Planning for Resiliency in the IV Fluid Supply Chain

00:00:00:20 - 00:00:40:09
Tom Haederle
Even as Baxter strives to restart its production of IV fluids critical for patient care, in the wake of the damage caused by Hurricane Helene, hospitals and health systems nationwide are reviewing and reevaluating their response playbooks for dealing with supply chain disruption. For many caregivers, such as Ohio's Cleveland Clinic, this national shortage is just the most recent in a long line of shocks to essential supplies that preceded the Covid pandemic, dramatically escalated during the Covid years and still has yet to abate.

00:00:40:11 - 00:01:14:11
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Conservation, communication and cross-functional collaboration are the pillars of Cleveland Clinic's approach to leading through this IV fluid shortage and minimizing its impact on patient care to the extent possible. In this podcast hosted by Dr. Chris DeRienzo, AHA's chief physician executive, we get an overview of Cleveland Clinic's ongoing IV fluid conservation strategies from its surgical director for surgical operations, Dr. Mark Taylor.

00:01:14:13 - 00:01:30:24
Chris DeRienzo, M.D.
I am very lucky to be joined by Dr. Mark Taylor. He is the surgical director of surgical operations for the Cleveland Clinic, and to talk about the clinic's approach to how they've managed through this, frankly, national crisis. Dr. Taylor, thank you so much for joining us today.

00:01:30:27 - 00:01:32:15
Mark Taylor, M.D.
Well, thank you, Chris, for having me.

00:01:32:18 - 00:01:44:17
Chris DeRienzo, M.D.
Let's go back a few weeks. So, when did you first learn about the true level of this IV solution shortage? And what actions did you and your teams at the clinic put in place around conservation?

00:01:44:20 - 00:02:08:11
Mark Taylor, M.D.
So, we first heard the day following Hurricane Helene’s landfall, when reports of significant damage were sustained at the Baxter facility in North Cove, North Carolina area. We immediately stood up teams between supply chain and some operational leaders to start to assess the situation. And then as the next several days played out, it became apparent that the damage was significant.

00:02:08:11 - 00:02:27:06
Mark Taylor, M.D.
And that that Baxter facility was going to be in a compromised position for not just a number of days, but probably a number of months. That really sort of planned our response, if you will, in that first four days, which was critical to where we are today in terms of some sustainable cadence around our meetings and our multidisciplinary teams.

00:02:27:09 - 00:02:52:09
Mark Taylor, M.D.
What we did immediately was, as we looked internal to determine what our inventory looked like, what our usage patterns were, and where we had supply opportunities to centralize and then allocate appropriately. Respectful of the fact that this may be a much longer-term situation, that both the Cleveland Clinic, in Ohio and Florida were going to face, but also, health care systems across the U.S. market.

00:02:52:11 - 00:03:20:12
Chris DeRienzo, M.D.
I remember being on the phone with chief physicians in those first couple of days after the storm. And, you know, there was some real concern about what can we do short term, recognizing that all those images coming out of western North Carolina looked pretty scary. But I think one thing our listeners would really appreciate is from an operational standpoint, and we talk about conservation and there's some just assumption you flip a switch and magically, you know, conservation efforts are going on.

00:03:20:12 - 00:03:30:14
Chris DeRienzo, M.D.
But what was actually involved at Cleveland Clinic, what kind of teams were involved and what processes did you have to turn on in order for the impact of conservation to really be felt?

00:03:30:17 - 00:04:00:10
Mark Taylor, M.D.
Yeah, I think the first step was to really get a sense from Baxter and from some teams internal to the Clinic, what fluids were specifically going to become necessary for conservation? We quickly assessed that it was IV fluids, OR irrigation fluids and fluids specific to peritoneal dialysis. And once we knew that that was the platform, we could then create teams, if you will, that were subject matter experts in those areas to address some of the nuances that may exist.

00:04:00:12 - 00:04:21:19
Mark Taylor, M.D.
From an operational standpoint, this work is at the forefront of what a large team of professionals at the Cleveland Clinic is focused upon daily. We meet twice a day with these groups, but I know that there's a lot of work that goes on in between those twice-daily meetings to make sure that work is ongoing. Given the size and scope and the impact.

00:04:21:22 - 00:04:46:07
Mark Taylor, M.D.
These products are daily-use products. When one thinks about the amount of IV fluid that is moving through our organization, through all kinds of clinical areas, through the pharmacy, the emergency rooms, the ICUs, the ORs, the fact that we had a facility taken offline that was really sort of the standard part of what a patient would experience for either a simple procedure or a large procedure, or an inpatient or short outpatient admission —

00:04:46:09 - 00:04:53:03
Mark Taylor, M.D.
you could see how critical the response has to be so that flow of care continues.

00:04:53:05 - 00:05:05:24
Chris DeRienzo, M.D.
No question. It sounds like there's a pretty large team at Cleveland Clinic involved in the issue. Speak a little bit for our listeners about the importance of collaboration and what it takes to manage such a widely disparate group.

00:05:05:26 - 00:05:42:26
Mark Taylor, M.D.
Yeah, well I think it's important to recognize that the teams that we brought together represented operations, nursing, pharmacy, supply chain, anesthesia, ICU, nephrology, informatics, communications, infection prevention specialist, and several more that come and go as we manage through this crisis. You know, as we explore changes to our operations, we have to make sure that we reach out to other partners within the clinic to ensure that changes in workflows align with our policies, align with our regulatory affairs.

00:05:42:28 - 00:06:17:09
Mark Taylor, M.D.
Make sure that things are in alignment with how we want to deliver care. So I think what's really critical with these multidisciplinary teams is you have to have a forum where these teams can come together, obtain information, ask insightful questions, allow others to speak and offer suggestions about changes in strategy, changes in operations or, equally important, inclusion of others so that we don't make a step that may potentially create a different situation than we have to manage.

00:06:17:12 - 00:06:38:29
Chris DeRienzo, M.D.
Let's go deeper on that forum for a minute, because communication is absolutely crucial to successfully leading through these kinds of disruptions. And I remember past experience during Covid with other disruptions to our normal daily work. It is really hard to communicate quickly, efficiently and effectively, both internally and externally. So how are you doing it?

00:06:39:01 - 00:07:04:15
Mark Taylor, M.D.
Yeah, that's a great question. So, I like the term disruptions. And we learned during the pandemic to become comfortable, if you will, with disruptions. Many of us in operations and in clinical leadership roles, I think we're happy to think that the disruptions were behind us. But I think disruptions are going to be part of our operational work and leadership portfolio for the foreseeable future, because it's just the nature of the work that we are doing.

00:07:04:16 - 00:07:30:03
Mark Taylor, M.D.
And to focus specifically on communications, communication and leadership from communications was central to this. We have to reach our caregivers across a wide variety of different platforms. We have to reach them where they work. We have to reach them through a medium with which they continually engage with the organization. And so we have a variety of different tactics or techniques that we utilize.

00:07:30:05 - 00:07:55:00
Mark Taylor, M.D.
We have a daily huddle approach. Every unit has a huddle, that starts at the beginning of their shift. And we use the huddle to disseminate information in a daily fashion. And that huddle is scripted for some communications. And that huddle we then hope is one way to get it to sort of pass to the caregivers that are providing care in the clinical environments.

00:07:55:02 - 00:08:30:26
Mark Taylor, M.D.
We also have a very robust intranet page, and the source of a lot of communication for information, which is standard for most health care organization, is on that intranet page that you see when you go to log in to your computer before you log into Epic, or into your email. We have lots of bulletin boards or video Scala boards, and we like the Scala boards because that's another way when someone's passing through the hall or passing in a break room, or at a point where they're able to take in new information, they're able to sort of take a look at that board and hopefully get a snapshot.

00:08:30:28 - 00:08:54:06
Mark Taylor, M.D.
And then most importantly, we have one central source of resources. On our intranet we created a page where with one click you can see an icon of an IV fluid drip chamber. And once you click that icon, it then takes you to four or five intranet pages that are specific to your service line. So we have a page dedicated to OR irrigation.

00:08:54:08 - 00:09:25:29
Mark Taylor, M.D.
We have a page dedicated to peritoneal dialysis. We have a page dedicated to inpatient IV fluid management, which is slightly different than our ambulatory or procedural area or OR IV fluid conservation strategies. And with that form of communication, we're really trying to make our communication specific to our caregivers, respectful of time constraints, respectful of restrictions in terms of how they're able to interact with that information

00:09:26:02 - 00:09:47:15
Mark Taylor, M.D.
during a busy clinical day. And then finally, we really leverage our senior leadership team. Our CEO has been extremely interested in this situation. We utilize him frequently to send out important messages  that we want everybody to understand. Most importantly, the impact of conservation.

00:09:47:18 - 00:10:11:01
Chris DeRienzo, M.D.
I think it has been widely said, seven times seven ways is the way we've got to do it. And we're hearing that the impact of that conservation is pretty substantial. When hospitals are taking the kinds of steps that you've described, you know, taking at the Clinic. We're seeing up to 40% reductions in utilization of some of those products, which we know is having a dramatic effect on decreasing the impact to patients right now.

00:10:11:08 - 00:10:38:02
Chris DeRienzo, M.D.
Because that hole in the supply chain caused by the loss of this Baxter facility, that's a gaping hole. It's 60% of IV fluids in the country. As you indicated, though, this is not the first time and definitely won't be the last time that we we've experienced challenges in the resiliency of our supply chain. What kinds of lessons have you learned from past incidents at the Cleveland Clinic, Dr. Taylor, that you've actually been able to apply to this situation?

00:10:38:03 - 00:10:39:19
Chris DeRienzo, M.D.
I imagine there are several.

00:10:39:21 - 00:11:08:14
Mark Taylor, M.D.
Yeah, I think many would agree with me that, you know, the pandemic prepared us for supply chain interruptions. Obviously, the pandemic was on a global scale, but we learned during the pandemic to manage through supply chain interruptions and to accept changes in supplies or changes in the way we managed our supplies. We have worked post-pandemic to ensure that we have strong relationships with our supply chain partners.

00:11:08:16 - 00:11:37:16
Mark Taylor, M.D.
We have a better understanding of how they work, where they have facilities, where they have redundancy in their facilities, where there could be some potential challenges in that. We also have worked to build alternative avenues of supply chain connections so that if one avenue comes up insufficient, we're able to pivot or fully explore another avenue to continue to bring in the products we need to care for our patients.

00:11:37:18 - 00:12:08:26
Mark Taylor, M.D.
We also share information with our supply chain partners. We provide them forecast with number of lives to be treated. What's our daily census look like? What's our anticipated volume in the upcoming months or quarters? So our supply chain partner has a better understanding of our needs, and then we obviously hope that they'll share with us their resources. And if they have any operational challenges that may not align with what we're forecasting, we can work on that as a team and come up with solutions.

00:12:08:29 - 00:12:29:06
Chris DeRienzo, M.D.
Really is a continuous process. I mean, you said it well, if you turn off a hospital supply of IV fluid, it's like turning off the water to your house. You really don't last very long until you start increasing in intensity the challenges that you face. We've talked a lot about the way that you're approaching this, Dr. Taylor at Cleveland Clinic.

00:12:29:09 - 00:12:52:06
Chris DeRienzo, M.D.
What are some things that hospitals and health systems should think about doing, you know, throughout the year to both prepare for these kinds of potential supply disruptions? And be ready, you know, no matter the cause, be it, this kind of a natural disaster or other events. What are some leading practices that you would leave our listeners with, that hospitals could be taking action on today?

00:12:52:08 - 00:13:14:27
Mark Taylor, M.D.
We want patient safety to be the number one priority. And that's our driving mission here. We don't want to make operational changes to focus on one component of a supply chain interruption that would ever harm our patients, but many people know that it's probably, you know, easy to hang one liter bag on everybody, whether or not they're going to be on campus for 20 minutes or whether they're going to be undergoing a two hour-long surgical procedure.

00:13:14:27 - 00:13:50:17
Mark Taylor, M.D.
So we really focused on conservation. And we've been able to cut the indiscriminate use of large bags of fluid down to the appropriate size, including using IV push for short procedures that require one or two medications and a quick IV push or IV flush. In regards to supply chain, I really think it's having those supply chain experts understand their partnership with our vendors, understand their strengths, understand their potential opportunities or weaknesses, and really let them sort of explore a resiliency plan.

00:13:50:20 - 00:14:23:07
Mark Taylor, M.D.
This is not an area where any health care organization wants to cut corners or take a pathway that may put too many eggs in one basket, so to speak. You need to have backup plans because natural disasters will occur, supply chain interruptions will continue. And what, like you say, I mean, we have to continue to care for patients and we have to continue to embrace this idea that we have to have teams that can step up at a moment's notice and keep the supply of products coming into our health care facilities so that hopefully we don't have to interrupt care.

00:14:23:10 - 00:14:43:06
Chris DeRienzo, M.D.
Well said. As I talk to hospitals across the country, I think we understand the role that we play for our communities. Being ready to care 24-7, 365, and we are nothing if not always learning. Dr. Taylor, we've learned a lot from you today. Thank you so much for being willing to share the experience of the Cleveland Clinic walking through the shortage.

00:14:43:06 - 00:14:44:13
Chris DeRienzo, M.D.
It was a real privilege.

00:14:44:21 - 00:14:46:09
Mark Taylor, M.D.
Thank you for having me.

00:14:46:12 - 00:14:54:18
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us rate stars on Apple Podcasts, Spotify, or wherever you get your podcasts.