Saline shortages: A 3-step action plan

Hospital pharmacists are on the frontline of intravenous (IV) saline shortages and need to prepare an action plan to ensure patient safety.

IV saline is one of the most commonly used drugs in a hospital. Millions of units of IV saline are used each week for hydrating patients, during dialysis treatment, in providing emergency care and surgery, so making a shortfall in supply particularly challenging to navigate.

In a recent survey conducted by the American Society of Health-System Pharmacists (ASHP) 76% of hospitals reported being affected by the IV saline shortage. Of respondents reporting a shortage, 29% showed that their supplies are not adequate to meet patient need. Pharmacists and other healthcare professionals have responded by using alternatives, switching doses, prioritizing patient care, and in some cases, delaying treatment.

“Until manufacturing can be more fully ramped up, manufacturers have responded by rationing IV saline, with hospitals and other healthcare facilities receiving IV saline supplies based on order history rather than on current need,” said Marvin Finnefrock, PharmD, divisional vice president of clinical and purchasing services at Comprehensive Pharmacy Services (CPS), a pharmacy management services provider.

Why the shortage?

Supply shortages and the higher incidences of the flu have been suggested as the main contributors to the IV saline shortage.

Manufacturer supply issues date back to last September when a major manufacturer notified customers of a temporary shortage in its 1-L saline product. The situation was further exacerbated by the routine shutdown later in the year of another manufacturer’s production facility.

“FDA was aware of both situations, and while it cannot mandate that manufacturers produce a certain amount of IV saline or require them to increase production, it was working with the three major IV saline manufacturers to meet demand,” according to Dr Finnefrock.

In addition, it has been reported that the saline shortage may be due to a high incidence of flu this year.

“We have not seen a demand influx-ie, higher incidences of flu-significant enough to cause the shortage,” said Dr Finnefrock. “In fact, according to CDC data, the 2011/2012 flu season was significantly worse, yet there was no corresponding shortage of IV saline.”

“Hospitals exist to care for patients, and their number one priority is to ensure that the best and most appropriate care is given to every patient, whether admitted or treated on an outpatient basis,” he said. “Critical shortages of any drug or drug therapy force hospitals to make decisions on how to manage patient care, divert attention to finding alternatives, raise questions about the reliability and flexibility of the drug supply chain, and could impact quality and cost of care, all of which are of concern to hospital and managed care decision-makers.”

3-step action plan

Dr Finnefrock recommends a 3-step action plan that includes: communication, conservation, and substitution, which is “an action plan we immediately put in place for our 400 hospital and healthcare facility clients when the effects of the IV saline shortage began to be felt at the hospital level,” he said.

Communication. With any drug shortage, timely, actionable and reliable communication is critical, and generally involves communication between multiple parties. Having a communication plan in place allows for the efficient receipt and dispersion of critical information, and its importance cannot be emphasized enough.

At CPS, for example, purchasing and clinical teams meet to develop and activate a communication plan. This plan can include the next steps and a weekly update to network hospitals.

“A key component of our communication update was to advise our hospitals to be prepared for a protracted shortage and provide an action plan to help mitigate the effects of the shortage on their facility,” Dr Finnefrock said.

“We also needed to be on hand to assist them with navigation through the allocation process,” he continued. “Each manufacturer has a different process for how medications are distributed during a rationing period. Our purchasing teams are working with the manufacturers to get the latest information and the process of allocation to our hospital members. This includes transit times, inventories, and release dates,” he said.

Conservation. “When drugs or drug therapies are in short supply, conservation becomes a major area of focus,” said Dr Finnefrock. “The IV saline shortage is no different.”

The CPS medical team advises that hospitals conduct a wastage review in all areas where IV saline is routinely used without specific direct indication, for example, in elective procedural areas and emergency departments, and to establish guidelines leading to conservation of this limited resource. For instance, CPS and its clients immediately conducted a wastage review so that those patients who could take liquid by mouth would receive hydration by this means. 

Substitution. Hospitals should put in place plans for adequate substitution regimens as indicated, a step that requires careful oversight from a qualified pharmacy and clinician team to safely and effectively use substitutions on a patient-by-patient basis.

“While this is a necessary step, we have to also keep in mind that alternatives to IV saline may soon be in short supply. This necessitates, once again, that a robust, effective, and timely communication plan be in place,” he said. “Until the IV saline shortage subsides, it is imperative for physicians, nurses, and pharmacists at each site to work closely together to ensure the safety of patients.”