Emergency/Disaster 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

2. 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

3. 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.

4. Common Disaster Planning Assumptions versus Research Observations Source: Auf der Heide, “The Importance of Evidence-Based Disaster Planning”, Annuals of Emergency Medicine”, 47:1: January 2006

5. 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.

6. 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.

7. 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.

9. 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

10. 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

12. Requirements Authority (cont.) • The ICS contains five functional areas: Command, Operations, Planning, Finance/Admin, and Logistics • An emergency plan and ICSfor 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

13. HICS Structure

14. 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

15. Mutual Aid Flow for SEMS Assumes hospitals will exhaust access points for supplies and pharmaceuticals.

16. 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.

17. Example Hazard Vulnerability Assessment

18. Requirements For Supply Chain Management

19. 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

20. 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.

21. 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.

22. 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

23. 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 • A process for obtaining the caches and transporting to the desired locations. • A process for loading supplies and equipment in an efficient manner (e.g. loading docks).

24. 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.

25. Example – Customized Plan

26. Example – Customized Plan (cont.)

27. The Joint Commission's Emergency Management Standards 2008

28. 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.

29. 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 organization’s 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

30. Other Considerations

31. 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

32. 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

33. 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

34. 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 [>60%], 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

35. 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.

36. 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.html#app2

37. 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

38. 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. 38

39. 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

40. THANK YOU