Hospital Pharmacy - February 2018 - 12

747454
letter2017

HPXXXX10.1177/0018578717747454Hospital PharmacyLetter

Letter to the Editor

Immediate Attention Required: Another
Shortage

Hospital Pharmacy
2018, Vol. 53(1) 12-14
© The Author(s) 2017
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https://doi.org/10.1177/0018578717747454
DOI: 10.1177/0018578717747454
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Alfred Adam L'Altrelli, PharmD1, Lindsay Moreland, PharmD2,
Marissa Davis, PharmD3, Rachel Marini, PharmD4,
J. Alex Viehman, MD5, Jessica Daley, PharmD6,
and Greg Wilson, PharmD7
To the Editor:
Hurricane Maria has devastated and displaced countless
families in Puerto Rico. The unfortunate wrath of Hurricane
Maria has also affected many patient lives here in the continental United States by wreaking havoc on the production of
several critical medications and intravenous (IV) fluids.
Manufacturers of affected products have advised their customers to conserve existing supplies of normal saline and
dextrose IV fluid bags. University of Pittsburgh Medical
Center (UPMC) began early, systemwide efforts to manage
supply, to improve sourcing opportunities, and to implement
clinical and operational changes to ensure that the shortage
would have minimal impact on patient care.
UPMC developed a multidisciplinary leadership team
with representation from supply chain, information technology (IT), physicians, nurses, and pharmacists. This IV Fluid
Shortage Taskforce works to standardize and centralize rapid
decision-making capabilities to support the UPMC system's
utilization of precious IV fluid resources and antibiotics.
Open, daily communication and interprofessional collaboration with diverse team members, including nonclinical partners, is responsible for the success of the Taskforce:
** Inventory and supply chain leaders determine the current and expected future availability of IV fluids and
affected parenteral medications. This information is
shared daily with the Taskforce and with various
stakeholders across the UPMC system and partner
facilities in the region. The on-hand supply status has
become a critical component of the UPMC system
approach to selection of viable clinical and operational changes.
** Surveillance data are collected by UPMC's IT professionals to develop reports to evaluate fluid utilization
trends across the system. These reports allow for daily
IV fluid monitoring and surveillance and support physicians and pharmacists in developing clinical guidelines for IV fluid administration. Most recently, the
information provided by UPMC IT has supported
development and implementation of an oral hydration
protocol that has significantly reduced the strain on IV
bags at some of the largest facilities in the system.

The unique expertise of each member allows the Taskforce
to make rapid, informed decisions to maintain high-quality
patient care and has equipped the UPMC system to focus on
3 main conservation efforts: (1) conversion of IV hydration
to oral hydration, (2) IV fluid surveillance and discontinuation, and (3) evaluation of antibiotic alternatives.

Conversion of IV Hydration to Oral
Hydration
All patients should be assessed for appropriateness of oral
hydration prior to initiation of IV fluids. If IV fluids are
deemed necessary, then the patient should be reassessed by
nursing at change of shift handoff with the attempt to favor
for conversion to oral therapy. Patients appropriate for oral
rehydration should meet the following criteria:
** Patient is alert and can swallow
** Patient has an intact gastrointestinal (GI) tract
** Patient is hemodynamically stable; not on vasopressors*
*Patients who do require vasopressors should be converted
to oral hydration as soon as possible after vasopressors are
no longer required. Health care providers were also advised
to consider:
** If a patient is on goal tube feedings, their hydration
status may be maintained through salt and free water
flushes via feeding tube as needed.
1

UPMC Presbyterian Administrative Director of Pharmacy, Pittsburgh, PA,
USA
2
UPMC Presbyterian PGY-1 Pharmacy Resident, Pittsburgh, PA, USA
3
UPMC Presbyterian Pharmacy Administrative Fellow, Pittsburgh, PA,
USA
4
UPMC Presbyterian Infectious Disease Pharmacist, Pittsburgh, PA, USA
5
UPMC Infectious Diseases Division, Pittsburgh, PA, USA
6
UPMC Senior Director of HC Pharmacy and Clinical Services, Pittsburgh,
PA, USA
7
UPMC Director of Clinical Pharmacy Strategy, Pittsburgh, PA, USA
Corresponding Author
Alfred Adam L'Altrelli, PharmD, UPMC Presbyterian Administrative
Director of Pharmacy, 200 Lothrop Street, Pittsburgh, Pennsylvania
15213, USA.
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