Transcript 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
1
Agenda
Introduction
II. Overview of Disaster Planning & Emergency
Preparedness
(Background – Requirements Authority)
III. Requirements for Supply Chain
A. Surge Preparation
B. New Joint Commission Standards
IV. Other Considerations
V. Available Resource Material
I.
2
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 nonconventional (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.
3
Common Disaster Planning Assumptions versus
Research Observations
Assumption
Observation
•Casualties will be transported to hospitals by
ambulance.
•Most casualties arrive by non-ambulance
means (private cars, police, buses, taxis,
helicopter, and by foot). Transport outside of
EMS system poses challenges for patient
tracking.
•Casualties will be transported to hospitals
appropriate for their needs and available
capacity
•Most casualties are transported to the closest
or most familiar hospitals. Do not assume
patients will be triaged, decontaminated, or
given first aid in the field.
•The most serious casualties will be the first to
arrive at hospitals.
•The least serious casualties often arrive first
(with info about events in the field).
Source: Auf der Heide, “The Importance of Evidence-Based Disaster Planning”,
Annuals of Emergency Medicine”, 47:1: January 2006
4
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.
5
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.
6
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.
7
Characteristics of L.A. Hospital Disaster Plans
Hospital Disaster Plan
Characteristic
Community Hospital
(n = 40), n (%)
Public Hospital
(n = 5), n (%)
Level 1 Trauma Center
(n = 6), n (%)
Level 2 Trauma Center
(n = 8), n (%)
Nontrauma Center
(n = 31), n (%)
All Hospitals
(N = 45), n (%)
38 (95%)
5 (100%)
6 (100%)
6 (75%)
31 (100%)
43 (96%)
• EMS-compatible radios
40 (100)
5 (100)
6 (100)
8 (100)
31 (100)
45 (100)
• Walkie-talkies
Hospital Emergency
Incident Command
System–based system
Equipment, supplies, and
pharmaceuticals:
40 (100)
5 (100)
6 (100)
8 (100)
31 (100)
45 (100)
• Availability of ham radios
25 (63)
2 (40)
2 (33)
2 (25)
23 (74)
27 (60)
• Level C personal
protective equipment
34 (85)
5 (100)
6 (100)
8 (100)
25 (81)
39 (87)
• Warm-water
decontamination shower
17 (43)
2 (40)
2 (33)
3 (38)
14 (44)
19 (42)
• Availability of Geiger
counters
38 (95)
5 (100)
6 (100)
6 (75)
31 (100)
43 (96)
• 3 Days of hospital
supplies
40 (100)
5 (100)
6 (100)
8 (100)
31 (100)
45 (100)
• Chemical antidote
stockpile
18 (45)
5 (100)
5 (83)
2 (25)
16 (52)
23 (51)
• Antibiotic stockpile
16 (40)
3 (60)
5 (83)
3 (38)
11 (35)
19 (42)
• Immediate availability
>5 ventilators
10 (25)
3 (60)
3 (50)
2 (25)
8 (26)
13 (29)
• Current number of
ventilators >20
31 (78)
4 (80)
6 (100)
7 (88)
22 (71)
35 (78)
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.
8
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
9
10
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
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
HICS Structure
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
Mutual Aid Flow for SEMS
Assumes hospitals will
exhaust access points
for supplies and
pharmaceuticals.
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:
1. Supplies, pharmaceuticals, and equipment to be self sufficient
for 72 hours at a minimum, with a goal of 96 hours.
2. Expectation to operate at 20 to 25% above their average daily
census.
3. Hospitals may need to rely on the available market supply (e.g.
MOUs, retailers or wholesalers) and State stockpiles.
4. The type of inventory to be stockpiled should take into
consideration some likely specific risks i.e., earthquake zone.
5. 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.
Example Hazard Vulnerability Assessment
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Acquisition Process
Pre-Event:
1. Identify the “authorized official” in charge of compiling,
analyzing, and relaying mutual aid requests to the SEMS
systems
2. 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
3. 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
Acquisition Process
During Surge:
1. Engage the hospital's acquisition process for
additional supplies, pharmaceuticals, and equipment.
2. Notify the SEMS emergency contacts identified in their
emergency response plans in order
3. Complete a status report and a formal request for assistance
when the resources prove to be inadequate
4. Ensure that when acknowledgement of the request is
received, it is saved and used to track request status.
5. Prepare to reconfirm a response time of request if the
request is not fulfilled as anticipated.
Considerations for Surge Planning
Examples:
1. 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.
2. 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.
Determining Surge Supply Needs
1. 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

2.
3.
4.
5.
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
A process
A process
A process
needs.
for
for
for
for
ensuring the security of the supply and equipment caches.
controlling access into the area.
controlling access within the area.
working with local authorities prior to surge to address heightened security
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).
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.
Example – Customized Plan
Event/Definition
Response
Plano Technology Center
Z9 Mainframe 617MIPS
EMC Symetrix
Perot Systems Tier 3 Data Center
Sungard DR Service 72 hour recovery
Mirrored and nightly backups taken off-sight to Iron
Mountain
Duplicate power feeds, UPS and generators with enough
fuel for 3 days of continuous operations
Loss of Power
CSW System Failure (Nashville)
CSW Server in PTC
Building
Roof/Structural Failure
Redundant hardware with failover,
Building engineer/architect to be alerted for building
evaluation
Communicate inspection result to Richmond Corporate
offices & Hospital Leadership
Initiate alternate warehouse plan
Inventory And Order Continuity
Hospital’s Critical Item List of SKUs will be diverted to
DISTRIBUTOR Knoxville, Birmingham, Atlanta or
Memphis Distribution Center.
Divert Hospital orders to Birmingham, Knoxville, Atlanta
or Memphis Distribution Centers
Atlanta DISTRIBUTOR Purchasing will review Hospital
product inventory levels at the Birmingham, Knoxville,
Atlanta or Memphis DCs
Atlanta Area Purchasing will review Hospital item stock
levels for immediate buy-in and order expediting to meet
demands
Activate DISTRIBUTOR On-Site Support Teams
Activate Outside Area Support Team to assist in
Receiving and Order Processing
Example – Customized Plan (cont.)
Transportation
DISTRIBUTOR Home Office Transportation will
coordinate line hauls and set delivery schedules utilizing
nearest DC’s.
Power Loss
Street power is lost with a potential down time of
greater than 6 days
Tele-Communications
Loss of WAN Main Connection
Loss of main data connection along with dial up
rollover
Incident Command Center
Richmond Technical Support Services
Generator hook-up due to be installed at Nashville DC in
2nd Quarter.
Activate the priority designation with fuel vendor to insure
ample diesel to cover all outage periods.
Automatic Satellite backup communications.
Automatic satellite backup for data communications
DISTRIBUTOR Technical Support will work with
hospital and DC systems. GM will be on site at
DISTRIBUTOR DC.
27
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.
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
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
OHSA Guidance
Preparing 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
32
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
33
Suggested Inventory of Consumable Supplies
Department 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
34
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.
35
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
36
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
37
Training Resources
www.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
Essential Reference Materials
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
39
THANK YOU
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