2026 Southeastern Residency Conference

Evaluating Provider Behavior Around Alternative Fluid Orders During the 2024 IV Fluid Shortage
Authors: Cady Thomas, Jennifer Peltz, Christopher Dennis
Practice site: ECU Health 
Contact: [email protected]


Background: In September 2024, Hurricane Helene hit the western part of North Carolina and caused damage to a Baxter manufacturing plant which produces multiple sterile IV fluid products. Most health systems across the US relied on this plant for at least a portion of their IV fluid needs. Damage to the plant led to a major IV fluid shortage across the country. ECU Health utilized a series of medication alternative alerts to provide guidance to providers that were ordering IV fluid products during the shortage. Providers were allowed to select from the approved alternative list or to cancel the orders. The list of alternatives established limits on the amount of fluid that could be ordered and the duration of the orders. After selecting an option from the alternative list, providers had the ability to deviate from the recommendations by modifying order details before signing the orders. The purpose of this study was to evaluate the effectiveness of the medication alternatives in guiding ordering practices and to identify patterns in provider behaviors surrounding use of the tools throughout ECU Health. To establish a baseline expectation for alternative performance during shortages, we referenced prior studies with comparable clinical decision support designs. Sandler et al. reported alternative acceptance in 4.8% of cases and order cancellation in 6.2%.1​​​​ When combined, 11.1% of provider actions resulted in a desired outcome (recommended use accepted or no use), a rate we define as non-deviation for the purposes of our analysis. Whether similar outcomes occur around alternative fluid orders in other health systems is unclear.

Methods: The health system’s Clarity database was queried to identify all instances of medication alternatives triggered for IV fluids that were on shortage between October 9, 2024 and January 13, 2025. To better understand provider behavior and clinical impact, alternatives were then grouped into episodes which serve as the primary unit of evaluation for this study. 15,774 IV fluid episodes were included for analysis. The primary objective was to compare the proportion of episode non-deviations at our institution with rates previously reported in the Sandler et al. study. Episodes resulting in orders with deviations were further categorized by waste production and time deviations. Episodes were also categorized by provider type, type of IV fluid ordered, source of the order, hospital location of order origin, and patient age. The rate of non-deviation in our cohort was compared with the rate reported by Sandler et al. using a Chi-square test of independence. Descriptive statistics were used to describe other data points collected.

Results: Among 15,774 episodes, the non-deviation rate was 86.3% in our cohort compared with 11.1% in the comparator study, representing an absolute difference of 75.2% (95% CI 74.3 –76.1). This difference was statistically significant (χ²(1) = 12,203.007, p < 0.001). Of the episodes that resulted in deviations, 181 episodes resulted in time deviations; 2,034 episodes resulted in waste deviations. It was estimated that 815 L of fluid was wasted because of order deviations.  

Conclusion: Deviation from recommended alternatives occurred less frequently in our study compared with a prior alternative order study, though direct comparison is limited by differences in clinical context.  While our study shows a statistically significant improvement, the vast majority of episodes indicate providers still choose to deviate from the alternative recommendations which resulted in substantial IV fluid wastage. By recognizing prescribing patterns in areas that were more impacted by order deviations during the IV fluid shortage, the institution can employ additional strategies to help further minimize orders that deviate from recommendations.  


1. Sandler M, Cavanaugh J, Walton T, Cavendish L, Shah K. Management of an i.v. fluid shortage through use of electronic medical record alerts. American journal of health-system pharmacy. 2020;77:546-551.