“Our whole goal is to preserve patient safety. The situation is serious, but because of the work of everyone around the hospital – whether it’s changing an NPO [nothing by mouth] strategy before patients go to the OR, whether it’s exchanging saline for lactated ringers, or any of the other alternatives we’ve introduced – the quality of patient care has been the same. It’s just delivered in a different way.” – Paul Biddinger, MD, chief of the Division of Emergency Preparedness

Members of the MGH Hospital Incident Command System (HICS) IV Fluid Working Group gather around a conference room in the Founders Building. Will Rosales, senior manager of MGH Materials Management, begins the meeting by reviewing the supply chain spreadsheet, a document that has become like a daily newspaper, detailing the good and difficult news the group can expect that day.

The list is long.

“We are placing the maximum orders daily,” he says. “As you know, it’s peaked and flowed at different times. But we look OK for today.”

When Hurricane Maria tore through Puerto Rico Sept. 20, 2017, its path of destruction included three Baxter International manufacturing plants, which produced more than 40 percent of the United States’ supply of saline fluid bags. Although more than 1,500 miles away, the MGH has seen and felt the ripple effect of Mother Nature’s wrath – experiencing first-hand how the massive destruction there has become a major disruption here.

Within days of the storm, staff throughout the hospital jumped into action, knowing that the tens of thousands of bags of fluids the hospital relies on every week would soon be in jeopardy.  Various departments began to investigate alternate ways to obtain supplies, and staff worked to outline potential workarounds and clinical treatment alternatives. In November, the MGH activated its HICS team to help coordinate the response, bringing together representatives from major departments throughout the institution.

In the five months since the hurricane made landfall, the HICS team – and its accompanying subcommittees and advisory groups – have met on a daily basis, sometimes multiple times a day, to evaluate, assist and strategize for today, tomorrow and the coming weeks and months. There have been dozens of clinical alternatives introduced, in addition to staff closely adhering to the situation’s repeated mantra that “conservation is key.”

While this specific IV fluid bag shortage is a first for the MGH, it is one that its staff members are well-equipped to handle thanks to the hospitalwide emphasis on continual emergency preparation efforts, and lessons learned from past experiences. This crisis comes on the heels of numerous other emergencies, including caring for the badly injured patients following Boston Marathon bombings, and planning for possible outbreaks of H1N1, Ebola, and other epidemics.

“While the IV fluid bag shortage is something we need to look at and deal with very carefully, it isn’t a situation that we were unprepared to address,” says Dave Reisman, associate director, Center for Disaster Medicine. “It has been different in that we are using the emergency management structure internally on a long-term basis, as this is one of the most extended events that we’ve seen. But, the training and preparation we work on every day of the year – coupled with the dedication and commitment of our staff – makes this manageable.”

“We won the lottery today, but may not win it tomorrow.” – Ali Parmar, senior administrative manager, Center for Disaster Medicine, when a recent fluid bag supply order is fulfilled

Lisa Martino sits in the empty Materials Management conference room, tucked in the basement of the Lunder Building. Laptop open, the department manager concentrates intently on a document filling the screen.  The only sound in the room is the click of keys as Martino enters the morning’s clinical supply statuses. She details some entries with an accompanying color – bright hues that are in stark contrast to the spreadsheet’s sea of black and white words and numbers. Yellow depicts caution. Red denotes critical. Then there are the black squares with the most concerning status – out.

While always part of her job duties, this monitoring, updating, ordering, adjusting – and readjusting – has become a much more in-depth and time-consuming part of daily life. “This is a unique case,” Martino says. “It’s taken up a good portion of my time. Looking at reports, compiling the data, discussing them at the HICS working group meetings – it takes about three hours a day.”

Martino says the HICS structure and the dedication of its active team members have helped alleviate some of the concerns that come with any shortage. “We all typically work together on a smaller scale – a much smaller scale – on backorder issues,” she says. “But here, everyone is in the room. We ask for and need everyone’s input. I’m not a clinician, so working closely with the larger team helps me to prioritize what needs to be done.  And, it’s not just the emergency group.  There have been a lot of conservation efforts put into place and we’ve seen a decrease in usage allocations. Everybody has really made these great, strong efforts to conserve products.”

Technicians in the Central Pharmacy IV Compounding Unit pump fluid from a large IV solution bag into smaller bags.  More than 1,000 intravenous medication doses are mixed in IV fluid bags daily in this room.  After the storm, the Department of Pharmacy started making its own IV fluid bags to fulfill the needs of the hospital. It’s a time-intensive process, and one of the adaptive measures the MGH introduced in October.

“It’s really nerve-wracking not knowing when – or if – there is a reliable supply coming in,” says Lindsey Smith, PharmD, manager of Pharmacy Operations. “It’s one of those things that you really don’t know what you have until it’s taken away from you. But, I do not think we ever deviated too far from our norm. I think we were really helped by the collaborative approach we took.”

Smith points to the silver racks of supplies – a glaring visual reminder of exactly what is available at any given moment. “Imagine walking in here and seeing only a small supply when there normally are 7,000 units available,” she says. “There were three times when we ran almost to zero. We all take patient care very seriously, and we know what it would mean if the fluids were gone.”

“There have been 47 adaptive strategies implemented since October. Staff have really come together to help with conservation efforts and this has been immensely helpful.” – Sue Algeri, RN, associate chief nurse

Eleven floors away – on the Cardiac Care Step-Down Unit on Ellison 10 – Kate Benacchio, RN, clinical nurse specialist, reviews the daily medical supply spreadsheet. On her desk – surrounded by Post-It notes and a child’s colorful Crayola drawings – are a stack of Practice Updates created by the Patient Care Service Quality and Safety Office. The documents feature updates to Epic orders and other key information specific to the IV fluid bag shortage.

“Because this was so unexpected, it caught us off guard,” Benacchio says. “I don’t think you realize how much of an impact one single storm can make. It’s been interesting to see how we have evolved in the four to five months since this happened.”

Benacchio says although the shortage has been challenging at times, it also has been rewarding to see the dedication and commitment across so many levels of the institution. As Benacchio walks through the unit, she passes by a nurse guiding and encouraging a patient on his second lap around the reception desk, and she closely monitors the screens beeping in rhythm of the hearts of the nearby patients. An alarm sounds and Benacchio races to a nearby room, gently redirecting the patient at risk for falls from trying to get out of bed unassisted.

“Nurses are really good at improvising and getting the job done,” she says. “I feel really lucky to work in an institution that values nursing. Nurses are always at the table and they are well represented. We are in the thick of things and our input is valued and appreciated – and listened to.  And, it’s not just nursing leadership, we all sit at the table equally. It’s really refreshing to see.”

“Although this situation has been – and continues to be – challenging, it also has allowed us to gain an incredible education and helpful insights into future emergencies. The lessons we’ve learned from these collaborative efforts will help drive our planning in the years to come.”– Rob Krupa, Planning, Training and Exercise program manager, Center for Disaster Medicine

Quality and safety are commitments that the hospital and its caregivers stress when talking with patients, their caregivers and families. “It’s true that how care is provided may look a bit different in some areas, but the goal of providing kind, compassionate, top-notch care remains top of mind,” says Colleen Snydeman, RN, director of Quality and Safety for Patient Care Services. “We’ve kept quality and safety at the forefront of everything we are doing because we don’t want this shortage to impact patient care.”

Snydeman says to ensure ongoing, high-quality care her team has been encouraging staff to submit safety reports – documenting anything they see that could impact quality and safety – which are monitored 24 hours a day, seven days a week. “It’s important that we detect any problems early and make immediate changes,” she says. “These are the guiding principles – every day, whether or not we are in a situation like this shortage – and we keep them front and center to everything we do.”

This article was originally published in the 01/26/18 Hotline issue.