Skip to main content

With Saline in Short Supply, Hospitals Look for Alternatives

 |  By Lena J. Weiner  
   May 16, 2014

A widespread shortage of saline solution is forcing hospital pharmacists and healthcare clinicians to stretch existing supplies, find workarounds, and formulate substitutes.


As director of pharmacy and materials management at Union Hospital of Cecil County in Elkton, MD, David Jaspan, RPh, MBA, is used to dealing with shortages of pharmaceutical products. He's not, however, used to supply problems affecting one of the most basic hospital staples—intravenous saline solution.

"It's not just saline solution, it's all IV solutions in general," says Jaspan. Since saline is a key ingredient to administering drugs to hospital patients, this is an especially tough shortage to face. "Most inpatients get IVs… I'd say 85% of inpatients are affected by this," says Jaspan.

The Federal Drug Administration has issued three updates so far this year on the nationwide shortage of saline. The dearth of the product is forcing healthcare clinicians and hospital pharmacists to stretch existing supplies and find alternatives.

Drug shortages are not uncommon. But hospitals have more experience dealing with not enough cancer drugs than not enough bags of saline.

"We've been dealing with national drug back orders for years. We're used to this in pharmacy, but it's unusual to see [a shortage] at one of the most basic levels with solutions… This is just another one in a long line of unavailable products," Jaspan says.

'Very Serious' Shortage
Erin Fox, PharmD, director, Drug Information Service, University of Utah Hospitals and Clinics, characterizes the saline supply problem as "very serious. It's serious when clinicians have to make a decision to use an alternate product. A big part of the treatment plan now has to be asking, 'is that product available?'"

Until recently, saline solution was routinely taken for granted. Jaspan recalls that it used to be standard practice to use a 1000 milliliter bag of saline solution in any situation calling for an IV in order to avoid refilling it.

"You used what you needed and tossed what was left at the end of day. A lot of people are used to doing that," he says. Now staff at his hospital are conserving saline by using smaller bags and changing them frequently.

"If you just need to keep a vein open, you can use a 250-milliliter bag rather than a larger one," he says.

Another way Jaspan's team has been coping with the shortage has been by formulating substitutions. "We can use Dextrose 5% and half-normal solution in saline's place," he says.

Jaspan has other tricks to make sure patients get the right solution, too. "If there's no half-normal solution available for the patients who need it, pharmacists can compound that [in house]. You just take sterile solution with sodium chloride added. Need Dextrose? We'll find a way to compound that as well."

"For the most part, we're able to use an alternative. You can [stretch supplies] for a long period of time, but if you run out of product, you can find an alternative that works for the patient," he said.

Still, the widespread saline shortage can be more than inconvenience. It can drive up costs. Some providers, particularly small and rural community hospitals, may not have a pharmacy resources to formulate alternatives and have fewer options for sourcing alternatives.

Root Cause Analysis
"The question I'd like answered is, why is this happening?" says Jaspan. "I can't get a straight answer from anyone as to why this is occurring. We had adequate supplies until five months ago.

"I read through one [pharmaceutical] company's letter—they blamed the shortage on flu season. But the flu wasn't that big [of a problem] here," he said.

Bona E. Benjamin, director of medication-use quality improvement with the American Society of Health-System Pharmacists (ASHP), has another theory. She believes the saline shortage is rooted in product recalls.

"Most saline solution used in the US comes from one of three big pharmaceutical firms. There is one other supplier that is significant as well. Of the three firms, two [had] recalls of saline solution in late 2013. [The other] announced that they had a routine maintenance shut down. With the recalls and [manufacturing] shutdown, that strained the supply. Additionally, one more supplier from Europe that supplies saline solution for dialysis had an import delay from their plant in Mexico, which shifted demand to US suppliers," explained Benjamin.

Wayne Russell, senior director of pharmacy at Premier, Inc., a group purchasing organization, has a similar take. "My view is not the same as the FDA's. The FDA has said the shortage was caused by an increased number of flu cases and extra hospitalizations… and use of fluids, but I can tell you that every manufacturer of IV fluids in the US has had recent [manufacturing related] quality issues."

Russell says those quality issues necessitated a manufacturing slowdown and "they still haven't caught up with demand."

A High Price to Pay
Whatever the cause of the shortage, its effect is hitting hospital budgets. Jaspan's longtime supplier, proposed a price hike of "300%—that would have been my increase had I stayed with Hospira," says Jaspan. He found an alternate vendor.

When substitution or careful rationing of saline isn't enough, organizations can expect to feel the pinch when paying for saline. "The product being imported to the US is about ten times higher than [what hospitals are accustomed to paying], said Russell.

So far, the FDA has given a major European manufacturer of saline, Fresenius Kabi, permission to export saline manufactured in Norway to the US, and is allowing Baxter to supplement its normal supplies with saline manufactured in its plant in Spain.

It must be distributed through the normal channels and "it's being very tightly managed," says Russell.

The manufacturers have handled allocation and distribution of saline throughout the shortage. "They try to fairly distribute it. If they didn't do that, you would have some hospitals buying more than they need and hoarding it," he said.

But the allocations have been meager. "You get maybe 60% of what you usually get," said Jaspan. "Sixty percent will not cover everything you need when you're used to 100%."

No Impact on Quality Detected
And "sometimes, what you thought you were going to get doesn't come through. Every day is disaster mode planning, figuring out how to minimize the impact for patients," Fox says.

Despite all the work Jaspan's team has done in substituting and stretching their resources, there's been no impact on the quality of care to his organization's patients. "I haven't read or heard about it impacting [quality in] any other hospitals, either," he said.

"We're working so hard to make the problem invisible [to patients]," says Fox. Until the shortage has completely cleared up, she urges healthcare leadership to be supportive of the clinicians who need additional time to build a plan, and that they understand the cost implications.

According to Russell, it may be a long wait. He takes the FDA's recent decision to grant Fresenius Kabi permission to export saline to the US through the end of 2014 as a sign that the shortage will last until at least the end of the year.

Lena J. Weiner is an associate editor at HealthLeaders Media.

Tagged Under:


Get the latest on healthcare leadership in your inbox.