March 28, 2018

Brigham's simple, 3-step workaround to the IV bag shortage

Daily Briefing

    Brigham and Women's Hospital has developed an oral rehydration protocol that offers other hospitals struggling amid a national shortage of IV bags an evidence-backed solution, a team of Brigham physicians write in a recent article published in the New England Journal of Medicine.

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    Background

    IV bags are one of the most commonly used medical supplies. The bags often are manufactured to contain saline solution, which hospitals use to administer and dilute patient medications.

    The United States for months has been experiencing a shortage of small IV bags (50- and 100-mL). That shortage was exacerbated when Hurricane Maria hit Puerto Rico in September 2017, causing damage to many of the commonwealth's medical supply manufacturers.  As a result, the shortage now affects both small and large (500- and 1,000-mL) IV bags.

    To address the shortage, Brigham asked a team of emergency physicians with international humanitarian aid experience to devise a workaround—and they came up with a new protocol that they said should be used year-round.  

    Brigham's solution

    The team's oral rehydration protocol was first implemented in the ED and later expanded to the rest of the hospital, according to senior author Stephanie Kayden, chief of the Division of International Emergency Medicine and Humanitarian Programs at Brigham.

    Brigham's consists of three key steps. First, clinicians order oral rehydration fluids and appropriate antiemetic or pain control medicines via the patient's EHR.

    Next, the EHR directs nurses to provide the patient with a 30-mL cup, a straw, and 1,000 mL of rehydration fluid, with marks denoting every 250 mL. Patients can choose from water or diluted juice, and those with a suspected electrolyte imbalance are offered a flavored electrolyte solution or a diluted sports drink. Patients are directed to drink 30 mL every three to five minutes.

    The patient or a family member should time the sips and mark progress on a log sheet. The goal is for the patient to consume 500mL of oral fluids in 50 to 80 minutes and 1,000 mL within 100 minutes to 160 minutes. The authors note that patients who are able to consume 500 to 1,000 mL of liquid in the ED, will most likely be able to safely continue oral rehydration at home.

    Brigham's protocol recommends patients who are vomiting consume the liquid more slowly, until they can tolerate it well. A clinician should stop in regularly to offer encouragement, provide additional antiemetics or pain control as needed, and change drinks if the patient does not like the one given.

    The third step focuses on troubleshooting any problems that may arise and re-evaluating to ensure that oral rehydration is sufficient.

    The authors said the protocol should only be used for patients with mild dehydration due to diarrhea, vomiting, morning sickness, and similar problems. It is not intended for patients with major electrolyte imbalances, such as due to kidney disease, or those with moderate or severe dehydration.

    The authors wrote, "As with IV strategies, clinical judgment must be used when choosing oral hydration in patients with coexisting conditions such as renal disease, diabetes, or heart failure."

    Implementation

    Brigham piloted the protocol in its ED and quickly adopted it throughout the hospital. But the implementation required a lot of messaging and education to change how clinicians approach rehydration.

    Unlike some less developed nations, the United States has "a culture that supports use of IV fluids even though the data show that, in many cases, oral rehydration and IV rehydration are equivalent in benefit," Kayden said.

    Hospital leaders also worked to ensure providers were comfortable engaging patients in their care.

    Kayden said, "It's something relatively new to have the patient or family be so involved in the care, and I think the newest and possibly hardest part was to get folks to interact in that way."

    A model for other hospitals

    While oral rehydration may take longer and require more patient participation, Kayden said in many ways it is "a better solution for patient care," as it eliminates the need of a painful IV catheter. 

    "It's not for all patients, but it would definitely work in all hospitals. It's actually easy to do and can be very broadly applied," Kayden said (Haelle, Medscape, 3/22; Knowles, Becker's Hospital Review, 3/23; Patiño et al., New England Journal of Medicine, 3/21).

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