EmergencyDisaster Planning For The Hospital Supply Chain

1
Emergency/Disaster Planning For The Hospital
Supply Chain

• S. Scott Watkins
• Vice President, OMSolutions
• A Presentation To The
• California Association of Hospital Purchasing
  Materials Managers
• October 24, 2007
• Shell Beach, CA

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Agenda

• Introduction
• Overview of Disaster Planning Emergency
  Preparedness
• (Background Requirements Authority)
• Requirements for Supply Chain
• Surge Preparation
• New Joint Commission Standards
• Other Considerations
• Available Resource Material

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Types of Disasters(Joint Commission definitions)

• Natural Disasters
• Meteorological cyclones, typhoons, hurricanes,
  tornadoes, hailstorms, snowstorms
• Topological landslides, avalanches, mudflows,
  floods
• Geologic earthquakes, volcanic eruptions,
  seismic tsunamis
• Biological communicable disease epidemics and
  insect swarms (locusts)
• Man-Made Disasters
• Warfare conventional (bombardment, blockade,
  siege) and non-conventional (chemical,
  biological)
• Civil riots and demonstrations strikes
• Criminal/terrorism bomb threat/incident,
  nuclear, chemical, biological, hostage
• Accidents transportation, structural collapse,
  explosions, fires, chemcial (toxic waste,
  pollution), biological (sanitation)

NOTE The Joint Commission discourages the
development of separate plans for each situation.
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Common Disaster Planning Assumptions versus
Research Observations
Source Auf der Heide, The Importance of
Evidence-Based Disaster Planning, Annuals of
Emergency Medicine, 471 January 2006
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Patient Surge

• Surge Capacity the ability to manage increased
  patient care volume that otherwise would severely
  challenge or exceed the existing medical
  infrastructure.
• Surge Capability the ability to manage
  patients requiring unusual or very specialized
  medical evaluation and intervention, often for
  uncommon medical conditions.

SOURCE Hick, John L., MD, No Vacancy
Healthcare Surge Capacity in Disasters, July 22,
2004.
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Hospital Response

• At least 50 arrive self-referred
• On average, 67 of patients in
• any given disaster are cared for
• at the hospital nearest the event
• (range 41-97)
• Redistribution from the hospital closest to the
  incident scene to other facilities may be as (or
  more) important than transport from the scene

SOURCE Hick, John L., MD, No Vacancy
Healthcare Surge Capacity in Disasters, July 22,
2004.
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Per 1000 patients injured

• 250 dead at scene
• 750 seek medical care
• 188 admitted to hospitals
• 47 to ICU
• Rule of 85 / 15 (total injured to admitted)
  has applied to all disasters thus far, including
  NYC 9-11

SOURCE Hick, John L., MD, No Vacancy
Healthcare Surge Capacity in Disasters, July 22,
2004.
8

Characteristics of L.A. Hospital Disaster Plans

Source Amy H. Kaji, MD, MPH and Roger J. Lewis,
MD, PhD, Hospital Disaster Preparedness in Los
Angeles County, Academic Emergency Medicine,
Volume 13, Issue11 1198-1203, 2006.
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Novation Survey on Pandemic Flu Preparedness
Showed Hospitals Will Run Out of Supplies in
Less Than One Week

• 68 percent reported that they have devoted
  resources to developing comprehensive
  pandemic-specific disaster plans
• 54 percent believe operations could continue for
  1-3 days external resources
• 25 percent believe operations could continue for
  4-7 days without external resources
• 93 percent have identified key products and
  suppliers that are essential to provide treatment
  to patients during a pandemic
• 60 percent have a dedicated/separate inventory of
  key products and supplies
• 31 percent have preprinted disaster preparedness
  order forms
• 78 percent plan to obtain additional respirators
  (either rent or purchase)
• 66 percent have created collaborative plans with
  other hospitals, as well as their distributors

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Overview of Disaster Planning Emergency
Preparedness
11
Background Requirements Authority

• National direction comes from the law signed in
  2006 - Pandemic and All Hazards Preparedness
  Act
• Empowers Health Human Services (HHS) to lead
  federal response via National Response Plan
  (NRP)
• HHS assigned Emergency Support Function (ESF),
  for Health Medical Services, ESF-8 includes
  Support Area-4, Medical equipment supplies
• HHS established method for organization and
  operations, the National Incident Management
  System (NIMS)
• NIMS outlines the Incident Command System
  (ICS), which defines the organizational structure
  for response

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Requirements Authority (cont.)

• The ICS contains five functional areas Command,
  Operations, Planning, Finance/Admin, and
  Logistics
• An emergency plan and ICS for healthcare
  facilities is required in the following
• Occupational Safety and Health Act (OSHA)
• Homeland Security Presidential Directive 5
• The Joint Commission (TJC), Environment of Care
• California Emergency Services Act (ESA)
• Hospital Incident Command System (HICS) adapts to
  any unusual situation, and no longer tied to
  declared disasters
• Note HICS, formerly HEICS, established in CA in
  1993 for earthquakes

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HICS Structure
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California Requirements

• The California Emergency Services Act (ESA) of
  2006 creates the Office of Emergency Services
  (OES)
• The OES developed regulations for the Standard
  Emergency Management System (SEMS)
• The SEMS outlines components for responding to
  Healthcare Surge, or excess of demand over
  capacity
• The California Dept. of Health Services (DHS)
  published
• Development of Standards and Guidelines for
  Healthcare Surge during Emergencies
• References TJC EC.4.11, 4.12, and 4.14, effective
  January 1, 2008

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Mutual Aid Flow for SEMS
Assumes hospitals will exhaust access points
for supplies and pharmaceuticals.
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How SEMS Affects Acquisition

• Overall goal of surge planning is to have enough
  inventories on hand to maintain existing
  operations, with recommended types and
  quantities
• Supplies, pharmaceuticals, and equipment to be
  self sufficient for 72 hours at a minimum, with a
  goal of 96 hours.
• Expectation to operate at 20 to 25 above their
  average daily census.
• Hospitals may need to rely on the available
  market supply (e.g. MOUs, retailers or
  wholesalers) and State stockpiles.
• The type of inventory to be stockpiled should
  take into consideration some likely specific
  risks i.e., earthquake zone.
• This planning can be supplemented with a Hazard
  Vulnerability Assessment (HVA) which attempts to
  identify the risk of the event by quantifying the
  probability of the event occurring and its
  potential severity.

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Example Hazard Vulnerability Assessment
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Requirements For Supply Chain Management
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Acquisition Process

• Pre-Event
• Identify the authorized official in charge of
  compiling, analyzing, and relaying mutual aid
  requests to the SEMS systems
• The official should set up a meeting with the
  medical health operational area coordinator
  (MHOAC) to begin active sharing of relevant
  supplies, pharmaceuticals and equipment
  information
• Contact non-medical disciplines within the SEMS
  structure (e.g., transport vendors), especially
  at the local levels, to provide assistance in the
  transportation, handling, storage, or management
  of clinical resources

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Acquisition Process

• During Surge
• Engage the hospital's acquisition process for
  additional supplies, pharmaceuticals, and
  equipment.
• Notify the SEMS emergency contacts identified in
  their emergency response plans in order
• Complete a status report and a formal request for
  assistance when the resources prove to be
  inadequate
• Ensure that when acknowledgement of the request
  is received, it is saved and used to track
  request status.
• Prepare to reconfirm a response time of request
  if the request is not fulfilled as anticipated.

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Considerations for Surge Planning

• Examples
• Is the surge created by a disaster that has
  impacted transportation and routing capabilities?
• Recommendation If so, alternate routes and means
  of transportation need to be identified and
  hospitals should contact the State Department of
  Transportation for specific information regarding
  the condition of roads.
• If requesting equipment, does the hospital have
  the appropriate personnel trained to operate that
  equipment?
• Recommendation If not, it should be considered
  what hospital can better utilize the equipment
  with appropriately trained personnel or determine
  if training can be done at the hospital in need.

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Determining Surge Supply Needs

• Measures to consider when determining surge
  capacity
• Total beds plus expansion potential using cots
• Average daily census plus expansion potential
  using cots
• Licensed beds plus 20 (HRSA Guidelines)
• Emergency Department capacity
• Employees and dependents
• Determine what supplies and equipment are already
  in stock
• Identify the supplies and equipment that may be
  required during a surge from Tool 4
• Based on the number of potential patients to be
  treated during a surge, calculate the supplies
  and equipment needs for 72-96 hours
• Determine if the supplies and equipment will be
  part of the existing inventory or cached

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Supplies Considerations Checklist

• Inventory Management
• A process for monitoring and maintaining
  preventive maintenance requirements Batteries,
  Ventilator seals, Electrical equipment
• A process for returning stock to the vendors for
  replacement or credit, if applicable.
• A process for monitoring the obsolescence of
  equipment, e.g., AEDs.
• Considerations for storing large amounts of
  supplies and equipment .
• Security Existing Healthcare Facility (assuming a
  heightened state of security)
• A process for ensuring the security of the supply
  and equipment caches.
• A process for controlling access into the
  building or area.
• A process for Identifying and tracking of
  patients, staff, and visitors.
• Monitoring of facilities with security cameras.
• Caches (external to an existing facility or ACS)
• A process for ensuring the security of the supply
  and equipment caches.
• A process for controlling access into the area.
• A process for controlling access within the area.
• A process for working with local authorities
  prior to surge to address heightened security
  needs.
• Transport

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Supplier Considerations Checklist

• Identify any disaster clauses within the
  contract and understanding the requirements of
  the supplier.
• Understand the options of how supplies,
  pharmaceuticals, and equipment will be delivered
  during a surge.
• Understand where supplies, pharmaceuticals, and
  equipment will be delivered during a surge (e.g.
  where at the facility they will be delivered to).
• Understand who the supplies, pharmaceuticals, and
  equipment will be delivered to during a surge.
• Identify the supplier lead time of critical
  supplies, pharmaceuticals and equipment.
• Rotation of stock and inventory (control
  management) agreement.
• Identify payment terms under a surge scenario.
• Understand the days on hand inventory of the
  suppliers.

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Example Customized Plan
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Example Customized Plan (cont.)
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The Joint Commission's Emergency Management
Standards 2008
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Highlights of New TJC Standards

• EC.4.11 - A 4. When developing its emergency
  operations plan (see Standard EC.4.12), the
  organization communicates its needs and
  vulnerabilities to community emergency response
  agencies and identifies the capabilities of its
  community in meeting their needs.
• EC.4.11 - A 9. The organization keeps a
  documented inventory of the assets and resources
  it has on-site, that would be needed during an
  emergency (at a minimum, personal protective
  equipment, water, fuel, staffing, medical, (CAH,
  HAP surgical,) and pharmaceuticals resources and
  assets). Note The inventory is evaluated at
  least annually as part of EP 11.

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Highlights of New TJC Standards (cont.)

• EC.4.11 - B 10. The organization establishes
  methods for monitoring quantities of assets and
  resources during an emergency.
• EC.4.12 - B 6. The Emergency Operations Plan
  (EOP) identifies the organizations capabilities
  and establishes response efforts when the
  organization cannot be supported by the local
  community for at least 96 hours in the six
  critical areas.
• EC.4.14 - B 8. Potential sharing of resources and
  assets with health care organizations outside of
  the community in the event of a regional or
  prolonged disaster

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Other Considerations
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Staff-Family Preparedness Planning

• Employees should be trained and supported in
  Family Preparedness planning
• Hospitals should assist in the preparation
• Plan and prepare Family Assistance during
  response and recovery
• Employees will be more inclined to support
  operational needs if their families are cared for
  and safe
• Checklists are available at FEMA, Homeland
  Security, and American Red Cross websites

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OHSA GuidancePreparing Workplaces for a Flu
Pandemic

• Those who work closely with (either in
• contact with or within 6 feet) people
• known or suspected to be infected with
• pandemic influenza should wear
• Respiratory protection
• (N95 or higher rated filter for most situations
  )
• Face shields
• (may be worn on top of a respirator to prevent
  contamination of the respirator)
• Medical/surgical gowns or other
  disposable/decontaminable protective clothing
• Gloves to reduce transfer of infectious material
• Eye protection if splashes are anticipated

SOURCE Guidance on Preparing Workplaces for an
Influenza Pandemic, OSHA 3327-02N, 2007
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Examples of Pandemic Supply Needs SOURCE HHS
Pandemic Influenza Plan, Supplement 3 Healthcare
Planning

• Consumable resources
• Hand hygiene supplies (antimicrobial soap and
  alcohol-based, waterless hand hygiene products)
• Disposable N95, surgical and procedure masks
• Face shields (disposable or reusable)
• Gowns
• Gloves
• Facial tissues
• Central line kits
• Morgue packs
• Durable resources
• Ventilators
• Respiratory care equipment
• Beds
• IV pumps

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Suggested Inventory of Consumable
SuppliesDepartment of Veterans Affairs, VA
Pandemic Plan

• Consumable resources
• (consider stockpiling a 4-week supply)
• Hand hygiene supplies (antimicrobial soap and
• alcohol-based gt60, waterless hand hygiene
• gels or foams)
• Disposable fit-testable N95 respirators
• Elastomeric respirators with P100 filters
• Surgical and procedure-type masks Goggles
• Gowns, Gloves
• Facial tissues
• Central line kit
• Morgue packs

• IV equipment
• Syringes and needles for vaccine administration
• Respiratory care equipment
• Portable oxygen
• Regulators and flow meters
• Oxygen and ventilator tubing, cannulae,
• masks
• Endotracheal tubes, various sizes
• Suction kits
• Tracheotomy
• Vacuum gauges for suction and portable suction
• machines
• Intensive care unit (ICU) monitoring equipment

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Disaster Response Shelters Kits

• Disaster products are available from several
  companies to help simplify and expedite the
  response needed to handle the convergence of
  patients to a medical facility in the aftermath
  of a mass casualty.

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Strategic National Stockpile

• The federal government is acting to ensure that
  there are adequate medical personnel and adequate
  medical equipment supplies.
• In the event of a pandemic, virtually every piece
  of medical equipment in the country would be in
  short supply.
• The federal government is stockpiling critical
  medical supplies as part of the Strategic
  National Stockpile.
• HHS is helping states create rosters of medical
  personnel ready to respond, and every federal
  department involved in healthcare is ensuring
  their capacities are ready to support local
  communities.
• Source US Department of Health and Human
  Services, http//www.hhs.gov/pandemicflu/plan/sup3
  .htmlapp2

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Resources for Disaster Planning Emergency
Response

• National Associations
• AHRMM Association of Healthcare Resource
  Materials Management
• ASHCSP American Society of Healthcare Central
  Services Professionals
• ASHE American Society for Healthcare Engineering
• ASHRM American Society for Health Risk
  Management
• Health Industry Distributors Association
• Hospital Industry Group Purchasing Association
• California Associations
• CHA California Hospital Association
• HCSC Hospital Council of Southern California
• HASDIC Hospital Assn of San Diego Imperial
  Counties
• HCNCC Hospital Council of Northern Central
  California

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Training Resourceswww.training.fema.gov/

• IS-100 Introduction to Incident Command System
• This course describes the history, features and
  principles, and organizational structure of the
  Incident Command System. It also explains the
  relationship between ICS and the National
  Incident Management System (NIMS).
  Approximately 3 hours.
• IS-200 ICS for Single Resources and Initial
  Action Incidents
• ICS 200 is designed to enable personnel to
  operate efficiently during an incident or event
  within the Incident Command System (ICS). ICS-200
  provides training on and resources for personnel
  who are likely to assume a supervisory position
  within the ICS. Approximately 3 hours.
• IS-700 National Incident Management System
  (NIMS), An Introduction
• This course explains the purpose, principles, key
  components and benefits of NIMS. The course also
  contains "Planning Activity" screens giving you
  an opportunity to complete some planning tasks
  during this course. Approximately 3 hours.
• IS-800.A National Response Plan (NRP), An
  Introduction
• The NRP describes how the Federal Government will
  work in concert with State, local, and tribal
  governments and the private sector to respond to
  disasters. It is intended for DHS and other
  Federal staff responsible for implementing the
  NRP, and Tribal, State, local and private sector
  emergency management professionals.
  Approximately 3 hours.

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Essential Reference Materials

• AHRMM (developed by MEDLOG, Inc.), Disaster
  Preparedness Manual for Healthcare Materials
  Management Professionals, 2007.
• AHRMM, HIGPA and HIDA, Medical-Surgical Supply
  Formulary by Disaster Scenario, March 2003.
• American Society for Healthcare Engineering,
  Hazard Vulnerability Analysis, 2007.
  www.ashe.org
• California Emergency Medical Services Authority,
  Hospital Incident Command System Guidebook, 2006.
  www.emsa.ca.gov/hics/hics.asp
• California Department of Health Services,
  California Hospital Bioterrorism Response
  Planning Guide, 2002.
• California Department of Health Services,
  Development of Standards and Guidelines for
  Healthcare Surge during Emergencies Operational
  Tools Manual, 2007.
• Centers for Disease Control, Hospital Pandemic
  Influenza Planning Checklist, June 2007.
  www.pandemicflu.gov
• Joint Commission on Accreditation of Healthcare
  Organizations, Hospital Accreditation Standards
  for Emergency Management Planning, 2007.
  www.jointcommission.org
• Occupational Safety and Health Administration,
  Pandemic Influenza Preparedness and Response
  Guidance for Healthcare Workers and Healthcare
  Employers, 2007. www.ohsa.gov

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THANK YOU