How Brigham and Women's is solving the IV bag shortage through oral hydration

In the wake of the IV fluid bag shortage sparked by Hurricane Maria, which slammed Puerto Rico in September, Boston-based Brigham and Women's Hospital is using oral hydration protocol to curb IV fluid bag use, according to an article published in the New England Journal of Medicine.

Although U.S. hospitals have faced varying degrees of IV fluid shortages since 2014, the hurricane in Puerto Rico, which produces 44 percent of the IV fluid bags used in the U.S., escalated this critical shortage.

Initially, small-volume bags, which are 50- and 100-ml bags used to dilute medications, were in short supply. However, the larger 500- and 1000-ml IV fluid bags are also currently in short supply. U.S. hospitals are working to develop strategies for rationing IV fluids, which can be particularly useful for emergency department patients, who are some of the most substantial IV fluid consumers.

Brigham and Women's 59-bed ED treats over 62,000 adult patients annually. In the five months from September 2017 through January 2018, the hospital's ED used 8,519 liters of IV fluids, which was nearly 30 percent of the hospital's total consumption. 

As the current IV-fluid shortage worsened, the team in the Division of International Emergency Medicine and Humanitarian Programs of the Department of Emergency Medicine developed an oral rehydration protocol for ED patients experiencing mild dehydration. The article authors, who are emergency physicians with over 50 combined years of work in healthcare, outlined the oral rehydration protocol, which is now adopted hospital-wide.

The protocol can be used for patients with mild dehydration due to conditions such as acute gastroenteritis, pregnancy-related hyperemesis, mild viral upper respiratory infection or pharyngitis. However, the protocol cannot be used for patients experiencing moderate to severe dehydration or patients who are unable to receive oral intake for a different reason.

Under the protocol, orders for oral rehydration fluids are entered into the patient's EHR, which will direct the nurse to bring the patient two 500-ml pitchers of their desired drink, which can be a flavored oral electrolyte solution, a dilute sports drink or juice. The patient then drinks two large sips or 30 ml every three to five minutes. through a straw. Nurses can explain target hydration goals and provide a tracking sheet. Either the patient or their family member should complete the tracking sheet.

Oral rehydration therapy, which researchers have studied for nearly 60 years, has been shown to reduce mortality from diarrheal illnesses by 93 percent and reduce the case fatality rate of cholera from 30 percent to 1 percent, the authors noted. The therapy is also less costly than IV-fluid therapy and its use results in fewer admissions and shorter hospital stays.

At Brigham and Women's, IV-fluid use by volume decreased by about 30 percent in the first week after the oral hydration protocol was distributed throughout the hospital, according to the authors' preliminary data. In the three weeks after the protocol was implemented, the fraction of ED patients with IV-fluid orders decreased by 15 percent. However, the authors noted providers must use clinical judgment when choosing oral hydration in patients with coexisting conditions such as renal disease, diabetes or heart failure.

"We share this protocol as a replicable model for other U.S. hospitals looking for strategies during the IV-fluid shortage," the authors wrote. "We believe that widespread use of oral rehydration protocols would therefore be a rational practice change and a mainstream model for use in the United States even after the current IV-fluid shortage crisis ends."

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