The impact of climate change induced natural disasters on healthcare: Rethinking intravenous fluids

Hurricane Maria devastated Puerto Rico in 2017, wreaking havoc on the national pharmaceutical and medical supply industries, which are largely concentrated on the island.1 The impact was profound, particularly on the supply of small bags of intravenous (IV) fluids. For months afterward, hospitals across the United States struggled to obtain basic IV fluids, forcing clinicians to rethink how and when they used these products. The crisis highlighted the vulnerability of our healthcare supply chain to environmental disasters and underscored the need for more judicious use of IV fluids in the inpatient setting. In the wake of Hurricane Helene in September 2024, we find ourselves grappling with similar supply chain disruptions. By mid-October, ~86% of US physicians and providers had experienced IV fluid shortages.2 Some hospitals delayed noncritical surgeries3 and many hospitals continue to ration IV fluids until supplies return to their pre-Helene levels.4 These events, which are associated with the increasing frequency and intensity of natural disasters due to climate change, demand long-term solutions. Hospitals face numerous challenges from extreme weather across the clinical care continuum. In addition to critical supply shortages, climate change and extreme weather can affect disease patterns (e.g., heat-related illness, injury, and vector-borne illnesses), resulting in care interruptions, and delay in diagnosis and treatment. As health care providers, it is incumbent upon us to not just treat the patient in front of us, but also to do our part in resource utilization to reduce waste and decrease patient care related greenhouse gas contributions and environmental harms that spur these events. Rather than relying on reactive and temporary workarounds, such as rationing supplies or importing from less-affected regions, it is time to reassess our dependency on IV fluids. While they are a cornerstone of inpatient care, used for everything from volume resuscitation in shock to rapid medication delivery, more environmentally sustainable, evidence-based practices exist that prioritize patient safety while conserving resources. We must also address the lack of supply chain resiliency and support broader efforts to reduce healthcare's large, negative environmental impact. There is growing evidence that IV fluids are often administered unnecessarily or continued longer than clinically indicated. The proportion of hospitalized patients who can safely receive oral hydration instead of IV fluids is likely substantial, particularly in cases where oral intake is feasible and safe. For patients with infectious diarrhea, the Infectious Diseases Society of America recommends oral rehydration solutions as the first line therapy for mild to moderate dehydration.5 In patients with chronic kidney disease undergoing contrast-enhanced CT or cardiac catheterization, oral hydration was as effective as IV hydration in preventing contrast-associated acute kidney injury.6, 7 Oral rehydration for clinically stable patients with hypernatremia has demonstrated safety in pediatric populations, and could be implemented for adult inpatients.8 Avoiding low-value practices restricting oral intake can reduce the use of IV fluids. Examples include shortening pre-procedure fasting times9 and early resumption of enteral nutrition for acute pancreatitis.10 Even for patients with dysphagia, a study by Leder et al. demonstrated that 90.7% of hospitalized patients who passed a 3-ounce water swallow challenge could be advanced to oral diets without subsequent signs of aspiration.11 Many medications such as antibiotics can be administered through IV push (like cefazolin and meropenem)12 or orally (as in azithromycin or fluroquinolones) with equal efficacy.13 IV proton pump inhibitors in the setting of upper gastrointestinal bleed can be administered as infusions or intermittently as twice a day IV pushes or oral therapy after the initial 80 mg bolus, according to American College of Gastroenterology guidelines.14 Wherever fluids can be minimized, doing so provides multiple benefits including improved resource utilization and ease of nursing medication administration. Overuse in these cases is not only wasteful but also increases the risk of complications such as fluid overload, electrolyte imbalances, and prolonged hospital stays in patients with heart failure and other conditions. Moreover, the unnecessary use of IV lines increases the risk of infections and thrombophlebitis, adding to patient morbidity. Despite the evidence, excess use of IV fluids and medications remains a default practice in many hospitals. The reasons are multifaceted. Orders may be part of standard protocols, sometimes with little thought given to whether they are truly necessary. Many clinicians view IV fluid administration as a simple, low-risk intervention to “do something” for patients, especially where the clinical picture is uncertain. The complex nature of insurance reimbursements also contributes to this confusion, as the use of IV fluids and medications can be perceived as the difference between inpatient and observation status. This mindset contributes to a cycle of overuse that is difficult to break. Using IV fluids and medications more judiciously and developing better decision-making frameworks for fluid management also includes work to reduce our overall dependency on IV medications. A report by the Department of Health & Human Services identified more than 25% of drug and device manufacturers are located in areas at high risk of natural hazards including flooding, tornadoes, earthquakes, and hurricanes.15 The climate change-induced disruptions caused by Hurricanes Maria and Helene offer opportunities to reevaluate our use of IV fluids. These events have forced hospitals to implement multifaceted measures aimed at conserving supplies, such as encouraging oral hydration when possible, limiting the use of IV fluids to critically ill patients, changing medications to oral equivalents, and more carefully monitoring fluid balance. From a greenhouse gas emissions perspective, the production of 500 mL of IV fluids generates about 0.5 kg of carbon dioxide equivalents (CO2e).16 If we can reduce annual usage by 25%, this could save emissions equivalent to driving a passenger car nearly 800,000 miles, or 285 trips from California to Maine in the United States. This rough estimate and other high-value care practices highlight the broader environmental benefits of simultaneously improving healthcare sustainability and potential cost reductions.17 Conservation strategies should not be seen as temporary measures but as part of a broader shift toward more mindful and evidence-based fluid management practices. Hospitals should consider implementing stricter guidelines for IV fluid administration. This includes regular reassessment of fluid needs, limiting automatic inclusion of IV fluids in admission orders, or requirements to reorder continuous IV fluids after a prespecified amount of time. Clinical decision support tools can help guide fluid management based on the patient's condition. For example, ask clinicians to consider if oral equivalents or oral hydration with fluid intake goals would be an appropriate first-line approach for patients with active diet orders. The practice of “keeping veins open” with IV fluids may also not be required as studies in the pediatric population suggest no difference between saline lock and continuous infusion on IV patency.18 As hospitalists, many of us are involved in administrative roles including resource utilization and supply chain issues as a part of process improvement and providing higher value. By taking steps now to reassess our utilization, we can create more resilient and adaptable healthcare systems better equipped to face the challenges of the future. This latest IV fluid shortage is not a supply chain anomaly. The COVID-19 pandemic is a lingering reminder that even the most basic elements of medical care are not immune to the forces of nature.19 Aside from causing severe equipment shortages, it also catapulted telehealth, once considered an aspirational next step for medicine, to the forefront of ambulatory care. Natural disasters, pandemics, and future unknown threats provide opportunities for innovation, improvement, and adoption of more sustainable practices. Rigorous and systematic research into best practices and disaster preparedness should be undertaken to inform our institutional policies and priorities given the increasing likelihood of future supply disruptions. Changing practice patterns will require more than updated guidelines and decision support tools. A cultural shift is necessary to reduce the default reliance on IV fluids and medications in inpatient care and to move to more sustainable hospital practice in general. This starts with education. Physicians, nurses, and other healthcare providers need to be trained in the risks associated with unnecessary IV fluid use and the benefits of alternative approaches. They should also be apprised of the downstream environmental harms of hospital waste and overuse and how this can adversely impact our communities and patients.20 Medical schools and residency programs should emphasize evidence-based fluid management, teaching future clinicians to carefully weigh the risks and benefits of IV fluid administration. Continuing education programs for practicing providers can also help to reinforce these principles, especially in the context of supply chain vulnerabilities and disaster preparedness. Medical societies also have a role in driving sustainable healthcare delivery through clinical practice guidelines. Members of the Medical Society Consortium on Climate and Health have committed to addressing climate change and health issues through their organizations and collectively through policy action and educational offerings. The frequent disruptions in IV fluid supplies due to climate disasters such as Hurricanes Maria and Helene highlight an urgent need to reduce overreliance on these products in the inpatient setting. We must seize this moment to promote smarter, evidence-based practices that not only conserve valuable resources but also enhance patient safety and care outcomes. This shift will require systemic changes, from updating clinical guidelines to fostering a culture that questions the routine use of IV fluids. By doing so, we can create a more resilient, patient-centered healthcare system capable of withstanding the growing pressures of climate-related disruptions (Table 1). The authors declare no conflict of interest.