Hospital Pharmacy - February 2018 - 13

Letter to the Editor
UPMC Presbyterian Hospital AnƟbioƟc Shortage MiƟgaƟon ScoreCard
Percent VariaƟon of Average Daily Use Post-Shortage MiƟgaƟon Efforts Compared to Baseline

100%

60%
50%

40%

0%
-24%

-28%
-50%

recommendations. The surveillance assignment is distributed
between the pharmacist residents and the unit-based
pharmacists.
In addition, clinical decision support was established in
electronic health record (EHR) applications to enhance prescriber awareness of the shortage, to prompt consideration of
more judicious IV fluid use, and to introduce an automatic
24-hour discontinuation of IV fluid orders.

Antibiotic Alternatives

-100%

-150%
-162%
-200%
IV Metonidazole PO Metronidazole

IV Linezolid

PO Linezolid

IV Amp/Sulb

Figure 1. Impact of shortage mitigation efforts by
interdisciplinary team on identified critical supply medications
including metronidazole, linezolid, and ampicillin/sulbactam.

Note. Baseline patient charge data were collected from 4/1/17 to
9/30/17 (185 days) to estimate a daily benchmark use prior to shortage
identification. Similar methods were applied to the intervention time
period (ie, estimated use postshortage mitigation efforts), and charge data
were collected from 10/1/17 to 10/22/17 to estimate daily use. Percent
variation between premitigation and postmitigation efforts is depicted
to confirm impact of interventions or identify additional opportunities
of need. There was not a single direct oral antimicrobial agent for the
transition of IV ampicillin/sulbactam. (Data courtesy of Tony Lacava
and Lloyd Clarke, UPMC Presbyterian Data Analyst). PUH UPMC =
Presbyterian; IV = intravenous; PO = by mouth; Amp/Sulb = ampicillin/
sulbactam.

** There may be an opportunity to liberalize patients'
diets to increase sodium intake and do not restrict
access to water.
** Some oral hydration vehicles contain potassium,
which needs to be monitored when appropriate.
** Oral hydration is a therapeutic modality, which needs
to be monitored with weights and electrolytes when
appropriate.
** Choice of oral hydration may be influenced based on
patient preference. Many patients could be sufficiently managed with diet sodium and fluid liberalization alone-salt tablets may only be necessary in
those with baseline electrolyte derangements or
requiring significant volume repletion.

IV Fluid Surveillance and
Discontinuation
The UPMC automation team developed reports of IV
maintenance fluids to identify patients who were receiving IV hydration. Patients eligible to receive enteral
hydration rather than IV hydration have IV fluids discontinued as soon as clinically appropriate and are converted
to an oral hydration regimen. The IV fluids report is generated daily, and prescribers are contacted in person, by
phone, or by pager about considerations for oral hydration

The shortage has significantly affected many antibiotic
classes. Representatives from the antimicrobial stewardship
team contribute expert advice for IV to less impacted IV and
IV to oral substitution of shortage-impacted antimicrobial
agents when clinically appropriate. Shifting treatment away
from less available options to more available antibiotic
options has contributed significantly to shortage mitigation
efforts. Additional opportunities are also being reviewed for
alternative administration techniques to conserve fluids
required for compounding sterile products including IV push
administration and IV syringe pump administration. All
patients receiving shortage-listed antibiotics are assessed
daily. First-generation cephalosporins, ampicillin/sulbactam,
and IV metronidazole are reserved for patients without clinically acceptable alternative options. All patients on antibiotic
therapy are also assessed for the potential opportunity to
transition to oral antimicrobial therapy or for switching to a
therapeutically equivalent IV antibiotic agent that is more
readily available. Oral metronidazole, oral linezolid, oral and
IV clindamycin, lipoglycopeptides, third-generation cephalosporins, oral fluoroquinolones, and oral sulfamethoxazole/
trimethoprim use has been impacted in response to the shortage mitigation efforts.
These interventions have led to a 53% reduction in IV
fluid use in the largest UPMC acute care facility. Prior to
implementing these changes, 160 patients per day were
receiving IV maintenance fluids. Through combined IV
hydration strategies of conversion to oral therapy, monitoring use for potential discontinuation/conversion to oral
hydration, and removal of prechecked order sets in order
entry, maintenance fluid orders were reduced to approximately 74 patients per day within a few weeks. In addition,
there is a noticeable shift of antibiotic use away from the
agents on shortage, IV metronidazole, IV linezolid, and IV
ampicillin/sulbactam (Figure 1). These measures related to
IV fluids and antibiotics have helped to mitigate the impact
of the abrupt shortage in IV fluids resulting from Hurricane
Maria's devastation of IV fluid manufacturing in Puerto
Rico.
Hurricane Maria has ravaged lives across Puerto Rico.
The UPMC IV Fluid Shortage Taskforce is working hard to
ensure that lives are not interrupted in Pennsylvania. The
Taskforce has enabled UPMC facilities to conserve fluids
and medications during this critical national shortage.

Table of Contents for the Digital Edition of Hospital Pharmacy - February 2018