A Demanding Flu Season Tightens Squeeze On IV Bag Supplies

The 2017-18 flu season is proving to be rougher than many, and is still placing a lot of demand on the American healthcare system to treat people with influenza and other respiratory illnesses that flare up during the winter. Along with most of the United States, Wisconsin is seeing a high level of seasonal flu activity, thanks in part to a type of influenza virus that's tough to vaccinate against and can be particularly hard on the elderly and small children. The subtype, called H3N2, is proving particularly good at putting people in the hospital.

The spike in flu cases comes as healthcare providers continue to deal with a shortage of one of their most common and crucial tools: pre-filled IV bags practitioners use for everything from hydrating patients to administering carefully measured medications. When Hurricane Maria struck Puerto Rico in September 2017, it devastated dozens of pharmaceutical and medical-supply manufacturers concentrated on the island. Hospitals and other medical facilities across the mainland U.S., including in Wisconsin, depend on those factories for IV bags and many other products. In the wake of the hurricane, pharmacy buyers and federal regulators scrambled to figure out other sources of IV bags, and in some cases had to figure out ways to treat patients without them, creating a cascading disruption in hospitals' workflows.

"We continue to hear that supply will be improving in the coming weeks, but healthcare providers are still unable to procure the amounts needed and are using strategies to conserve supplies as much as possible," said Michael Ganio, pharmacy practice and quality director at the American Society of Health-System Pharmacists, a professional organization that is tracking these shortages.

"Healthcare providers are conserving fluids when possible. That often means converting some medications to an oral dosage form, or giving some medications as an IV injection when it is safe to do so," he added.

The U.S. Food and Drug Administration addressed the shortage in a Jan. 16., 2018 statement, which noted: "We've heard from institutions that only have a few days' worth of supply on hand; as well as institutions that have to ration diminished stores of these products."

It's not only a hurricane

As devastating as Hurricane Maria was, the problem goes deeper. In recent years, the healthcare industry has experienced an increase in all kinds of drug and equipment shortages. Manufacturers, regulators and care providers don't have access to ongoing coordinated information that can help keep supply levels stable. Additionally, this system's infrastructure is dependent on situations when one crucial factory shuts down, some other facility faces more demand to help pick up the slack.

The University of Wisconsin hospital complex in Madison has been dealing with some IV bag shortages that followed Hurricane Maria and others that predated that event, said Philip Trapskin, UW Health manager of patient care services.

Baxter International, a crucial manufacturer of small-volume IV bags used for hydration and drug dilution, has been gradually working to restore electricity to its facilities in Puerto Rico and step up its capacity at factories in the U.S. territory. Following the hurricane, UW Hospital couldn't get any bags from Baxter, but as of the beginning of 2018 the company is supplying about 50 percent of what it did pre-Maria, Trapskin said.

"For the small-volume bags, our supply has improved. We still have active mitigation strategies in effect to conserve, but I don't lose sleep over that one as much anymore … one of the things that happened as a side effect of the shortage is people increased their utilization of the large-volume bags," he added.

However, medical distributors are having trouble keeping up with demand for the larger-volume IV bags, in part because of flu season, Trapskin said.

Both UW and other pharmacy buyers around the country have their eyes on shortages of other kinds of IV bags, particularly ones pre-filled with nutritional supplements and opioid painkillers. The culprit here isn't a natural disaster but the vagaries of the pharmaceutical industry — including the fact that, according to Trapskin, one crucial factory making such bags has "been out of commission for the last six months, and it could be as long as 2019 before it's back to 100 percent again."

There's no active system for tracking or forecasting where a disaster could disrupt a heavy concentration of medical manufacturing, as happened with Puerto Rico — not even the FDA. And it doesn't even take a disaster — sometimes a company decides that a particular drug or product isn't profitable enough to keep making and shuts down the factory, leaving providers to figure out an alternative or hope that some other manufacturer can make up for it.

"The IV saline shortage is unlikely to cause a life-threatening breakdown of medical treatments," Texas A&M University researchers Morten Wendelbo and Christine Crudo Blackburn wrote in a Jan. 18, 2018 piece for The Conversation. "But the shortage does expose a dangerous flaw in the medical supply chains that everyone relies on to counter disease outbreaks or bioterrorism."

Blackburn and Wendelbo discussed how the shortage of ready-made IV bags is making it harder for hospitals to treat patients in a difficult flu season. Winter is a time of year when hospitals usually experience a spike in demand, but there's an even bigger spike in early 2018. It's not merely that IV bags are important for treating the flu, but that they're important for treating just about anything that might land a person in an emergency room or hospital. Whenever there's a spike in the number of people getting sick or injured, there's more demand placed upon this resource.

When Blackburn and Wendelbo use the term "supply chains," they're referring to a whole sequence of infrastructure and institutional relationships that are in place when something gets made, purchased and sent to where it is needed, when it is needed. Given their structure and geographic concentrations, medical supply chains are disrupted by taking out just one link, putting more pressure on the U.S. healthcare community when it must respond quickly and decisively to unforeseen problems. While the 2017-18 flu season is not a pandemic, it serves as a stark reminder that even the most basic healthcare products can become scarce.