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October 14, 2024 Page 2 of 2 Practice Alert Conservation strategies to employ immediately: Nurses: Encourage oral/enteral intake of fluids and medications as soon as possible: o If a patient receives a change from NPO status and continues to have IV medications ordered, please contact pharmacy or physician/LIP to identify appropriate switch to oral agents as soon as possible. o Ensure oral/enteral intake is documented to help physicians make appropriately informed decisions before starting a patient on fluids. o If conditional orders to advance diet as tolerated are entered, prioritize advancing the diet with the patient to encourage oral hydration. Practice good stewardship of available resources: o Refrain from spiking IV fluids in advance of need. o Do not unwrap IV fluids in advance of need. o Validate and verify that you have the correct fluids before unwrapping. o Limit fluids being placed into the warmers. o Use the smallest volume IV fluid bag needed for the patient. o Do not start TKOs without an order or continue to run them if they have been discontinued. Consider scheduled saline flushes instead. o If patient has a peripheral IV (PIV) and gets a central line placed, consider finishing transfusion of fluids that are already hanging if the PIV is still functional. It is still best practice to hang new tubing and fluids when transitioning from a PIV to a central line. Utilize saline flush syringes for IV-line flushes where appropriate. When IV medications are to be hung as a primary, consider the following method to flush the line instead of using a bag of fluids to flush: o Run medication on primary tubing. o Allow the pump to infuse the medication until it gets just above the highest access port. This may take some excellent timing and a watchful eye. o Attach a 10mL flush to the access port (scrub the hub). o Clamp/pinch the tubing above the flush and port. o Flush the remainder of the medication through the line over 2 minutes. May attempt clamping above the port and programming the pump to administer 10mL. Dietitians: Encourage enteral nutrition when able. Limit duration of TPN and discontinue as soon as able. Avoid tapering off from TPN over days to reduce duration of TPN (titration over hours when discontinuing is appropriate). Physicians: Utilize oral/enteral route for fluids and medications as soon as possible: o Utilize oral rehydration whenever possible. If a patient can tolerate oral intake, strongly consider ordering oral rehydration therapy. o Utilize oral repletion for electrolytes when able. o Transition all IV medications to oral when clinically appropriate. o FYI: to assist with the shortage, many medications that have historically been given via IV piggyback will transition to IV push when appropriate. Please refer to your local pharmacy. Consider other alternatives for medications: o Partner with pharmacy to see if any medications given IV piggyback can be transitioned to IV push. o Utilize ferric gluconate (can also utilize iron sucrose) for IV iron replacement over iron dextran. Ferric gluconate (and iron sucrose) can be given IV push, while iron dextran requires administration in an IV fluid. Re-evaluate IV fluid orders frequently: o Add a stop time to these orders to avoid therapy continuing indefinitely. o Order IV fluids for a single bag or multiple of bags (125 mL/hr = 8 hours per bag, 100 mL/hr = 10 hours per bag). This will prevent the spiking of an additional bag and waste of a partial bag. o Reduce maintenance IV fluids in less critical patients. o Avoid TKO orders. Consider scheduled flushes instead of utilizing an IV bag for TKO. Scheduled saline flush = EPIC order ID 26770 Add a stop time to all IV fluid orders and round to whole bag size (125 mL/hr = 8 hours per bag, 100 mL/hr = 10 hours per bag) Critically evaluate the clinical need for TPN and follow ASPEN recommendations. Utilize enteral nutrition when able. Avoid tapering off from TPN over days to reduce duration of TPN (titration over hours when discontinuing is appropriate) Pharmacists: Prioritize IV to PO transition per hospital policy. Critically evaluate all fluid and TPN orders for clinical necessity and recommend appropriate alternatives. Assess iron dextran orders for switch to ferric gluconate or iron sucrose via IV push. Recommend oral electrolyte repletion when appropriate. Implement IVPB to IVP transition for the attached list of medications.

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