At MedStar Washington Hospital Center, doctors and nurses are moving as many patients as they can from intravenous medications to the same drugs in pill form.
If the patients are getting common antibiotics like ampicillin, and they can swallow, they're likely to be switched to pills, says Bonnie Levin, assistant vice president of pharmacy services for MedStar Health, which includes 10 hospitals in the Washington, D.C., area.
That's because MedStar, like many hospitals across the U.S., is running low on IV bags, especially the minibags that are used to deliver certain types of medicine. Some of these bags contain saline solution when shipped, and a nurse or hospital pharmacist adds the drug when it's ready to be used. Other bags come premixed with commonly used medicines.
"The plain bags, the mixed bags. There are shortages of all kinds of small-volume medications," Levin says.
The shortage is a direct result of hurricane damage in Puerto Rico. It has been eight weeks since Hurricane Maria hit the island, knocking out electricity and wreaking havoc on many roads, homes and other buildings.
The storm damaged many of the island's more than 100 drug and medical device manufacturers. Puerto Rico produces about $40 billion worth of pharmaceuticals for the U.S. market, according to the Food and Drug Administration — more than any other state or territory.
Three of those plants belong to Baxter, one of the biggest suppliers of IV bags to U.S. hospitals. All three of Baxter's plants shut down temporarily, the company says, and at least two are still running on generators.
One of Baxter's factories that makes the minibags for intravenous medicines is very remote.
"It's atop a mountain, and the roads have been very compromised. They are still running on generators the last we knew, and they are at partial capacity," says Christi Guest, who runs the disaster response team for Vizient, a company that, among other things, sources medical supplies for hospitals all over the U.S.
Baxter isn't the only company on the island struggling to meet demand.
"The manufacturing environment in Puerto Rico, as far as we are informed, is largely still running on generators — compromised capacity," Guest says.
But getting back to normal "is a monumental task given the logistical challenges they face," he told reporters.
So the manufacturers are rationing the medications and supplies that they do manage to make. The idea is to prevent any one hospital from buying the entire supply.
For example, Baxter has restricted distribution of IV bags to 50 percent of a hospital customer's usual order, according to Vizient and MedStar.
Levin says the hospital isn't even receiving that much.
"I don't think we're getting 50 percent, but we're getting sporadic shipments," she says. "We used to get shipments every week. One of our hospitals got five cases of IV bags yesterday, and it was an order they had placed a month ago."
The shortage has become severe enough that the FDA is allowing Baxter to import minibags, amino acids and other products from its plants in Ireland, Australia, Canada, Mexico and England.
The FDA updates its list of medication shortages regularly and many products have been added since Maria hit Puerto Rico. But it's impossible to know exactly which shortages are linked to disruptions on the island.
Stephanie Hale also works at Vizient, helping the company's hospital clients manage how they use products that are in short supply
She says she and her colleagues are trying to change how hospital emergency rooms think about the use of IVs.
"Every patient that came into the emergency department, that was admitted to a unit, automatically was placed on fluids to maintain hydration," she says. "But what we've been suggesting to our members more recently is that they evaluate the actual need and assess patients more specifically and accurately for IV solutions."
In Washington, D.C., MedStar's Levin says her hospital has been able to manage the shortages, so far.
"We're really fortunate in that we haven't disrupted patient care," Levin says. "If this went on for two years, I'd have some concerns. We expect supply to return in three to six months."
STEVE INSKEEP, HOST:
A hurricane damage from Puerto Rico - from Puerto Rico is being felt in hospitals across the rest of the United States. That's because a lot of medical devices are manufactured in Puerto Rico. In fact, more than 100 plants there do that kind of work, or did that kind of work until Hurricane Maria struck a couple of months ago. Production, as you may expect, is down, and the manufacturers have a long way to go to return to full capacity. Alison Kodjak reports that's causing shortages on the mainland.
ALISON KODJAK, BYLINE: At MedStar Washington Hospital Center, doctors and nurses are moving as many patients as they can from IV medications to the same drugs in pill form if they're available.
BONNIE LEVIN: Ampicillin is one. Keflex has a equivalent. So yeah, common antibiotics.
KODJAK: Bonnie Levin is the head of pharmacy services for all 10 MedStar hospitals. She says there's a shortage across the country of IV bags, specifically so-called MINI-BAGS that are used to deliver medications. Some contain saline solution and others are pre-mixed with medicine.
LEVIN: So the plain bags, the mixed bags, there's - so there are shortages of all kinds of small-volume medications.
KODJAK: So now the hospital staff has been told to change their habits and conserve.
LEVIN: We use those small bags to deliver many medications, and some we can only deliver that way, some there are other alternatives.
KODJAK: The shortage is a direct result of the hurricane damage in Puerto Rico. There are more than 100 drug and medical device plants on the island. Three of them belong to Baxter, one of the biggest suppliers of IV bags to U.S. hospitals. All three of Baxter's plants shut down temporarily, and at least two are still running on generators. Kristi Guest says the Baxter plant that makes MINI-BAGS is pretty remote.
KRISTI GUEST: It's atop a mountain, and the roads have been very compromised, and they are at partial capacity.
KODJAK: Guest runs a disaster response team for Vizient, a company that sources medical supplies for hospitals. She's been working with companies in Puerto Rico since the hurricane, and she says Baxter isn't alone.
GUEST: The manufacturing environment in Puerto Rico, as far as we are informed, is largely still running on generators, compromised capacity.
KODJAK: And so the companies are rationing the medications and supplies they do manage to make. For example, hospitals are only getting about half or less of their regular shipments of mini IV bags. And Vizient says even surgical staples made on the island are in short supply, and their distribution is being restricted. The idea is to prevent any one hospital from hoarding supplies and to make sure everything is distributed as evenly as possible. Stephanie Hale also works at Vizient. She helps the company's hospital clients manage how they use products that are in short supply.
STEPHANIE HALE: Every patient that came into the emergency department that was admitted to a unit automatically was placed on fluids to maintain hydration. But what we've been suggesting to our members more recently is that they evaluate the actual need and assess patients more specifically and accurately for IV solutions.
KODJAK: Bonnie Levin at MedStar in Washington, D.C., says so far they've been able to manage the shortages.
LEVIN: We're really fortunate in that we haven't disrupted patient care. You know, if this went on for two years, I'd guess I'd have some concern, but at this point, we expect that the supply is going to return in three to six months.
KODJAK: But that prediction depends on how fast the island's roads and electric grid can be restored. Alison Kodjak, NPR News.
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