Colleen Snydeman, director of quality and safety for Patient Care Services at Massachusetts General Hospital, felt the full force of Hurricane Maria three weeks after September 20, 2017, the day the storm devastated Puerto Rico. A pharmacist informed her that the hospital would soon run out of the 50- and 100-milliliter “minibags” of normal saline and dextrose that nurses use to administer antibiotics and other medications from an intravenous pump. It wasn’t an isolated situation. Baxter International’s three Puerto Rico manufacturing sites, which provide almost half of the intravenous fluids and bags used in the continental United States, had shut down during the storm. They were able to resume only partial operations a week later, using emergency generators. Suddenly, some the most widely used hospital products were in perilously short supply.

It’s not that unusual for hospitals to run short of particular drugs. But normal supply gaps are intermittent, and there are often short-term substitutes available. This time was different. With a major supplier of crucial medical goods sidelined, MGH and other hospitals around the country had to mount a two-pronged response. Immediate, short-term solutions had to be created throughout the hospital, with nurses, pharmacists, physicians and administrators working together to minimize the impact on patients. At the same time, the crisis led to longer-term questions: Are other supplies at risk? What can we do to keep patients safe? These revealed the need to change protocols and policies to prevent this kind of situation from occuring again.

As a first order of business, MGH nurses had no choice but to begin delivering medications and fluids in different ways. Instead of using IV bags and infusion pumps, they had to stand at patients’ bedsides and, using a syringe, slowly inject drugs mixed with sterile water into veins by hand—a laborious process that is no longer used, so many of the nurses had never been trained to do it.

“We educated 3,500 nurses in a week on the proper techniques for mixing medications and safely administering them,” says Snydeman. This kind of “IV push” can take from 10 to 30 minutes, and it can’t be rushed. Pushing too much fluid too quickly can rupture a vein.

Christopher Fortier, chief of pharmacy for MGH, and his staff also had to make immediate changes. Although the Food and Drug Administration gave permission in October for Baxter to import IV fluids from its facilities in Ireland and Australia, that alternative supply never materialized at MGH, Fortier says. And with a daily demand for 2,500 to 3,000 bags of IV fluids, Fortier’s staff has had to work frantically. “This has been totally consuming, with shortages of products that change hour by hour,” Fortier says.

At first, pharmacists were able to work around the lack of Baxter’s 50- and 100-milliliter bags of saline and dextrose, and their small bags of premixed medications. Pharmacists simply opened larger bags of fluids and used them to fill smaller bags that were empty. “Some weeks we were pumping 1,000-plus bags, which is not what we normally do,” says Fortier. But then the unfilled small bags as well as the large bags of fluids began to run out. Fortier and his staff turned to other suppliers, placing emergency orders.

By the end of December, Baxter announced that all three of its facilities in Puerto Rico were operating again, but Fortier expected it to take several months for supplies of IV fluids to return to normal. In the meantime, with a particularly virulent flu season in full swing, the situation could easily move from critical to dire, he says.

One reason the current crisis developed so quickly is that the IV fluid market is a low-margin business dominated by only a few companies that run plants at full capacity, says O’Neil Britton, chief medical officer for MGH. “When one supplier goes offline, the ability of others to pick up the slack is extremely limited,” he says. Nor do hospitals have large inventories to tap in an emergency. “To be cost effective, hospitals have a just-in-time inventory of four to five days of medical supplies,” explains Britton, who notes that for emergencies, MGH normally keeps enough essential medical products to meet two weeks of peak demand.

“This crisis has shown us how incredibly thin the supply line for critical health care supplies is,” says Paul Biddinger, chief of the division of emergency preparedness at MGH. “There’s no room for a patient surge, no redundancy and no tolerance for any hiccups in the system. When a disruption happens, there’s no safety net.”

In the weeks and months after Maria, other suppliers, inundated with orders, had to resort to rationing, and hospitals had no way to predict how much would arrive in each shipment. “One day we might get 60% of what we ordered, and on other days we received none of certain products,” says Britton.

To help cope with those fluctuations, MGH reprogrammed its electronic medical record system so that the internal orders for what patients needed could be changed on the fly. Pharmacists reviewed each order for IV fluids and medications and asked providers to alter orders if they couldn’t be filled on that day. “This was an enormously intensive effort,” says Biddinger.

At the end of November, after almost two months of struggling with the shortages, MGH activated its Incident Command System—an emergency operations team that is mobilized during a pandemic or other medical emergency, and the same one that sprang into action after the Boston Marathon bombing. A group of hospital leaders, including physicians, nurses and pharmacists, began to consider changes in normal practices that could help conserve IV fluids. “If we don’t have to administer fluids, we don’t, and if there are two clinical strategies that are equivalent, we choose the one that uses the least fluids,” says Biddinger, who emphasizes that these alternative approaches haven’t put patients at risk.

Patients are now switched to oral medications whenever possible, and IV hydration is stopped as soon as it safely can be. “Typically, orders for IV fluids might not get canceled promptly, even when patients are able to eat and drink,” says Biddinger.

Staff members have learned to be careful about gauging exactly how many bags of IV fluid a patient is likely to need during a procedure, rather than grabbing a few extra just in case. And when patients are transferred from one part of the hospital to another, their IV bags go along. “Before the crisis, we would discontinue one bag and start another in the new care setting,” says Britton. “Now we wait until a bag runs dry before replacing it.”

“Some of our new strategies are actually better for the patient and less costly, so finding those has been a silver lining for this crisis,” says Biddinger. Even those inconvenient, presumably outmoded IV pushes may have their uses. “This could be a more effective way to treat some infections because the drug is delivered in a faster, more concentrated way,” says Colleen Snydeman.

Yet even now, the situation remains critical, says Biddinger. “We’ve run out of adaptive strategies, and any additional pressure may force us to cut back on admissions and elective surgeries,” he explains. “Obviously, we can’t sacrifice quality or safety, so the only alternative would be to deliver care to fewer patients.”

In the longer term, after the crisis is past, MGH will continue to work with government officials and regulators to keep a spotlight on persistent U.S. shortages of IV fluids. One fix, Biddinger suggests, would be to use government-provided incentives to persuade new manufacturers to produce IV fluids—a strategy that has helped increase the supply of flu vaccine. The FDA could also require manufacturing plants to have the capacity to ramp up production in an emergency, so that if one of a few facilities were knocked out, the others could take up the slack. “A natural or manmade disaster could cause this kind of shortage to happen again,” says Biddinger. “We have to make sure the public’s health isn’t as vulnerable next time.”