Saline exposed the risk that hides in a hospital’s cheapest line items

The week

At the end of September 2024, flooding from Hurricane Helene forced Baxter International to shut its North Cove facility in Marion, North Carolina. The plant was Baxter’s largest and, according to the American Hospital Association, produced about 60 percent of the IV fluids used in the United States. One river, one plant, and more than half the nation’s supply of a basic hospital staple was suddenly offline.

North Cove had opened in 1972 and employed more than 2,500 people. Baxter described it as the largest U.S. manufacturer of both intravenous and peritoneal dialysis solutions. Its scale is the reason its loss reached so many hospitals so fast.

Baxter had activated its hurricane plan before the storm, shutting and evacuating the plant and moving finished product to higher ground where it could. It was not enough. In its first public update, on September 29, the company said heavy rain and storm surge had triggered a levee breach, water had entered the site, and the bridges leading to it were damaged. Production stopped, and Baxter warned that the disruption would hurt its financial results.

Almost every hospital patient meets the product in question: a clear plastic bag of fluid hanging from a pole, dripping slowly into a vein. Intravenous, or IV, fluids are mostly sterile salt water or sugar water. They rehydrate patients, keep veins open, and carry many medicines into the bloodstream. They are cheap, ordinary and everywhere, and that autumn American hospitals discovered how few places make them.

After an initial 48-hour hold on shipments while it assessed inventory, Baxter placed IV and peritoneal dialysis solutions on allocation. Peritoneal dialysis is a form of kidney dialysis, often done at home, that uses large volumes of sterile fluid. “Allocation” is the supply-chain word for rationing: instead of filling every order, the manufacturer gives each customer a fixed share of what it normally buys.

Baxter explained the formula. Allocations limited what each customer could order based on its historical purchases and medical necessity, and on available and projected inventory. The stated aim was to limit stockpiling and spread available product fairly. The company said it was coordinating with the Food and Drug Administration, HHS and its preparedness office ASPR, FEMA, the Department of Homeland Security, and state and local officials.

By October 9, Baxter had raised direct customers’ allocation of its highest-demand IV fluids from 40 to 60 percent of usual volumes. Customers buying through distributors had been held at 10 percent until then; they too moved to 60 percent. Designated children’s hospitals were raised to 100 percent for IV solutions and nutrition products. Even after the increase, most hospitals were receiving well under their normal supply.

Baxter sent a medical information letter to health care facilities on September 30 and another to home dialysis customers on October 1. Other manufacturers, among them B. Braun, ICU Medical and Fresenius Kabi, also supply IV fluids in the United States. Replacing the output of the country’s largest plant was beyond any of them in the short term, and orders shifted their way as hospitals hunted for supply.

Hospital associations warned of shortages. Many health systems activated conservation measures. Some encouraged patients who were able to drink fluids to do so rather than receive IV hydration. Some gave certain medications as an “IV push,” a small dose injected directly over a minute or two, instead of diluting them in a fluid bag and infusing them over a longer time.

Baxter, for its part, worked with the FDA on temporary importation of product from nine of its plants abroad. That step required regulatory sign-off, because imported medical products normally need US approval for their specific labeling and manufacturing. Its stated goal was to restart North Cove in phases and return to 90 to 100 percent allocation of certain IV products by the end of 2024.

There was precedent. After Hurricane Maria struck Puerto Rico in 2017, damage to plants there, including Baxter’s, deepened an existing shortage of small IV bags, and the FDA allowed temporary imports then too. North Cove was a larger version of a failure the industry had already seen once.

The week put a question to hospital executives and boards that few had thought to ask: where does our cheapest, most essential stuff actually come from?

A bag of saline is among the cheapest items a hospital buys and among the most essential. Before October 2024, few boards would have asked where it came from. North Cove showed why they should. A single flood at a single site changed care across the country within days.

The concentration was no accident. In low-margin products, the competitor that survives is the one with the largest and most efficient plant. Purchasing teams measured on unit cost reward that scale every year, and the market narrows to a few sites. Everyone acts sensibly, and the result is fragile.

No individual health system can redesign that market. Each can, however, manage its own exposure through four levers that act on different things: information about where supply comes from, demand for the product, the contractual terms of supply, and physical buffers. Together they cover every way a hospital can change its position in a shortage, and they do not duplicate one another.

The exposure differs by type of provider. Consider an academic medical center buying directly from manufacturers and a 25-bed critical access hospital buying through a distributor. Add a freestanding children’s hospital, an ambulatory surgery center and a dialysis organization serving patients at home. Each met North Cove differently. The sections below explain why the concentration happened, then take the four levers in turn, then show them working together, and end with the ways hospitals stay exposed.

How a cheap product ends up with a single point of failure

The economics explain why this keeps happening.

Making sterile IV fluid is not glamorous, but it is demanding. The fluid must be free of microbes and particles. The bags must be sealed, tested and tracked. Factories need specialized equipment, clean rooms and regulatory approval. That means high fixed costs. At the same time, the selling price per bag is low, and hospitals buy in enormous volumes, often through group purchasing organizations, which are buying cooperatives that negotiate prices on behalf of many hospitals at once.

In that kind of market, the winner is whoever can spread fixed costs over the most units. Big plants beat small ones. Over years, smaller producers exit, and volume consolidates into a handful of very large facilities. Each step is rational. Purchasing teams are rewarded for lower unit prices. Manufacturers are rewarded for efficiency. Nobody is rewarded for spreading production across more sites, because that costs more and the benefit appears only in a disaster.

A town where every household buys bread from the one huge bakery on the edge of town, because it is the cheapest, works perfectly until the bakery floods. Then there is no bread, and no small bakery left to fill the gap.

Spend-based purchasing, where attention goes to the products a hospital spends the most money on, makes this blind spot worse. Saline barely registers on a spend report. Expensive implants and specialty drugs get scrutiny; a bag that costs a small fraction of that does not. Yet if the implant is unavailable, a procedure is postponed. If saline is unavailable, almost every department feels it. The right way to rank risk is by clinical criticality, meaning how badly patient care suffers without the item, not by dollars.

A failure the industry had seen before

North Cove was the largest version of a recurring pattern. After Hurricane Maria in 2017, damage to manufacturing in Puerto Rico worsened a shortage of small IV bags. In 2022, a COVID lockdown in Shanghai shut a major plant making iodinated contrast media and forced radiology departments across the country to ration scans. In 2008, contaminated heparin traced to raw material from China was linked to serious reactions and deaths.

The causes differed: a storm, a public health lockdown, a quality failure in the supply chain. The structure did not. In each case a widely used, low-profile product depended on a small number of sites or sources, and hospitals learned of the dependence when it broke.

Why the market does not correct itself

Reliability is hard to buy because it is hard to see. Two bags of saline from two manufacturers look identical on a contract. A buyer cannot easily tell which supplier has a second plant, a backup source of plastic film or a levee designed for a rarer flood. A manufacturer that spends on those things cannot charge more for them, because the buyer is comparing unit prices.

Contract structure adds to the pressure. Group purchasing organizations negotiate multi-year agreements that reward suppliers able to serve enormous volumes at the lowest price. Under a federal safe harbor, GPOs are typically funded by administrative fees paid by suppliers. Critics argue this favors large incumbents. Defenders say GPOs drive down costs that hospitals could not cut alone. Either way, nothing in the standard arrangement pays for redundant capacity.

Entry is slow as well. A new sterile fluids plant needs years of construction, validation and FDA approval before it ships a bag. When a shortage begins, no new competitor can appear in time to help. The capacity that exists on the day is the capacity that exists for months.

Information: finding the single points of failure

Most health systems know their suppliers. Fewer know their suppliers’ plants, and fewer still know their suppliers’ suppliers. A distributor may offer several brands that come from one facility. A product with two listed sources may share a single sterile component or container maker. What looks like choice in a catalog can be one factory with different labels.

The work is to map critical products to manufacturing sites, prioritized by clinical criticality rather than by spend. A short first list might cover IV solutions, certain sterile injectables, contrast media, heparin and a handful of single-source devices. Contrast media are the dyes used to make blood vessels and organs show up clearly on scans; heparin is a widely used blood thinner. All are low-profile and high-stakes.

Group purchasing organizations, distributors and FDA shortage data can help, but the health system has to ask the question and keep the answer current. A useful output is a one-page register: product, sites, share of supply from the largest site, days of stock on hand, and the clinical owner for conservation.

At a regional health system, one line of that register might read: “IV sodium chloride, 1 liter. Primary site: one plant. Share from largest site: most of our supply. Days on hand: 9. Clinical owner: Director of Pharmacy.” That single line tells an executive more about real operational risk than a dozen pages of spend analysis. It also tells everyone who will lead the response if that plant stops shipping.

Reading the early signals

A register is most useful when it is watched. For the products on it, supply chain teams can track distributor fill rates weekly, so a slow decline shows up before an outright stoppage. Manufacturer customer letters, FDA shortage postings and notices from the group purchasing organization belong in the same view. A named person should review them and decide when to alert the clinical owner.

The first hours of a disruption are the cheapest time to act. A hospital that knows on day one that most of its supply comes from the affected plant can start conservation, contact a second supplier and talk to partner systems before everyone else does. One that spends two days working out its exposure joins the queue late.

Where the data comes from

Building the register is harder than it sounds. Product labels and catalog numbers identify the company that markets a product, not necessarily the plant that made it. A distributor’s catalog may list several brands that come from one contract manufacturer. Public FDA shortage information describes shortages once they exist, not which plant a hospital’s supply depends on.

The most reliable source is the supplier itself. Health systems can ask manufacturers and distributors, in writing, to disclose the manufacturing sites for a defined list of critical products and to notify them when a site changes. Some suppliers will treat this as confidential. A clause in the next contract renewal, limited to a short list of items, is usually more productive than a broad questionnaire that nobody answers well.

The register also needs an owner and a refresh cycle. Supply chain teams can keep the site data current; pharmacy and nursing keep the criticality rankings. Reviewing it twice a year, and after any major supplier change or acquisition, keeps it from going stale.

How the channel shaped exposure

Baxter’s October figures show why the purchasing channel matters. Direct customers began at 40 percent of their usual volumes, while customers buying through distributors started at 10 percent. Both moved to 60 percent on October 9. For a small hospital that bought through a distributor, the first days of the shortage were far more severe than for a large system with a direct contract.

Patient mix mattered too. Designated children’s hospitals received full allocations of IV solutions and nutrition products, reflecting the vulnerability of their patients. Baxter also handled exception requests, and by early November said it had approved more than 200 of them for neonatal and pediatric needs. A community hospital with a busy pediatric unit, but no children’s hospital designation, had to make its case through that process.

Home patients were a separate problem. People on peritoneal dialysis at home depend on regular deliveries of large volumes of fluid, and Baxter limited new home dialysis starts for weeks after the storm. Dialysis providers, nephrologists and the hospitals that discharge kidney patients needed their own plan for that population.

Demand: conservation that does not harm patients

In the first weeks of a shortage, demand is the only variable a hospital controls. Supply is set by the manufacturer’s allocation, and new contracts and stock take time. But how much the hospital uses is, at least partly, in its own hands.

After North Cove, many systems found that part of their IV fluid use was habit: maintenance fluids left running after they were needed, IV medications given where oral forms would do, and large-volume bags used for small-volume tasks. Each is harmless in normal times, the path of least resistance in a busy hospital, and together they add up.

Conservation needs pharmacy, nursing and physician leaders acting together, with protocols approved in advance. Changes to electronic health record order sets and defaults change practice faster than memos. An order set is the menu of pre-built orders a physician picks from when admitting a patient or ordering a treatment. If the default on that menu is “start maintenance IV fluids,” many patients will get them. Change the default to require a deliberate choice, and usage falls without anyone having to read a policy.

Organizations that had kept protocols from the 2022 contrast media shortage had a starting point. They had already worked out who decides, how changes are communicated and how they are monitored, and could adapt that playbook rather than invent one.

The conservation menu

The measures hospitals used after North Cove were mostly familiar. They switched patients who could drink to oral hydration earlier. They gave some drugs by IV push or in smaller bags instead of standard infusions. They reviewed maintenance fluids daily rather than letting them run. Some told staff to finish one bag before hanging another, or to continue fluids that paramedics had started instead of starting fresh.

The results could be large. Inova, a health system in the Washington, D.C., area, told KFF Health News in November 2024 that its IV fluid use had dropped 55 percent since early October. That figure comes from one system and should not be read as typical. It does show how much of normal use was discretionary.

Who approves, and how fast

Governance determines speed. In most hospitals, changes to drug administration go through the pharmacy and therapeutics committee, and changes to order sets go through clinical informatics. Both can be slow in normal times. A shortage protocol approved in advance, with a named physician, pharmacist and nurse leader authorized to switch it on, removes that delay.

Communication needs the same preparation. Nurses on night shift, hospitalists, emergency physicians and anesthesia all need to know what changed and why. A one-page summary, built into the electronic health record as an alert on affected orders, reaches more people than an email from the chief medical officer.

Measure it, and watch for harm

The tracking matters as much as the protocol. A daily view of usage against allocation, by unit, lets leaders see where conservation is working and where it is not. If the emergency department is on target but two medical floors are using fluids at the old rate, leaders know exactly where to focus.

Safety review belongs in the same loop. A pharmacist or quality lead should check substitutions, such as IV push in place of infusions, for errors and adverse events, so that saving supply does not add clinical risk unnoticed. A drug given faster, by a different route, or prepared differently can carry its own hazards, and staff under pressure are more prone to mistakes.

The workload shifts too. An IV push takes a nurse’s time at the bedside, both to give the drug and to watch the patient afterward, where an infusion pump would have run unattended. Nurses raised exactly that concern during the shortage. Conservation that saves fluid but adds nursing time on an understaffed unit trades one scarce resource for another, and leaders should decide that trade deliberately.

Extended dates and imported product

The shortage also brought unfamiliar product into hospitals. The FDA authorized extended use dates for more than 50 Baxter IV and irrigation codes, adding up to a year of shelf life, but only for product made before the end of September 2024. Inventory teams had to know which lots qualified and make sure staff did not discard usable bags as expired.

Temporarily imported product can differ in labeling, packaging or presentation from the version staff know. Baxter provided specific resources and training to customers receiving imported product. Pharmacy should check each imported item against the hospital’s systems and practices before it reaches a unit, and nursing should know what will look different.

Timing compounds every shortage. North Cove’s supply gap ran into the respiratory virus season and the year-end rush of elective surgery, when demand for fluids rises. A conservation plan that only just balances supply in October can fall short in December.

Some conservation should outlast the shortage. Switching appropriate patients to oral hydration earlier, and using smaller bags for drug dilution, reduces cost and waste in normal times. Making those changes permanent shrinks the next shortage before it arrives.

Contract terms: how allocation works when there is not enough

When a manufacturer goes on allocation, it usually bases each customer’s share on historical purchases. That sounds fair, and it often is. But it produces awkward results at the edges. Customers who bought through several channels, recently switched suppliers or grew quickly can find their allocation lower than their need.

Take a health system that acquired two community hospitals six months before a shortage. Its purchase history reflects the old, smaller system. When allocation begins, it receives a share of a baseline that no longer matches the patients it serves. Or take a hospital that moved most of its volume to a different supplier last year to save money; it may find itself near the back of the line with its old supplier and without much history at its new one.

These terms matter only in a crisis, which is why they are rarely negotiated with care. Health systems can ask how allocation will be calculated, which purchase history counts, how fast they will be told about disruption, and which substitutions are allowed without penalty. They can split volume across two manufacturers for the most critical products, accepting some loss of volume discount in exchange for a second supply path.

Counsel should review these terms, along with any most-favored-customer or exclusivity clauses that would block a second source. An exclusivity clause, for example, might commit a hospital to buy a product only from one supplier in return for a discount. That saves money in normal years and can leave the hospital with nowhere to turn when the supplier cannot deliver.

Terms worth negotiating

A short list of clauses covers most of the risk. The contract can state how the allocation baseline is calculated, including how acquisitions and new facilities are counted. It can commit the supplier to treat direct and distributor customers on comparable terms. It can define how quickly the supplier must notify the hospital of a disruption, and how exception requests for vulnerable patients will be handled.

It can also allow substitution of equivalent products from another source without penalty during a declared shortage, and suspend volume commitments that the supplier itself cannot meet. These terms do not change price in a normal year, which makes them easier to win than a discount.

What the purchasing organization can do

Group purchasing organizations negotiate price and terms for their members, but allocation in a shortage is the manufacturer’s decision. A GPO can still carry resilience requirements into the contracts it negotiates, such as site disclosure, a defined allocation method and notification duties. Members acting together have more bargaining power on those terms than any single hospital.

Health systems have also tried committed-volume models. Civica Rx, a nonprofit drug company formed by health systems in 2018, makes long-term commitments to supply generic drugs that are prone to shortage, in exchange for its members’ committed purchases. It focuses on sterile injectable drugs rather than IV fluids, but the principle is the same: pay for reliable supply with a long commitment rather than chasing the lowest price each cycle.

Committed-volume arrangements carry their own risk. A health system that commits to buy from one maker for years has concentrated its own supply, even if it has helped diversify the market. Such commitments work best alongside the register and conservation protocols, as one lever among four rather than a substitute for them.

The limits of a second source

Dual sourcing has real limits, and they should be stated plainly. When the largest plant goes down, every hospital turns to the remaining manufacturers at once. Those suppliers then allocate too, usually based on their own historical sales. A hospital that buys a token share from a second supplier may find that share protected, but it will rarely be enough to replace the first.

Splitting volume also has costs beyond price. Two suppliers mean two sets of products for nurses to learn, two sets of order codes and sometimes different equipment. For some items the clinical and operational cost of running two products outweighs the benefit. The decision belongs to a cross-functional group, item by item, rather than to a blanket policy.

Physical buffers: paying for safety in normal times

The last lever costs money. Holding extra stock of critical items, paying a premium for diversified or domestic supply, or joining purchasing arrangements that commit to new manufacturing capacity all carry costs. With thin operating margins, those costs compete with everything else, from nurse salaries to building repairs.

Collaboration spreads the cost. Health systems in one region can agree in advance to share inventory during a shortage, coordinate conservation, or jointly fund buffer stock held by a distributor. Such arrangements need antitrust review, because competitors coordinating on purchasing can raise legal questions, but they turn individual exposure into shared capacity.

Shelf life and storage space limit what any one hospital can hold, so pooled stock rotated through normal use is often more practical than a dedicated stockpile. Rotation means the buffer is used and replaced continuously, first in, first out, so it never sits until it expires.

IV fluids are an awkward product to stockpile. They are heavy, bulky and need controlled storage, and a hospital’s loading dock and storerooms were not designed to hold months of them. Space is often the binding constraint before money is. That is why distributor-held or manufacturer-held programs, where the hospital pays to reserve stock kept elsewhere, can make more sense than shelving in the basement.

There is also a timing problem. A buffer has to be built in calm years. A hospital that tries to build one when a shortage starts is competing with every other hospital for the same scarce supply, and allocation rules exist precisely to stop it. Buffers bought in a crisis mostly move the shortage from one hospital to another.

A federal signal on buffer stock

Federal payment policy had begun to recognize the cost. CMS issued its final inpatient payment rule for fiscal year 2025 on August 1, 2024. It created a separate Medicare payment for small, independent hospitals to establish and maintain a buffer stock of essential medicines. The new fiscal year began on October 1, the same week North Cove was under water.

The policy was narrow. It applied only to small hospitals not part of larger chains, and it targeted essential medicines rather than every critical supply. It still mattered as a signal that resilience has a cost, and that someone other than the purchasing department may need to pay it.

Antitrust and shared stock

Regional sharing agreements need careful legal design. In 2023 the Justice Department and the Federal Trade Commission withdrew their long-standing health care antitrust policy statements, which had included guidance on joint purchasing. Counsel now has less of a bright line to point to. Agreements limited to emergency sharing, with no exchange of pricing information, are generally easier to defend than broader purchasing coordination, but each needs its own review.

Boards come in here. A purchasing department is right to chase unit cost; that is its job. Only the board and senior management can decide to pay more for lower risk on a short list of products. The decision is easier when it is framed against the cost of a shortage: cancelled procedures, overtime spent on workarounds and patient safety events. A small premium on a cheap product can look very different when set beside a few days of disrupted operations.

Two health systems, one lost plant

The four levers interact, which shows most clearly when two regional health systems, each with a handful of hospitals, face the same sudden loss of a major IV fluid plant.

The first has done no preparation. On the first morning, its supply chain director learns of the shortage from a news alert. She does not know offhand how much of the system’s fluid comes from the affected plant, and spends two days finding out. Pharmacy and nursing leaders meet on day three to draft conservation guidance, which goes out as an email on day five. Usage barely moves, because the order sets still default to the old practice. When the manufacturer announces allocation, the system discovers that a recent switch in purchasing channels left it with a smaller baseline than its true needs. There is no second supplier under contract, and no agreement with neighboring systems. By the second week, procedures are being rescheduled and staff are working overtime on workarounds.

The second faces the same news with its register already in hand. Within an hour, the supply chain team knows that most of its IV fluid comes from the affected plant and that it holds a little over a week of stock. The named clinical owner, the director of pharmacy, switches on pre-approved conservation protocols that afternoon; changed order-set defaults go live the next morning. A daily dashboard shows usage against allocation for every unit, and a pharmacist reviews IV push substitutions for errors. The contract spells out how its allocation will be calculated, and a smaller share of its volume already flows through a second manufacturer. A regional sharing agreement, reviewed by counsel the previous year, lets it borrow from a partner system that is less exposed.

Neither system can conjure fluid that does not exist. But the second buys itself time, keeps more procedures on schedule and avoids the safety risks of improvised change. The difference was not luck or size. It was a register, a set of approved protocols, a few contract clauses and a board decision, all made in a calm year.

Where the comparison flatters preparation

The comparison has limits. Both systems still depend on what the manufacturer can ship, and in a deep shortage the prepared system will also ration. Its sharing agreement helps only if the partner buys from a different plant; if both systems depend on the same site, borrowing just moves the gap. Its second-source contract may cover a sliver of need.

Preparation also has a cost the first system did not pay. Staff time on the register, informatics work on order sets, legal review of contracts and a premium on some products all came out of a budget with other claims on it. The case for the second system rests on avoiding harm and disruption, not on a guaranteed financial return.

Each lever also matters on its own. Information told the second system how exposed it was. Demand management stretched what it had. Contract terms protected its share. Buffers and partnerships gave it somewhere to turn. Take away any one, and the others work less well.

How hospitals stay exposed to a cheap product

A well-prepared health system, in the light of North Cove, keeps a short register of critical low-cost products with their manufacturing sites and a named clinical owner for each. It has conservation protocols built into its order sets, ready to switch on, with a daily dashboard and a safety review process. Its contracts spell out how allocation works and allow a second source for the most critical items. And its board has made an explicit, recorded decision about how much it is willing to pay for resilience on that short list.

The ways of staying exposed are predictable.

• Ranking by spend. Reviewing supply risk only for expensive items, and missing the cheap ones that every department depends on.
• Mistaking brands for sources. Assuming that several product options mean several factories.
• Improvising conservation. Writing protocols in the middle of the shortage, without pre-agreed clinical sign-off.
• Conserving without checking. Substituting routes or methods without monitoring for errors.
• Forgetting the lessons. Reverting every wasteful habit once supply returns.
• Leaving it to purchasing. Expecting a team measured on unit cost to decide, alone, to pay more.

Ambulatory and home settings are easy to forget. Infusion centers, ambulatory surgery centers, urgent care clinics and home health programs use the same fluids and often buy through different channels from the hospital. A register that covers only inpatient units will miss part of the system’s exposure, and part of its ability to conserve.

The board’s role is narrow but essential. It does not need to approve conservation protocols or contract clauses. It does need to see the register once a year, know which products are most concentrated, and decide how much resilience it is willing to buy. A recorded decision, even one to accept the risk, is better than no decision at all.

Where the cheap essentials come from

1. Which ten low-cost products would hurt patient care most if we lost them for a month, and how much of our supply of each comes from the largest plant?
2. How many days of stock do we hold, and who is the named clinical lead for conserving it?
3. Are conservation protocols already approved and built into our order sets, or would we be writing them during the crisis?
4. Do our contracts explain how allocation is calculated, and do any clauses stop us from using a second source?
5. What would we be willing to pay, per year, to cut our exposure on our most critical cheap products, and has the board decided?

With hindsight

Baxter restarted North Cove line by line. The first line came back around the turn of November 2024 and, at its pre-storm peak, had made about half of the site’s one-liter IV bags, the size hospitals use most. A second line followed the next week. Baxter said the first new North Cove product could ship in late November.

The rest took longer. On January 28, 2025, Baxter announced that all ten of the site’s manufacturing lines had restarted, and by mid-February it said production was back to pre-hurricane levels, less than five months after the storm. Allocations rose through the winter, toward Baxter’s stated goal of 100 percent for most critical IV product groups by the end of 2024.

Inventory took longer than production. In May 2025 the company said inventory was restored and allocations had been removed for virtually all IV solution codes made at North Cove. From flood to normal supply, then, the disruption stretched from late September 2024 into May 2025, far longer than most hospital plans assume a shortage will last.

The people who restarted the plant were themselves storm survivors. Baxter said all of its more than 2,500 North Cove employees had been accounted for. It set up a temporary support center near the plant with food, water, showers and internet access, and its foundation gave more than $4 million to employees and local communities.

How the gap was bridged

Baxter’s own account of the recovery shows how much of the gap was filled by measures no hospital controls. It salvaged more than 1,200 truckloads of finished product from the site. It secured temporary FDA authorization to import from nine plants abroad, with the first shipments arriving about three weeks after the storm. By the end of 2024, it said, nearly 200 aircraft had brought in nearly 18,000 tons of product.

Regulators also stretched existing stock. The FDA authorized longer use dates for more than 50 IV and irrigation product codes, adding up to a year of shelf life for product made before the flood. Temporary bridges, installed with help from ASPR and the state transportation department, reopened the road to the plant.

The shutdown became a well-documented case of how quickly a single-site disruption reaches the bedside, and how long recovery takes even when the manufacturer moves quickly and spends heavily.

What changed and what did not

Baxter said it had strengthened the on-site levee, and pointed to supply stock programs it offers customers. It also said it had adjusted its allocation process to account for the time product takes to move through distribution, to improve transparency for customers. That last change is a reminder that the mechanics of allocation, as much as its percentages, shaped what hospitals experienced.

Policy debate about medical supply concentration continued through 2025, increasingly entangled with tariffs and domestic manufacturing, without a single decisive federal fix. The market structure that created the exposure has not fundamentally changed. The next disruption could come from weather, a quality problem at a plant, or trade policy, and the playbook would be much the same.

For individual systems, conservation proved the fastest and cheapest lever. It needed no new contracts, no capital and no outside approval, only clinical leadership, good data and a willingness to change habits. Contract terms and paid-for buffers moved more slowly, as financial pressure on hospitals grew through 2025. When margins are tight, spending money on a risk that has just passed is a hard case to make. Understandable as that is, it leaves many organizations relying on the one lever that only works once the crisis has started.

The practical course is to bank the gains. Keep the conservation habits that cut waste, keep the product register current, and revisit contract terms and resilience spending at each renewal while the memory of North Cove is still fresh enough to justify them.