know that, there's a whole sector of outsourcing facilities that can compound drugs.

Michael Ganio

That's going to be a little bit challenging with some of these large volume drugs, just because the supplies needed are also in short supply. But there are other things like turning down your KVO rates. So sometimes IVs are running just for the sake of having something running into an infusion catheter so that the catheter doesn't include.

Michael Ganio

Well, it's not always necessary. You can flush occasionally through that catheter to keep the vein open. And it's not really that invasive clinically to a patient to stop those IV fluids. So there are different tiers and approaches to doing this. And I think when you talk about implementing these strategies and looking at these different tiers, you can use this ethical framework to look for where can we do the most good as far as conservation with the least harm as far as disrupting patient care.

Michael Ganio

That's a really good place to start for any shortage, really. But especially these large volume fluids that are everywhere in our hospitals.

Michael Schiller

So you've mentioned the large volume fluids. Are there going to be different approaches from a conservation strategy when we're looking at large volume products versus some of the smaller volume products?

Michael Ganio

Yeah. And let's step back a second. So small volume, this is defined by the United States Pharmacopeia. So small volume is anything under 250 mls. Usually those are used to deliver medications. So a 100 ml bag with a gram of an antibiotic in it, or 250 ml bag could also be used for for infusing an antibiotic.

Michael Ganio

But when we start getting these 500 and 1 liter bag sizes, we're usually talking about hydration, things used during surgeries. This particular shortage also is affecting irrigation solutions. So some of the things that are used in the ORs, there's different strategies for managing these. A lot of the small volume parenterals that were in short supply after Maria hit Puerto Rico, coincidentally also a Baxter facility, nurses were standing at the bedside and administering through a syringe some of these antibiotics, rather than putting the antibiotic into a 100 ml bag and infusing it. That doesn't really work for hydration.

Michael Ganio

It may, in some specific instances where you can take a liter bag, draw out a bunch of 50 ml syringes, and use a syringe pump to provide that KVO rate at 25 ml an hour, potentially, during a procedure or something like that. But in general, we're managing these very differently.

Michael Schiller

In any type of emergent situation like we're experiencing, communication is critical, and we often say that you need to really overcommunicate in these types of situations, in these types of environments. How would you recommend organizations communicate changes, shortage management, distribution, utilization management, action planning and adjustments to their stakeholders?

Michael Ganio

Yeah, I completely agree overcommunication to the point where it's in your email. It pops up on the electronic health record. If it's an order or something that's applicable to the clinician. Huddles are a great way to make sure communication occurs just in time for that shift. So as nurses start their shift, there's a huddle. The nurse manager, whoever's leading, shares that information right there.

Michael Ganio

It's timely. There are other ways to communicate within the health system but use multiple modalities because this is a safety issue. The Institution for Safe Medication Practices collects data on medication errors in general, but they also will track during a drug shortage. And we know that drug shortages can lead to error and harm. Well, about 15 years ago, there were a few fatalities associated with improper conversion of hydromorphone to morphine, and vice versa during injectable opioid shortages.

Michael Ganio

So it's very important that everyone is on the same page as far as the strategy. And it's also critical because some of these things can change week to week. So what was true yesterday is not going to be true next week. And it's also important to know that some clinicians work in different hospitals. And so when you go from one hospital, if they're floating to another hospital they may have different policies.

Michael Ganio

So overcommunication is never a bad thing. But when possible make it really, really difficult to do the wrong thing. Meaning if you can put hard stops into the electronic health record and into your infusion pumps, a lot of hospitals use smart pumps now. Find ways to make it very difficult to make an error and implement those strategies.

Michael Schiller

Yeah, I've heard of some organizations actually using the internet as one of those modalities, because to your point, this is such a dynamic environment that we're in, and there's so many different messages out there in the field that people become very quickly confused as to which is the most accurate message versus those that they may be, should not pay as much attention to.

Michael Schiller

So great advice.

Michael Ganio

That's a good point with the internet too. You know, you can point things to the internet so you have one single source of truth. If you put a policy in an email and someone reads it after coming back from vacation, there might be four more emails changing what was in that policy. So, you know, keeping a single source of truth somewhere is a great idea.

Michael Schiller

Yeah, yeah, single source of truth, that is absolutely the right approach. You know, overall, we've talked about the situation that's created the current environment that we're in. Right. The situation that we're faced with. But overall, how can the health care field, all of the stakeholders that comprise the health care field, how can we prepare for events like this one, now,

Michael Schiller

and for those that will happen in the future. What's the most important thing to know and maybe some of the other, other ideas or suggestions you might have for us.

Michael Ganio

Yeah, I think first and foremost, lessons learned from the past, right. So we've been through Covid-19, the pandemic, the supply chain challenges there. You know, specific to pharmacy and drugs, as I mentioned, this is not the first time we've had fluid shortages. A little over a year ago, we were grappling with chemotherapy shortages. There have been injectable opioid shortages in the past.

Michael Ganio

So applying lessons learned moving forward. Well, just the next time you go through this, this process, you've gone through a few iterations, you fine tuned whatever has worked to manage the shortages, knowing that this is not going away. You know, whether it's large storms, whether it's recalls of drugs, whether, you know, for other equipments and supplies outside of the pharmacy department.

Michael Ganio

This is not an isolated incident. And while it feels that way, while we're in the moment, when you look at your you zoom out and you see 20 years or so of history, realizing that we need to have a plan, maybe after this event, you debrief and with a leadership team, risk management, pharmacy leadership, supply chain, leadership, get everyone.

Michael Ganio

What did we learn? What can we put into policy to be prepared for the next time?

Michael Schiller

Great advice. I know that we've seen conservation strategies include clinical practice review, clinical practice changes. And what's interesting is those changes that were put into effect during the time of the shortage remain in place long after the shortage has dissipated, right. And we've got ample supply back into the health care supply chain.

Michael Ganio

Yeah. Sometimes we identify waste, you know, and that's, this is a I hate to call a silver lining to shortages, but, you know, there are research articles that get published and find out that this particular chemotherapy regimen is just as effective without a particular drug, you know, so over time, we do gain knowledge from these shortages and supply chain disruptions.

Michael Schiller

Well Michael thanks for your time today. It's been great talking with you. Appreciate your insights.

Michael Ganio

Yeah. Thank you. Appreciate having me on the podcast.

Tom Haederle

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