In the wake of the COVID-19 pandemic and upheaval in the global supply chain, the healthcare sector has grappled with acute shortages of essential resources. Such shortages, while intensified recently in scale and frequency, are not new, as natural disasters have posed recurrent challenges. An illustrative example is the impact of Hurricane Maria in September 2017, which severely disrupted the production of normal saline (% 0.9 NaCl fluid bags) in Puerto Rico. Hospitals relying on "just in time" delivery models found themselves in a precarious situation, prompting a need for innovative solutions to sustain care delivery amidst the crisis. The occurrence underscores the vulnerability of healthcare infrastructure to external disruptions and emphasizes the need for adaptive strategies to ensure the resilience of the system in the face of unforeseen challenges. Consequently, our focus shifted to an examination of the impact of Hurricane Maria on saline supplies at the University of Pittsburgh Medical Center (UPMC) towards building a resilient model. This study aims to elucidate how the flagship hospitals of the system navigated the challenges posed by the shortage, both at the individual provider level and on a broader, system-wide scale. This investigation spanned an 18-month study period, encompassing the analysis of intravenous (IV) fluid demand and usage patterns before, during, and after the hurricane. Employing a multi-faceted approach, we integrated quantitative data with qualitative insights derived from three months of "participant observation" and survey data. This mixed-methods approach enabled us to see how individuals and systems within UPMC adapted to the crisis. Systems level adaptation occurred at UPMCs operating room (OR), pharmacy and distribution supply chain levels, including by decreasing OR demand, while at the individual level healthcare providers changed their behavior by turning to alternative medications and carrier fluids. These adaptive measures undertaken at UPMC offer insights for future crises at both the organizational and individual levels within the healthcare system.

The authors have declared no competing interest.

This study did not receive any funding

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The UPMC Q.I. committee approved the project entitled "The pattern of use of IV fluids in the operating rooms before and after nationwide IV fluid shortage and associated complications - Project ID: 1445."

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