A shortage of the plastic bags used to deliver fluids and medicine to sick and dehydrated patients is spurring area hospitals to find alternative delivery methods in the midst of a nasty flu season.

Hospitals in Michigan and nationwide have resorted to jury-rigging solutions and even reverting to labor-intensive methods rarely used since the advent of the IV bags that have become indispensable in modern medicine. Those alternatives have increased the workload for pharmacists and nurses, and are forcing some hospitals to beef up staffing to keep pace with the need.

The problem comes in the wake of Hurricane Maria, which devastated operations in Puerto Rico at the major manufacturing plants for the bags.

Hardest hit have been the small-volume IV bags of 100 milliliters or less that are used to infuse antibiotics, cancer medicines and other critical drugs. Prior to the shortage, the five-hospital Beaumont Health system reportedly went through about 50,000 per month. Beaumont gets its small IV bags from Baxter, the nation’s largest supplier of the mini-bags, whose manufacturing facilities in Puerto Rico were idled by the storm. Their operations are expected to be back to full production by the end of January, but experts say it will take time to replenish supplies.

“We knew very early on that Hurricane Maria would have a very significant impact,” said Kathy Pawlicki, vice president and chief pharmacist at Beaumont. “As soon as the hurricane hit, they weren’t able to ship anything out.”

The shortage has been exacerbated by the flu outbreak, which has spiked emergency room visits and hospital admissions across the country. Beaumont Health announced Friday it was imposing visitation restrictions at its hospitals due to high volumes of patients with upper respiratory infections, predominantly the flu.

Lynn Sutfin, a spokeswoman for the Michigan Department of Health and Human Services, said the flu hit sooner and harder this year, though no deaths have been reported in the state.

“We’re seeing Influenza AH3, H1NI and Influenza B,” Sutfin said. “Any of them can be serious, but the AH3 is what we see is causing the most issues right now. All of them make you feel horrible.”

ProMedica hospitals have seen an influx of flu cases, said Paula Grieb, an associate chief nursing officer with the health care chain, which owns 13 hospitals in southeastern Michigan and northwest Ohio.

“Anything that is increasing volumes of patients is something of risk or concern for us,” Grieb said. “We have seen an increase in our influenza patients in our emergency department and those who have been admitted for ongoing patient care.”

Scramble for alternatives

In Puerto Rico, generators quickly restored power to Baxter’s manufacturing facilities, but production was significantly hampered by the destruction across the island. Two other companies produce mini-bags, but lack capacity to fill the void.

“They were able to get the plants back up, but the employees homes and families were so disrupted that they couldn’t even come to work,” Pawlicki said. “Even transporting what supplies were on the island was a challenge.”

The health system keeps several weeks of inventory on hand, but as the devastation on Puerto Rico unfolded, Beaumont officials began planning for an extended shortage.

“We knew we needed to stretch supplies on hand as far as we could, and only reserve them for (treatments) that we couldn’t do another way,” Pawlicki said.

She said patients in the Beaumont system as in other hospitals who could safely be switched to oral medications were shifted to pills. At the same time, some medications could be mixed and loaded into syringes by pharmacists, and then slowly hand-pushed into the patients’ intravenous lines by nurses at the bedside.

Beaumont also resumed using buretrols, hard plastic cylinders that contain a reservoir that pharmacists can fill with carefully measured mixtures to infuse into patients.

“(The buretrol is) a very, very old technology that we used to use years ago in hospitals, when these bags weren’t available,” Pawlicki said. “You can actually put in 100 or 50 milliliters of solution from a large liter bag, and then add the drug to it.”

Grieb, of ProMedica, said the shortage of the smaller bags led to a chain reaction as hospitals scrambled to find alternatives. Large IV bags grew scarce because hospitals were draining them of fluid to fill syringes. Then supplies of syringes fell short.

“Here at ProMedica we’ve not hit that crisis where we’ve had to say that we are not able to care for our patients because we don’t have ‘X’ — I know that’s everybody’s concern across the country, that we’re going to get there,” Grieb said. “That’s why we’ve been working diligently ... to ensure we don’t. That’s our goal.”

Hampering cancer care

The shortage has also been felt at Karmanos Cancer Center, where small-volume bags are used for chemo therapy.

“It’s not just cancer care (that is affected by the shortage), but cancer care tends to be focused on because the drugs that we give can be very dangerous if they’re not given correctly,” said Stephen T. Smith, chief pharmacy officer at Karmanos.

Smith said the center is in daily contact with manufacturers to see which supplies are available. And daily changes in what’s on hand mean officials there are constantly shifting medication strategies.

“Some days we’re able to get saline solution, other days we can get dextrose,” he said. “We have to work very closely with our nursing staff and providers to make sure whatever changes we’re making are safe for the patients.”

Some of the alternatives implemented include using portable pumps instead to administer some medicines. Supportive medicines, like those for nausea or to calm anxiety, are given orally when possible. And nurses can hand-push medications into IV lines at the bedside as another alternative.

Communication among staff is critical to ensure patient safety, Smith emphasized. Karmanos uses its internal online communications system, tip-sheets and other methods to keep all staff informed of up-to-the-minute changes.

“Everybody has to be on the same page on what we’re doing,” Smith said. “The nurse at the bedside (needs to know) exactly what you’re doing.”

Preventive measures

The American Hospital Association joined six national health care organizations in sending a letter to the U.S. House Energy and Commerce Committee in November asking for reforms to prevent similar shortages from happening in the future.

The letter requested transparency from manufacturers about the locations of facilities, and what they produce, so hospital officials can better prepare for other emergencies. If a plant is the only supplier of a critical product, the health care groups said the manufacturer should have a back-up plan.

The Energy and Commerce Committee “is still considering next steps,” spokeswoman Jennifer Sherman said Friday.

“This is a collaborative effort that we have to look at going forward,” said Grieb, of ProMedica. “Nobody can predict a natural disaster before one occurs, but what we can do is take this opportunity to look at process improvement as we move forward.

“The hospital associations and the medical associations are asking for that consideration from a government perspective, but also from an industry perspective — to say what are we going to do to improve, how are we going to make sure this doesn’t happen again, and what are our backup plans.”

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