Theme 1: Preparedness.

Within the disaster management cycle, preparedness refers to planning activities that increase the readiness of healthcare systems for when disasters occur with the goal of decreasing their impact. Participants discussed ways in which their healthcare systems were prepared to handle the IV fluids shortage, including increased experience with a variety of shortages, protocol adaptability, and more effective systems for tracking utilization and remaining reserve of supplies. One person noted, “I think we’ve gotten better at adapting protocols. And adapting practices to account for the possibility of shortages.” While the lessons-learned from prior shortages were not always codified in new protocols, most believed that the combination of living memory and clinician flexibility to adapt to new challenges were more than adequate to address the supply shortages as they arose.

Participants also discussed failure points in preparedness, such as the difficulties of stockpiling perishable items and just-in-time supply chains. One participant in particular spoke to the difficulties of a supply-and-demand economy: “You know the corporatization of medicine in America, right? I mean, it’s just in time purchasing. You know we can’t get these guys to plan more than 30 seconds in advance.” Their point was that the economic incentives for disaster preparedness such as stockpiling or robust supply chain logistics are often not visible or easily grasped. Disaster preparedness pays dividends in the future – but only if a disaster occurs.

Lastly, participants provided recommendations for bolstering future preparedness by reevaluating clinical practices and suggesting private-public partnership and redundancy plans.

Theme 2: Impact of the Shortage.

While some respondents noted a minimal impact on their healthcare systems and others noted a severe impact, it was universally acknowledged that unlike other pharmaceutical or medical supplies shortages that were regionalized or system-specific, the IV fluids shortage was ubiquitous. Its effect was both negative and positive. Negative impacts included threats to patient care and safety, such as having limited resources to treat patients as one usually would. The most common cited example was sepsis, where if IV fluids are withheld in certain clinical scenarios the situation could become life-threatening. One participant captured this by stating, ““The main challenge was… discrepancies between what I felt was the standard of care. The main thing that comes to mind is sepsis… and trying to figure out if am I able to decrease the amount of fluids, or is this an appropriate clinical scenario to actually give sepsis protocol fluids?”

Psychological stress to providers played a significant role in participants’ perspective of the shortage as well, with one person saying, “There was always that knowledge that we are in a national shortage in the background of my mind to make me kind of double think, should I be giving fluids to this person or not.” While they admitted this helped them be more thoughtful and considerate of their clinical practice, it also created a constant anxiety.

Positive impacts included decreased medical waste of IV fluids and judicious use of fluids resulting in improvements in care in certain cases. Additionally, many other shortages of medical and pharmaceutical supplies were discussed, along with their impacts. This included blood culture bottles (which resulted in a more judicious use of this product), IV contrast (causing an increase in non-contrast CT scans, which were not always effective), and medications such as piperacillin-tazobactam (resulting in increased antimicrobial stewardship).

Theme 3: Response and Solutions.

Within the disaster management cycle, response refers to the immediate actions during and in the acute phase after a disaster and generally includes emergency medical care, resource mobilization, and restoration of critical infrastructure and supplies. Throughout healthcare systems, response to the IV fluids shortage was varied but robust. This included alerts on the electronic medical record, daily meetings with key stakeholders, and open communication. The transparency of expectations and the teamwork between all levels of employees was instrumental to the success of many of these strategies. As a participant stated, “[The hospital] mandate was: we want you to have conversations with every one of your providers… in your service line, not just sending an e-mail. This is so important that it has to be a conversation, and you have to be having closed loop communication. [The hospital] set that expectation from the beginning.”

To help with redistribution and allocation of supplies, there was often a centralization of IV fluids in the pharmacy, reallocation of IV fluids from areas of low urgency, cancellation of elective procedures, oral hydration protocols, and extension of expiration dates. However, these solutions were not without their drawbacks. One participant noted that “Centralization [of IV fluids] is helpful... at the expense of delays in using that supply when needed.”

When reflecting on the effectiveness of what their healthcare systems implemented or untapped potential solutions, participants proposed that future shortages could be mitigated by having disaster plans and protocols in place, decreasing medical waste and increasing reusability of products, fostering regional hospital collaboration, and diversifying the supply chain.

Theme 4: Ethics and Resource Allocation.

A core tenet of disaster medicine is to do the most good for the most number of people in situations where patient needs overwhelm available resources. In such situations, altered standards or crisis standards of care might be considered. Disaster medicine therefore necessarily encompasses ethical deliberation alongside clinical and operational concerns. Participants of this study acknowledged that in a disaster situation such as a critical IV fluids shortage, alternative standards of care were, in some cases, implemented, even if they were not labeled as such by the healthcare system. For many participants, this included canceling non-emergency surgery cases. Although canceling elective surgeries might be doing a disservice to those patients whom it affects, it might be the only way to ensure there are enough IV fluids to treat patients with life-threatening conditions. Yet there is a potential for inequity in a fractured national healthcare system such as the United States has where hospitals often exist in silos, isolated from other hospitals. Specifically, one participant stated, “I worry about some hospitals having to cancel non-elective or semi-urgent admissions or procedures while other hospitals continue to like practice full tilt because they have access to these resources and don’t want to cancel elective cases, which are often revenue generating for the system”

While most participants were impressed with the collaboration between neighboring hospitals during this time of crisis, they did worry that, “Some of the smaller hospitals that didn’t have as many resources… tended to suffer more.” If larger healthcare systems have access to more resources, participants noted, it is ethically laudable to help neighboring hospitals under critical stress from the shortages.

Theme 5: Collaboration.

Collaboration can take many forms, from national or state mobilizations to formal mutual aid agreements to aid rendered due to sense of civic responsibility. Capturing this sentiment, one participant of the study stated, “I think [collaborative relationships are] something that every system needs to cultivate. Because if you don’t have those relationships when the times are good, it’s going to be very hard to form those relationships and have them be productive and fruitful when it’s a stressful situation.”

During the IV fluids shortage, success in handling the crisis was made possible through the partnership of hospital leadership and staff, from physicians to nurses to pharmacists. Working with staff to come up with responses and solutions increased camaraderie and support from these healthcare workers, which increased their effectiveness in implementation. While in some instances, collaboration between hospitals across the region was hindered by financial concerns, in other places collaboration thrived through civic duty and cultivation of these interhospital relationships before the IV fluids shortage. One participant observed, “A really unfortunate thing with healthcare is that we approach it more capitalistically. We approach it in a competitive way. And I think that that’s a disservice.” The consensus among participants appeared to be that while market forces of supply-and-demand may encourage competitive behavior that threatens to harm patients in times of crisis, the humanity of clinicians and administrators won out more often than not during the IV fluids shortage. Collaboration and aid among hospitals was the norm rather than the aberration.

Theme 6: Governance.

Within the field of disaster medicine, governance refers to the policy-making and existing legal infrastructure as well as the authority structure and systems coordination for dealing with all aspects of the disaster management cycle (mitigation, preparedness, response, and recovery). Participants of this study reflected on what roles, if any, government should take in the management of supply chain logistics, which differs from other disasters such as earthquakes or hurricanes themselves in that it may be less visible and less well defined. Still, they decided, many of the guiding principles remained the same: “For a nationwide disaster that impacts everybody like this IV fluid shortage, I think there has to be some sort of federal coordinating role.”

Given that most disasters are local or regional, response to a crisis (or at least augmentation of a hospital’s response, as needed) usually falls into the purview of state government. As one participant emphasized, “Having enough of [a regional or state] stockpile that if something happened to your hospital and you needed three days of critical supplies is hugely important].” However, the IV fluids shortage impacted healthcare systems across the country. While all praised the Strategic National Stockpile and its key role in safeguarding the healthcare system in many regards, one person noted “the federal level is more about what are the regulatory barriers and or incentives that make us consolidate our supply chain in such a narrow fashion” Federal policy, therefore, could be beneficial in guiding response and preparedness, especially in regulating or assisting the production and distribution of scarce resources.