Months before Hurricane Helene would devastate the Southeast, the Institute for Healthcare Improvement (IHI) was launching its Chief Quality Officer (CQO) Network. The group was to serve as a forum for best practices on quality and safety for executives around the world.
When it became clear that Baxter’s closure of its North Cove plant would force major IV fluid shortages, the CQO Network sprang into action. Member Chapy Venkatesan, M.D., chief quality and safety officer at Inova Health System, asked the group a simple question: what conservation and stewardship strategies were others considering?
Immediately, peers started weighing in. An organization in Australia shared a 30-page guide from its past run-in with an IV fluid shortage. Others shared strategies for communicating with clinicians, pharmacists and patients. “Each day, I would send out the updated responses that I received and then more and more CQOs would weigh in,” Nikki Tennermann, senior director at IHI, explained.
The CQO Network’s U.S. members span hospital boards, safety net hospitals, small regional hospitals, freestanding hospitals and state associations. Key to the group’s success is transparency and collaboration. “We don’t compete on safety,” Tennermann noted. “When the leaders are coming together, they’re really sharing openly and honestly.”
The real-time exchange of ideas among peers served a practical and emotional purpose: Venkatesan felt less alone when implementing changes that felt radical. “It helps relieve some of the heaviness that feels like you’re going out on a limb,” Venkatesan said. Ultimately, the group’s learnings affirmed “we can’t do this alone.”
The storm decimated half a dozen states, killing hundreds and forcing local health systems to contend with the fallout. Some hospitals were well-prepared. Others were destroyed. Everyone was doing what they could to figure out contingencies on the fly. This, experts warn, will not be the last time.
“There’s really no excuse for a hospital not to have thought through an emergency preparedness plan because they think they’re not vulnerable,” Emma Mediate, chief program officer at nonprofit Health Care Without Harm, told Fierce Healthcare. The organization is focused on transforming sustainability in healthcare globally.
“Supply disruptions seem to be becoming sort of the norm in healthcare,” Venkatesan reflected.
“Our previous experience with crises had really helped us…to anticipate and react to this one.” Inova has dealt with shortages of things like personal protective equipment during COVID and, more recently, blood cultures. In 2022, the health system set up the role of chief of resource stewardship, “an extremely important driver of our success,” per Venkatesan.
“We’re sort of always in a state of preparedness,” echoed David Calloway, chief of crisis operations and sustainability at Advocate Health. “Hurricane season is where we always have heightened awareness.”
Before Baxter officially announced its supply of IV fluids was impacted, Inova’s supply chain team was already prepared for the possibility of disruptions. The team had been monitoring a longshoreman strike at the Port of Wilmington, which began days after Helene.
“They’re really on top of it,” Venkatesan said. “They were already looking at the situation and thinking ahead.”
Calloway, too, was tracking the hurricane’s progress — ironically, while presenting on climate risk mitigation at Climate Week New York City. He had informal updates with his emergency management team, regional president and CEO the weekend Helene made landfall. Official system-wide communications at Advocate ramped up the next Monday.
As an emergency medicine doc who previously supported the Marine Corps in combat and crisis zones, Calloway knew the importance of proactive communication in an emergency. “Go heavy upfront with communication and coordination, and then you can back off if you don’t need it,” he said.
Calloway also volunteers for Project Rubicon, a veteran-led humanitarian organization.
Having an emergency response background is “becoming increasingly a huge high-value asset for hospitals to invest in,” Mediate said.
Inova was operating with the same thinking. Three days after Baxter said it closed its plant, Inova’s emergency management committee held a meeting to review supply concerns, priority areas, contingency plans and a stewardship framework to manage the crisis, per a meeting agenda seen by Fierce Healthcare. The committee also planned to discuss lessons learned from Hurricane Maria in 2017.
Key to Inova and Advocate’s approach was allowing clinical leaders to evaluate their departments’ utilization and come up with suggestions on how to preserve supply. Analytics teams developed dashboards to help clinicians understand their utilization rates and target interventions accordingly. Quality teams weighed in on decisions to ensure health outcomes would not be compromised.
Inova warned staff the health system should prepare for a third of its usual IV fluid supply. “The nationwide shortage will significantly strain our system for the next few months,” an email to providers read. The health system labeled the crisis an “internal disaster” to prioritize workflows and set up a multi-disciplinary task force with system-wide representation to come up with solutions. It embedded alerts about the shortage into Epic, with the system recommending alternatives where appropriate.
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Health systems’ strategies ran the gamut. Some patients could be given oral hydration instead of IV fluids. Smaller-sized bags could be used in certain circumstances, or default durations of drips could be adjusted. If a patient had to move care settings, their bags could go with them. Some locations pulled back on the stock they kept on their floors, while some health systems canceled or rescheduled elective procedures altogether. And those who could leaned on secondary and tertiary vendors to fill gaps.
Those impacted were not just in the eye of the storm. Up north in Pennsylvania, Jefferson Health was dealing with many of the same questions. The health system relied on frequent meetings, clinical dashboards and comms channels to respond quickly to the IV fluids shortage. Workgroups across departments were charged with proposing clinically appropriate conservation strategies.
Because she helped lead Jefferson’s COVID response, EVP and Chief Clinical & Quality Officer Patricia Henwood, M.D., already had resource stewardship on her mind.
“We didn’t have to pull back on elective procedures and others because of the extreme efforts we took in low-balancing supply,” Henwood told Fierce Healthcare. Henwood is also a member of the CQO Network. It was important to the health system to avoid going into rationing.
Like others, Jefferson input a best practice alert into the IV ordering system. “Sensitizing” clinicians about the shortage helped reduce those orders by 15%, per Henwood. Having a care operating system that centers quality and safety also helped unify emergency response efforts, Henwood said.
The supply chain related to IV solutions remains “highly constrained,” Jim Churchman, Jefferson SVP and chief supply chain officer, said. “Focused usage conservation remains a critical strategic element in our return to health,” he said. He expects “hyper management” to be required into May.
By mid-November, Inova EDs had seen a 54% reduction in IV fluids. To date, Inova still maintains an overall 30% reduction in utilization from baseline and a 34% reduction across its EDs. “Like many other things in stewardship and supply, we always discover that there is some overuse that can be addressed,” Venkatesan said. He added Inova’s CEO always says, “Never let a good crisis go to waste.”
Inova plans to keep emphasizing resource stewardship and crowdsourcing approaches from peers. Regardless of immediate impacts to the supply chain, “overuse is a signal of poor quality care and can lead to a lot of other problems,” per Venkatesan.
Advocate’s recommendations to specialties ultimately resulted in a 55% decrease in IV fluid use through January. This approach “makes us better stewards of our resources,” Calloway said. Advocate had several advantages as one of the largest nonprofit health systems in the U.S. since its merger with Atrium. Its emergency management and incident command teams had already spent time and worked together. They trusted each other.
“If it’s not built beforehand, that trust can erode really quickly,” Calloway said. Because of the merger, Advocate also had a unified procurement system, which helped redristribute how many IV fluids were on hand at each of the system’s two major geographic service areas. The procurement team combined forces with clinical leaders on conservation approaches.
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Each part of the health system brought something meaningful to the table. Atrium Health mobilized its mobile critical care units, including helicopters and ambulances, to do more than move patients in need. Because of widespread communications blackouts, Atrium teams seized on the opportunity to collect key information as they picked up patients and to drop off supplies. They met with local emergency managers, then reporting their needs assessments back to the state.
“How do we use that asset that’s already in play to get more information and solve new problems that popped up?” Calloway said. “We want [teams] to be innovative, we want them to find problems to solve.”
In all, they flew 19 resupply missions from Sept. 30 to Oct. 8, providing 14,500 pounds of resources to western North Carolina communities. These included food, water, diapers, medications, generators and satellite communications equipment. Around the same time frame, they also transported dozens of patients by ground and by air from North Carolina’s hard-hit western countries to medical facilities.
“We view that with our size comes a responsibility to these [neighboring] communities,” Calloway said.
Meanwhile, Advocate’s 14-bed mobile hospital, MED-1, was deployed in a remote western North Carolina community after the storm. The unit includes operating rooms, generators, a water purifier and satellite communications system. “It provides a great anchor of stability in these crises,” Calloway said. In just under two weeks, the unit provided care to 116 patients and facilitated transfers to nearby medical centers. Federal teams were also on site to support these efforts.
Resources exist for healthcare professionals looking to get trained, such as through the Federal Emergency Management Agency. In Mediate’s view, everyone should seek these out, particularly if they need these skills for hospital incident command teams. Hospital leaders should also invest in system-wide exercises, Mediate recommended. They can work with local emergency planners to walk through hypothetical scenarios and what their response would be. “If you prepare for something and have walked through it in a really practical, hands-on sense, you sort of learn by doing,” Mediate said.
There are differences in how much hospitals prepare and invest based on their size and resources, Mediate acknowledged. Larger systems can afford better innovations, such as Tampa General Hospital’s $1 million AquaFence. But it’s not just about a one-off investment, Mediate noted. For instance, the hospital also had a large energy plant — a safe power supply — installed long before the storm. They had processes in place to review emergency stockpiles regularly, test backup systems regularly, have an emergency water usage plan. This was thought about long before the storm. “It’s the combination of all of these pieces that really make it successful,” Mediate said.
Hospitals are also more likely to be prepared if they are based in an area like Florida that is a well-known climate risk zone. But with the way climate change is going, all organizations should be making that assumption, Mediate cautioned.
“The thing that makes me really worried is that everywhere is now Florida,” Mediate said. From the recent Southern California wildfires to Helene, new disasters emerge every year that touch places that are perceived to be unexpected. These investments are well worth it to hospitals across the U.S., Mediate said. “The reality is that everywhere is now vulnerable.”
Health systems are still rebuilding post-Helene. HCA Healthcare recently reported a $200 million loss attributed to Hurricanes Helene and Milton in 2024. Community Health Systems had attributed a $7 million loss to the storms though Q3 of 2024. Long-term, hospitals should focus on supply chain resilience by diversifying their suppliers, Mediate said. Companies like Baxter also have a role to play in emergency preparedness.
More competition among vendors is a good thing, not only for reliability but also for innovation, Mediate added. When manufacturer B. Braun stepped up during the Baxter shortage, it manufactured IV fluid bags without PVC, a polymer harmful to the planet and to human health. Ultimately, by being better for the environment, they are mitigating contributions to the very climate events forcing such shortages. “Addressing that root cause through supplier diversity is another ancillary reason to be wanting to see that competitive environment,” Mediate said.
For other potential solutions, organizations can look to Boston Medical Center, home of the first-ever clean power prescription program. The program transfers revenues generated from clean energy to low-income patients to help them afford their utilities. Such a program would help facilitate a more reliable power source and minimize outages, per Mediate, so patients could use their medical equipment and other essential services during extreme weather events. “It would be great to see programs like that in some of the places that were hit,” Mediate said.
Finally, hospitals have a role to play in advocacy. In response to the California wildfires, many payers relaxed their policies around emergency refills for prescriptions. Hospitals should use their leverage to encourage payers to do so in times of crisis, Mediate noted. They could also advocate for trigger mechanisms to be put in place, so these flexibilities automatically kick in in an emergency. Doing so also helps keep patients out of hospitals, which frees up key capacity during serious events.
“The more that we can equip folks to stay out of the emergency rooms if they can during these events, that’s both better for the patient and quite frankly better for the hospital and the potentially overworked staff,” Mediate said.