Colorado hospitals are working overtime to find stock and are changing their daily practices to protect patients in the wake of an urgent national shortage of normal saline.
Normal saline, the single most-used medicine, is little more than salty water that closely matches blood serum’s natural salt levels, according to Dr. Eric Lavonas, the chairman of the Pharmacy and Therapeutics Committee at Denver Health.
“Normal saline is the workhorse IV fluid in American medicine,” Lavonas said.
At a time when law and economics are pushing health care providers to become more efficient, the shortage has proved a double-edged sword. It has forced hospitals to find more efficient ways to use saline, and it has eaten valuable work hours as skilled professionals chase down basic supplies.
About 20 million intravenous saline bags are used nationwide every month, according to the FDA.
“The vast majority of patients who are admitted to the hospital in the United States receive normal saline in some form,” Lavonas said.
An older patient with the flu or a baby with diarrhea? They’re often dehydrated, and saline is the first treatment. A heart that’s beating too fast? Use saline to give the heart more fluid to work with. A patient who’s been in a car accident and is bleeding internally? Replace the lost blood with just enough saline to buy a few critical minutes. Many medications, such as some antibiotics, are mixed into a bag of saline so they can be slowly dripped through an IV into a patient’s body.
Local hospital officials and doctors who were interviewed — from Denver Health, Longmont United Hospital, the University of Colorado Hospital and its partners Memorial Hospital, Poudre Valley Medical Center and the Medical Center of the Rockies, and the HealthOne hospital system — emphasized that all patients who need saline are receiving it.
Hospitals are, however, changing the way they use saline, and by extension the way they practice medicine.
“We’re being more efficient,” said Gerry Barber, coordinator for Pharmacy and Therapeutics and Clinical Pharmacy Services at the University of Colorado Hospital.
In the past, nurses would routinely use a bag containing a full liter of saline when starting an IV. Often it was simply intended to slowly drip through the IV catheter, preventing blood from clotting and blocking the IV catheter. That bag may never have emptied, and the leftovers were thrown away. Now, that’s changing.
“In reality, why do you need to hang 1,000 milliliters?” Barber said.
He and other hospital officials are encouraging staffers to use only the amount of saline needed — whether that be a liter or a bag containing a smaller amount.
Television medical dramas focus on heroic doctors and nurses, not pharmacists. But frequent drug shortages are revealing pharmacists to be critical foot soldiers in the effort to save lives, said Dr. Andy Ziller, an emergency room physician and the chief of medicine at Rose Medical Center.
“The patients won’t notice it,” Ziller said of the shortage. “The doctors won’t notice it, and the nurses won’t notice it. The pharmacists are really on the frontline of these shortages. They do the things to make the medicines safe so that the practitioners can focus on the patients.”
Protecting patients from the shortage has demanded what Barber describes as “hyper vigilance.”
Pharmacists now are calling suppliers several times a day.
“They may not have saline in the morning, but at 2 in the afternoon … saline has arrived,” Barber said. “We don’t want to let sleeping dogs lie there. We want to be Johnny on the spot.”
Even with the extra vigilance, stocks are less than perfect.
“Sometimes it’s take what you can get,” said Barber.
Officials at other hospitals echoed this, saying that they had enough saline to operate but not much more.
“We are basically able to resupply what we use, but we don’t have a cushion,” Lavonas said.
While no patient in need has gone without, there are still increased risks.
“Some drugs need to be mixed in certain portions,” the FDA’s Jensen said. “There can be medication errors.”
In recent years, hospitals have been working to reduce medication errors. While there might be five correct ways one could mix a medication, Lavonas said, hospitals will choose just one in order to simplify and master it.
When the amount of saline available changes, the math for delivering the prescription changes, and someone has to do the new math.
“The pharmacist is going to do it and have someone check it, then the bedside nurse is going to look at it and have someone check it,” Lavonas said.
Officials at the FDA said the shortage was caused by a spike in demand. As for the exact cause of the spike?
“We don’t have the answer to that,” said U.S. Public Health Service Capt. Valerie Jensen, one of the leading officials tracking drug shortages. “We really don’t have those details.”
Industry officials offered no more details.
Baxter Healthcare, one of three U.S. saline manufacturers, has boosted its production, spokesman John O’Malley said in an e-mail. “Baxter has seen an increased demand in the U.S. for its IV solutions amid decreased availability of such products from other suppliers.”
Jensen said there’s no end to the shortage in sight. The FDA is inspecting foreign manufacturing plants to shore up domestic supplies.
But importing saline would ease the shortage only slightly.
“It would really help the situation to have additional capacity,” Jensen said. But that might mean building new manufacturing lines, something that takes time, she said.
Numbers
20 million
Bags of intravenous saline used in the U.S. every month, according to the FDA
9
Grams of salt in a 1-liter IV bag — less than 2 teaspoons
76 percent
U.S. hospitals hit by the shortage, according to an American Society of Health-System Pharmacists survey
