Sterile Fluid Crisis Response After Hurricane Helene

Abstract

This quality improvement study describes the development, implementation, and outcome of a sterile fluid conservation strategy in a hospital.

Hurricane Helene made landfall in Florida’s Big Bend on September 26, 2024, as a Saffir-Simpson category 4 tropical cyclone—the most powerful storm to hit the region and the deadliest in the US since Hurricane Katrina in 2005. Extensive flooding, including up to 30 inches of rainfall, caused tens of billions of dollars in damage.¹ Among the hardest-hit areas was North Cove, North Carolina, home to Baxter International’s largest sterile fluid (SF) production facility, which supplies 60% of US SF needs.² Flood damage forced the facility to shut down,³ immediately reducing our hospital’s allocation of SF (including both intravenous and sterile irrigation fluids) by 40% to 60%, depending on fluid type. In response, we developed a conservation strategy to sustain critical and noncritical surgical services while ensuring patient safety. We detail the steps we took to mitigate this crisis.

Methods

In accordance with the Common Rule, this quality improvement study was exempt from ethics review because it was not human participant research. We followed the SQUIRE reporting guideline.

Immediately after the SF supply disruption, we created an incident response structure with leaders from medicine, perioperative, supply chain, pharmacy, and information services, holding frequent decision-making meetings. To assess inventory risk, we calculated daily consumption rates and developed projected depletion timelines under various conservation scenarios, supplemented by real-time tracking. We reinforced situational awareness through hospital-wide communications, targeted clinician education, and regular status updates. To reduce reliance on SF, we refined perioperative workflows and implemented an oral rehydration protocol. To support our efforts, we used clinical practice advisories and mandatory SF order durations.

To evaluate the effectiveness of the conservation strategy, we compared daily SF administration (in fluid bags) between the pre-Helene (October 1, 2023, to January 31, 2024) and post-Helene (October 1, 2024, to January 31, 2025) periods, using a 2-sample t test. To examine continuity in critical and noncritical surgical services, we compared monthly surgical case volumes between periods, using a 2-sample t test. To assess patient safety, we estimated the odds of postoperative acute kidney injury (AKI) as a function of period with multivariable logistic regression, adjusting for patient age, sex, race, overall health (American Society of Anesthesiologists status), and admission acuity (elective vs urgent or emergent). Race data were obtained from the electronic health record system and were included because race has been associated with the risk of AKI.

Two-sided P < .05 indicated statistical significance. Data analysis was performed with R, version 4.03.01 (R Project for Statistical Computing).

Results

After implementing the conservation strategy, SF administration significantly decreased in the post-Helene vs pre-Helene period (mean [SD] SF bags per day: 835 [243] vs 480 [149]; P < .001) (Figure, A). However, surgical services were uninterrupted, with inpatient volumes stable between periods (mean [SD] cases per month: 2564 [122] vs 2534 [76]; P = .69) (Figure, B). On regression, the odds of postoperative AKI did not differ significantly between the periods or by admission acuity (Table). Stratification by surgical service revealed stable odds of AKI across most specialties before and after the hurricane. While neurosurgery had higher odds in the post-Helene period (AOR, 2.69; 95% CI, 1.34-5.39), odds were lower in cardiac (adjusted odds ratio [AOR], 0.49; 95% CI, 0.31-0.79), thoracic (AOR, 0.17; 95% CI, 0.05-0.61), and transplant surgery (AOR, 0.42; 95% CI, 0.18-0.98).

Figure. Sterile Fluid (SF) Administration and Surgical Case Volume in the Pre– and Post–Hurricane Helene Periods.

Boxes represent IQRs for the 2 periods, with the line inside the box representing the median and the triangle representing the mean. The bottom and top of the box represent the 25th percentile and 75th percentile, respectively. Whiskers extend to the smallest and largest values from the 25th and 75th percentiles. Dots represent outliers. Pre–Hurricane Helene period encompasses October 1, 2023, to January 31, 2024. Post–Hurricane Helene period spans October 1, 2024, to January 31, 2025.

Table. Adjusted Odds of Acute Kidney Injury After Hurricane Helene^a.

	No.	AOR (95% CI)
Overall	7806	0.90 (0.74-1.09)
By admission acuityb
Elective	3584	1.08 (0.76-1.53)
Urgent or emergent	3760	0.82 (0.64-1.04)
By surgical service
Acute care	475	1.44 (0.63-3.28)
Cardiac	499	0.49 (0.31-0.79)
General	576	0.50 (0.19-1.31)
Neurosurgery	1131	2.69 (1.34-5.39)
Obstetrics and gynecologyc	880	1.22 (0.40-3.76)
Orthopedic	1312	1.76 (0.99-3.13)
Otolaryngology	316	1.90 (0.68-5.25)
Thoracic	187	0.17 (0.05-0.61)
Transplant	263	0.42 (0.18-0.98)
Urology	357	1.98 (0.69-5.68)
Vascular	761	1.10 (0.66-1.84)

Abbreviation: AOR, adjusted odds ratio.

^a The occurrence of postoperative acute kidney injury was determined using relevant International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes.

^b Admission status models included age, race, sex, and American Society of Anesthesiologists status.

^c Obstetrics and gynecology model did not include sex.

Discussion

Our findings demonstrate that a structured SF conservation strategy reduced utilization while maintaining surgical volumes and patient safety. Unlike many health systems that had to delay elective procedures due to SF shortage,⁴ our hospital preserved care continuity. While Baxter’s North Cove facility has resumed operations,⁵ and most customers have returned to full allocation, we have maintained several conservation measures beyond the crisis because they were not detrimental to care and added value—underscoring that necessity drives innovation.

A study limitation is the findings reflect 1 hospital’s experience; thus, generalizability may be limited given differences in supply chain, workforce capacity, and case mix across institutions. Nonetheless, this study highlights the importance of supply chain resilience and the advantages of a multidisciplinary, comprehensive approach to rapid response coordination.

Supplement.

Data Sharing Statement