Disruption of normal saline supply chain due to a disaster: an analysis of the impact of normal saline shortage on anesthesia practice in a large hospital system and models toward resiliency

Objectives: In the wake of the COVID-19 pandemic and upheaval in the global supply chain, the healthcare sector has grappled with acute shortages of essential resources. Such shortages, while intensified recently in scale and frequency, are not new, as disasters have posed recurrent challenges. An illustrative example is the impact of Hurricane Maria, which severely disrupted the production of normal saline (0.9% NaCl fluid bags) from Puerto Rico—the location of about half of the production of saline for the entire United States. Hospitals relying on “just in time” delivery models found themselves in a precarious situation, prompting a need for innovative solutions to sustain care delivery. The occurrence underscores the vulnerability of healthcare infrastructure to external disruptions and emphasizes the need for adaptive strategies to ensure the resilience of individuals and the system in the face of unforeseen challenges.

Methods: Our study investigates the impact of Hurricane Maria on saline supplies at the University of Pittsburgh Medical Center (UPMC) and efforts toward building an adaptable model in anesthesia services among providers as well as on a broader, system-wide scale. The study occurred over an 18-month study period, using mixed methods to analyze intravenous (IV) fluid demand and usage patterns before, during, and after the hurricane, integrating qualitative data from 3 months of “participant observation” and survey data.

Key findings and conclusion: System-level adaptation occurred through operating room scheduling, pharmacy-driven standardization, and alternative fluid adoption, while at the individual level, healthcare providers performed drug substitutions, changed mixing practices, and increased reliance on alternative crystalloids. These adaptive measures undertaken at UPMC offer insights for future crises at both the organizational and individual levels within the healthcare system.

Introduction

The pharmaceutical supply chain’s reliance on a “just in time” delivery model poses a vulnerability to hospitals with limited storage capacity for essential resources, particularly crystalloid solutions (1–3). This vulnerability became evident when Hurricane Maria struck Puerto Rico (the location of approximately 50% of the US production of Saline) (1), leading hospital systems, including the University of Pittsburgh Medical Center (UPMC), into a supply crisis.

In the operating rooms (ORs) of the UPMC Health System, where anesthesiologists and nurse anesthetists depend on readily available IV fluids for safe patient care, the shortage of 0.9% sodium chloride (normal saline or N.S.) posed a significant challenge.

Our investigation examined IV fluid demand and usage patterns before, during, and immediately after the hurricane, situating these findings within the broader framework of healthcare system resilience. Resilience in this context is defined as the capacity to absorb, adapt, and transform in response to shocks through coordinated mobilization of five critical components: space, staff, stuff, systems, and strategies. By analyzing adaptive responses at both the individual and organizational levels, we highlight how these elements were leveraged to mitigate risk and maintain perioperative care.

This case study underscores the systemic vulnerabilities inherent in ‘just-in-time’ supply models and offers insights into operational strategies that enhance preparedness for future disruptions. Lessons drawn from this event inform resilience-building measures that extend beyond local institutional responses to national policy considerations, emphasizing the need for integrated frameworks capable of sustaining essential services under conditions of uncertainty.

Our findings are contextualized within the broader landscape of the U.S. healthcare system, which grapples with persistent drug shortages (2, 3). The Food and Drug Administration (FDA) defines drug shortages as instances where the demand for a drug exceeds its supply (4). Sterile injectables and parenteral medications are particularly susceptible, given their high production costs and the stringent requirements for maintaining manufacturing facilities. Notably, compliance issues with regulatory standards at manufacturing facilities have contributed to significant shortages in the past (5).

Since the onset of the COVID-19 pandemic, these supply strains have become even more pronounced, with heightened demand for critical supplies such as alcohol hand sanitizers, face masks, and intermittent shortages of various other medical supplies. This underscores the urgency of learning from case studies such as ours, as they offer insights into adaptive strategies and innovations that can enhance the resilience of healthcare systems—defined as the utilization of components’ space, staff, stuff, systems, and strategies to absorb, adapt, transform, and learn (6)—in the face of acute demands and supply chain disruptions.

Materials and methods

The UPMC Q.I. committee approved the project entitled “The pattern of use of IV fluids in the operating rooms before and after the nationwide IV fluid shortage and associated complications - Project ID: 1445.” We collected the data needed to study the crisis response from the two major teaching non-pediatric hospitals of UPMC—Presbyterian (PUH) and Montefiore University Hospital (MUH), which have a total capacity of 750 medical and surgical beds, 150 ICU beds, and 40 anesthetizing locations, including ORs, cystoscopy, and bronchoscopy suites.

Data collection encompassed OR usage of crystalloid from central databases and qualitative survey responses from operating room providers in the Department of Anesthesiology and Perioperative Medicine. We chose the study period of 18 months from April 2017 to the start of October 2018 to include IV fluid demand and usage before, during, and after Hurricane Maria in September 2017 (7). We collected IV fluid “demand” data (requested volume and supply by OR pharmacy) for both small (≤500 mL) and large-volume (>500 mL) IV fluid from the supply management and pharmacy services at UPMC for the 18-month study period. Data on “usage” were collected from electronic medical records, pharmacy charges, and supply chain management. To elucidate how the UPMC system responded during this shortage in the adult ORs, we conducted surveys and analyzed them using qualitative methods. We surveyed anesthesia providers involved in the administration of IV fluids, and our questions focused on the use of IV fluids in the OR, use patterns in the OR, what they were used for, alternative solutions, and perceptions of how the shortage impacted care in 2019.

Results

Operating room IV fluid demand and usage data

The demand data for small and large IV fluid bags over the 18-month study period are presented in Figures 1, 2. The hurricane started on 16 September 2017, and major storm activity ceased on 2 October 2017. Small-volume IV fluid bag demand began to decrease in October 2017. Strain in the supply was detected by the UPMC supply management system and was readily apparent in November when the full-scale implementation of alternatives took place. The total number of small-volume IV fluid bags supplying PUH and MUH operating rooms decreased dramatically from 1,652 in October 2017 to zero in November 2017. It remained depressed well below pre-hurricane numbers until supply began to increase again in June 2018.

Figure 1

Figure 1. (a) The impact of small volume (≤500 mL) IV fluid use with the Hurricane Maria at Presbyterian Hospital. Month of Hurricane Maria highlighted. (b) The impact of small volume (≤500 mL) IV fluid use with the Hurricane Maria at Montefiore Hospital. Month of Hurricane Maria highlighted.

Figure 2

Figure 2. (a) The impact of large volume (1,000 mL) IV fluid use with the Hurricane Maria at Presbyterian Hospital. Month of Hurricane Maria highlighted. (b) The impact of large volume (1,000 mL) IV fluid use with the Hurricane Maria at Montefiore Hospital. Month of Hurricane Maria highlighted.

At PUH, this trend appeared to be primarily driven by changes in 100 mL and 250 mL bags. For example, the 100 mL bags ranged from 388 bags/month in July 2017 to 288 bags/month in September 2017 and 96 bags/month in October 2017 and remained zero after that until June 2018 (Figure 1a). Small-volume IV fluid bags followed a similar trend at MUH, with all small-volume bag types diminishing to zero in November 2017 until supply began to increase slowly in March 2018 (Figure 1b). The total demand for large-volume IV fluids remained relatively unchanged through the 18 months at both PUH and MUH; however, the choice for IV PlasmaLyte 148, also known as Plasma-Lyte A, did almost double at both locations, with an inflection point in January 2018 at PUH and in November 2017 at MUH (Figures 2a,b, respectively). Demand for large-volume Lactated Ringer’s (L.R.) solution appeared to experience a mild decline starting in November 2017 at both hospitals. Large-volume normal saline demand remained relatively stable at MUH until it decreased in December 2017. Demand for large-volume 0.45% sodium chloride or half-normal saline also declined at both PUH and MUH during the study period, although less severely than small-volume bags, with less usage at baseline (Figure 2).

Qualitative and survey data

A total of 80 unique anesthesia providers (nurse anesthetists and anesthesiologists) who were self-selected to have been present during the shortage responded to the survey from the total anesthesiologist, resident, and nurse anesthetist staff at UPMC Presbyterian and Montefiore. The survey consisted of questions about the utilization of large and small normal saline IV fluid bags.

Drug shortage survey data

One question asked participants, “Which medications were on shortage that you felt most adversely affected your care?” Survey respondents reported that their experience of shortages was related to normal saline (21.25%, n = 17), lidocaine (11.25%, n = 9)—both specifically affected during Hurricane Maria—, narcotics (21.25%, n = 17), sodium bicarbonate (3.75%, n = 3), and “other” (41.25%, n = 33), which included responses such as bupivacaine spinals, beta-blockers, vasopressin, and ketamine (drugs periodically in shortage generally).

Some of the key comments regarding the shortages (in general and specific to fluid) included:

• “We often have medication shortages that result in my using either non-optimal drugs or drugs that I am less familiar with to treat our patients.”

• “Not having availability to the best medication options for our patients. Not having IVF bags and treating a lot of hypotension.”

• “I have had to choose medications that were not ideal for my patients’ care.”

• “The decease (sic) or lack of remifentanil does alter the care of some of my neuro-anesthesia care. The saline shortage with not being able to hang saline on all G.I. patients so even today the G.I. lab no longer uses maintenance fluids for their cases not even colons who had preps.”

Small saline bag survey data

Small-volume saline bags are commonly used to dilute and deliver medications. In response to a question regarding their use of small-volume saline bags, 60% of respondents reported using small saline bags daily. When asked for what purpose they used small saline bags, 13.75% (n = 11) of respondents replied they used them for insulin, 18.75% (n = 15) responded for antibiotics, 5% (n = 4) for ketamine, and 50% (n = 40) responded “other,” with the comment field revealing that 45% of those specifically mentioned remifentanil, 10% responded with a vasopressor, and the remainder listed magnesium or dilute medications generally. A follow-up question asked what their alternative crystalloid of choice was, to which 16.25% (n = 13) responded D5W, 12.5% (n = 10) responded D5LR, and 51.25% (n = 41) responded “other.” Under “other,” respondents did not have a uniform or trend in responses for alternatives, writing in a range of responses, from “none” to “pharmacy prepared bags” to “unsure” to “larger bags.”

Large saline bag survey data

Though the large normal saline bag supplies were less strained, we collected IV fluid use responses and changes in their use patterns. Regarding the purpose of use, there was limited scope for the use of these larger bags: 10% (n = 8) of respondents replied it was their “routine crystalloid,” 25% (n = 20) responded it was used as a carrier with blood transfusions, 20% (n = 16) responding it was continued from pre-op, 5% (n = 4) using it with hyperkalemic patients, 2.5% (n = 2) using it to help start an IV, and 33.75% (n = 27) responding “other”—with 15% of those reporting use for a neurosurgical case and the rest declining to use it at all. When asked about the frequency of use of the larger saline bags, 36.25% (n = 29) responded never using it at all, 15% (n = 12) monthly, 31.25% (n = 25) weekly, and 15% (n = 12) daily. Additionally, for their alternative crystalloid, respondents overwhelmingly responded Plasma-Lyte at 53.75% (n = 43), followed by lactated Ringer solution (LR) at 31.25% (n = 25) and 10% (n = 8) chose “other” writing “Plasmalyte or LR” in the comments section. Specific medications in the OR affected (in terms of usage) included remifentanil, a rapidly esterified opioid used for neurosurgical cases that must be mixed before a case usually; ketamine used for chronic pain patients and as an adjunct to enhanced recovery after surgery (ERAS) protocols; insulin; and antibiotics. Surgical load, as determined by hours of OR time, decreased in a planned manner, correlated with the time of the hurricane (see Figures 3a,b), providing some relief during the crisis. Nonetheless, innovation and adaptation were implemented, as seen in the survey at the level of bolus dosing medications used previously in infusions, providers making their own syringe pumps for drugs, or relying on new pharmacy preparations, which took planning to implement (e.g., ordering the night before to ensure availability for a scheduled case).

Figure 3

Figure 3. (a) Operating room hours logged per month at Presbyterian Operating Rooms (O.R.s) along with total number of bags of crystalloid (small and large). Shortage months highlighted. (b) Operating room hours logged per month at Montefiore Operating Rooms (O.R.s) along with total number of bags of crystalloid (small and large). Shortage months highlighted.

Discussion

Evidence-based from study

We present a case study detailing the healthcare system’s response to a critical shortage of small bags of normal saline in the aftermath of a disaster. The crisis had a dual origin, stemming from chronic shortages in the parenteral drug and fluid supply, exacerbated by the immediate impact of an environmental disaster—specifically, Hurricane Maria. The adverse effects were particularly pronounced in the U.S. supply of small bags, defined as 250 mL or less of normal saline (8). Notably, this is different from the definition used in our study of 500 mL or less, which was similarly affected at our institution. Baxter, a leading IV fluids manufacturer, temporarily ceased operations at all Puerto Rican plants for a month, with power restored only by November 2017 (9, 10). UPMC, operating normally in August 2017, found itself unexpectedly facing a disruption in saline bag supply due to the hurricane—an unforeseen and “random” event. This disaster provided a unique opportunity to analyze the repercussions of such seemingly arbitrary occurrences. Throughout this period, the strain on anesthesia supply services necessitated adaptive strategies until a sustainable solution could be implemented.

Adaptation during this crisis manifested at various levels, encompassing both system-based adjustments within the pharmacy and supply chain sectors, as well as individual responses, particularly notable among anesthesia providers in the operating room. The emphasis on adaptability in crises can foster innovation to ensure the survival of the system, albeit with an inherent risk of potential errors.

Individual adaptation by anesthesia providers in the operating room revealed a heightened risk of errors, such as drug dilution and microbial contamination. The shift to individual mixing outside the controlled environment of a compounding pharmacy raised concerns. Survey participants, when queried about preferred alternatives to small-volume saline bags for mixing medications, presented diverse responses, indicating a lack of uniformity in their coping strategies during the shortage crisis.

Notably, providers expressed challenges safely administering anesthetics for neurosurgical cases, where the customary practice of mixing remifentanil infusions in small saline bags was disrupted by shortages. The reliance on small saline bags as a preparation source for crucial medications such as antibiotics, ketamine, insulin, vasopressors, and remifentanil became evident. In response, providers resorted to mixing medications in with alternatives or substituting with alternative medications, such as opting for long-acting narcotics and increasing the use of propofol instead of remifentanil. Interestingly, for ketamine and insulin, a systemic solution emerged with pharmacy pre-mixing bags, demonstrating a collaborative approach. The increased regulation of medications through pre-mixed or compounded bags from the central pharmacy mitigated challenges associated with drug preparation during the shortage, offering a systemic remedy to address individual concerns and enhance overall safety protocols.

Also at the individual level, a noticeable decline in demand for 1 L normal saline bags was observed, despite not being officially declared in shortage. Instead, there was a discernible shift toward alternatives such as Lactated Ringer and Plasma-Lyte. This trend coincided with recent clinical trials, specifically the SMART-SURG and SMART-MED studies, focusing on the impact of crystalloids on surgical and medical outcomes (11, 12). These trials, well-known during the study period, provided support for considering alternative crystalloids over normal saline.

The Isotonic Solutions and Major Adverse Renal Events Trial in Medicine (SMART-MED) and Surgical patients (SMART-SURG) investigated critically ill medical and surgical ICU patients, comparing the outcomes of normal saline versus balanced crystalloids. The primary endpoint was a major adverse kidney event within 30 days, defined as death, new renal-replacement therapy, or persistent renal dysfunction. The results showed a slight difference in major adverse kidney events (15.4% in normal saline vs. 14.3% in balanced crystalloids groups, p = 0.04). Notably, acute kidney injury rates suggested that the use of balanced crystalloids could be equally effective in resuscitation (11, 12). Some anesthesia providers acknowledged that these studies influenced their choice of crystalloid, reflecting a growing awareness and consideration of the evolving evidence base in their clinical decision-making processes.

Systemic solutions during this acute crisis have notably focused on two key areas: the operating room (OR) pharmacy’s provision of standardized solutions and the broader system supply chain at UPMC.

One of the principal ways this was performed was by a decrease in demand. This was done with decreased case volume, as seen in Figures 3a,b with surgical load. Elective cases were decreased, though the reason for this being the hurricane itself is unknown due to the retroactive nature of aspects of this study. Notably, though, all providers were made aware of the crisis and shortage affecting supply and need, with the resultant drop reflecting a systemic change in planning.

The emphasis on the OR pharmacy providing standardized solutions has proven crucial in addressing the challenges posed by the shortage. By preparing standardized solutions, the pharmacy significantly reduces the risk of dilution errors and contamination. This standardized approach not only enhances patient safety but also streamlines the process of adopting alternative solutions in a timely manner. The OR pharmacy, in this context, has emerged as a strategic player in improving the delivery of critical medications and actively contributing to closed-loop planning for scheduled cases. The study’s findings highlight the positive impact of this approach, particularly on the standardization and preparation of ketamine and insulin by the local pharmacy.

Implications

A need for the broader idea of localizing or “reshoring” pharmaceuticals within the continental US mainland, or even more specifically a local hospital and healthcare system frameworks, emerges as a proactive strategy based on these results. This approach aims to mitigate the impact of acute shortages by establishing a healthcare system-driven pharmaceutical model, thereby increasing the availability of high-quality pharmaceuticals.

The significance of localization became evident during Hurricane Maria when Baxter’s facilities were incapacitated, leading to the depletion of national reserves on the U.S. mainland (9). Subsequently, months later, the situation improved with increased supply from alternative manufacturers such as B. Braun Medical and ICU Medical, as well as the establishment of alternative production sites, including Brazil, by January 2018 (4). American manufacturing and safety standards from the FDA limit any unapproved or vetted source of drug or product (2–5).

Consideration of pharmaceutical localization aligns with the vision outlined by U.S. Homeland Security, envisioning large hospital systems such as UPMC and Kaiser Health taking on the production of key medications or medical supplies. While this proactive measure could enhance the healthcare system’s resilience, startup costs and the ongoing maintenance of such facilities on the mainland have been primary arguments against pursuing this strategy (13).

Lessons learned

Unfortunately, the frequency of disasters is projected to rise in the coming decades due to global environmental changes (14). The recent pandemic of COVID-19 exemplified the strain on the supply chain for sedatives and analgesics (15), compelling hospitals and providers to rapidly explore alternative sources or even resort to in-house manufacturing, often under non-standard hygienic conditions (5). As discussed, while the idea of health systems producing their own drugs presents challenges, particularly in terms of upfront investment and costs, local production supported by government initiatives could offer cost savings and strategic advantages (16).

Furthermore, this study underscores the crucial role of well-trained healthcare providers in building resilience into the system. Although providers can take the initiative individually, implementing system controls with feedback, such as pharmaceutical oversight of compounding with streamlined processes, is essential for ensuring the safe and timely delivery of medications. The study also reveals that resource limitations prompted a shift toward safer balanced crystalloids, aligning with recommendations in the literature. These changes, initiated at the individual level, contribute to systemic adaptations, while shifts in case volume demonstrate a bottom-up influence on the system.

Importantly, in response to disasters, the American Medical Association (AMA) and the United States Pharmacopeia (USP) recently published recommendations that hospital systems can take to overcome supply chain shortages. These include: (1) incentivizing advanced manufacturing technology and develop new continuous manufacturing technology for critical drugs and active pharmaceutical ingredients; (2) improving the function and composition of the Strategic National Stockpile; and (3) improving multinational cooperation to minimize supply chain disruption (17).

In future long-term planning, it is essential to integrate a systematic strategy that allows the healthcare system to adapt to individual-level changes. We present a framework, depicted in Figure 4, and a detailed approach, Figure 5, which outlines the steps to construct a resilient healthcare system. Based on our experience working with health systems and their suppliers, leaders can embrace four pivotal initiatives to strengthen their supply chains. First and foremost, enhancing visibility within the supply chain is crucial. Internally, this means consolidating inventory data and utilizing innovative tools such as RFID barcoding to improve comprehension of inventory levels across different care settings. Externally, partnering with group purchasing organizations (GPOs) and distributors provides valuable insights into supply chain dynamics, facilitating the early identification of potential disruptions (18). Second, health systems should adopt product-specific strategies to address supply chain disruptions. It is vital to pinpoint critical items through collaboration with clinicians, emergency preparedness teams, GPOs, and distributors (18). Subsequently, proactive actions can be initiated, such as establishing demand management protocols and exploring alternative products. Moreover, considering stockpiling strategies for essential items can mitigate the risk of shortages and serve as a protective measure during crises. Finally, the development of pertinent protocols, capabilities, and governance structures is indispensable for efficient supply chain management (18). Health systems need to set clear guidelines for product utilization in partnership with stakeholders and allocate resources to respond promptly to disruptions, including adjusting demands and adapting practices. Strong governance mechanisms ensure efficient decision-making, which is crucial for agile responses to supply chain issues. By optimizing expenditures and maintaining a lean financial base, health systems can reinforce their adaptability. This approach allows them to withstand potential challenges and ensure the continuous provision of vital healthcare services without interruption.

Figure 4

Figure 4. A summary of system-level and provider-level solutions to the saline shortage.

Figure 5

Figure 5. Infographic of provider-level and system-level responses for a model of resilience.

Future directions

The scope of this paper was limited to two university hospitals in a multihospital system. Further investigation encompassing multiple hospitals or the entirety of the health system would provide deeper insight into healthcare systems’ capacity to cope with drug shortages. Healthcare systems must operate under the assumption that future events like these will occur. Reports such as our investigation highlight the importance of a multi-pronged approach to innovation and solutions in the face of shortages so that healthcare entities, from pharmacies to supply management to providers, can creatively approach these issues. Further research and efforts are needed to address these inevitable crises.

Limitations

This paper provides qualitative descriptors and OR demand and usage data to present how a health system responds to shortages generally and a severe shortage more acutely. The surveys (2019) were completed 1 year after the hurricane and the impacted changes (2017–2018). The survey data would thus be vulnerable to recollection bias and selection bias by design, though not directly observed. The response rate was approximately 60% of the population, and there was no way to verify if the survey participants were present other than self-reporting. The study was not validated externally against other healthcare systems. Additionally, the data is limited in its specific scope of supply, demand, and usage, and cannot account for different causes, some of which were described in the discussion.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by UPMC QI Committe and IRB - Project ID: 1445. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

RH: Writing – review & editing, Writing – original draft. EP: Writing – original draft, Writing – review & editing. TL: Writing – original draft, Writing – review & editing. JT: Writing – review & editing, Writing – original draft. RR: Writing – review & editing, Writing – original draft. JC: Writing – original draft, Writing – review & editing. MF: Writing – original draft, Writing – review & editing. AK: Writing – review & editing, Writing – original draft.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The authors AK, RH declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Generative AI statement

The author(s) declared that Generative AI was used in the creation of this manuscript.

Figures 4, 5 were modified using Microsoft Co-Pilot.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2025.1671978/full#supplementary-material

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