CHESTGuidelines & Topic CollectionsCOVID-19 Resource CenterEssential Institutional Supply Chain Management in the Setting of COVID-19 Pandemic

Essential Institutional Supply Chain Management in the Setting of COVID-19 Pandemic

Pritish K. Tosh, MD; and Lisa Burry, PharmD

Dr. Tosh is with the Division of Infectious Diseases ad Emergency Management, Mayo Clinic, Rochester, MN; Dr. Burry is with the Department of Pharmacy, Mount Sinai Hospital; and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.

Background

The COVID-19 outbreak has manifested in supply chain shortages, the most notable of which is in the personal protective equipment (PPE) needed for the safe care of suspected or confirmed patients. As the outbreak evolves, further supply chain disruptions for medical supplies and medications are anticipated. As a result, health-care facilities must examine and optimize their supply chain management in order to detect and respond to supply chain disruptions.1

Inventory management

As supply chain disruptions emerge, meticulous control of existing inventory becomes crucial. Many computerized systems are available to help to track products from the point of entry into a facility through to final distribution to the individual patient care unit.2 Many of these systems are robust enough to manage all medical supplies at a health-care facility and deliver real-time analytics to provide situational awareness to facility leaders regarding inventory levels, as well as other capabilities, such as the early detection of unexpected product loss. For facilities that have not yet adopted a computerized system of inventory control, strong consideration should be made to do so with initial monitoring of only a limited set of key medical supplies that are known to be in shortage in order to have better visibility into the specific institutional needs while deferring the integration of other medical supplies until time permits. For small facilities, inventory management may be feasible without computerized control, provided a consistent manual process is used to understand product availability and needs in an updated manner for highly critical products, including PPE; supplies needed for supportive care of respiratory illness, including mechanical ventilation; and medications used for supportive care of respiratory illness, including antimicrobials, bronchodilators, and sedation for mechanical ventilation.

Purchase management

When manufacturers and distributors have product demands they are unable to meet, such as during shortages, medical facilities are often given fractional allocations of the requested material based on historic purchases. To ensure an institution’s allocation is being used in the manner consistent with the practice priorities, health-care facilities should have, at minimum, visibility into product purchasing throughout the institution for critical products. This can avert ordering of critical products in shortage for a variety of unauthorized purposes, including nonessential services or even personal use. In an ideal circumstance, ordering would be through a centralized, computerized process by which ordering controls for any medical product can be placed to facilitate the purchase by work units with high priority need for specific products, while restricting or requiring approval for purchasing by other work units with low or no prior business need for the product.2 If it is not feasible to institute computerized purchase management, manual processes should prioritize highly critical products as listed above.

Calculating product utilization

Facilities should understand the anticipated utilization of critical products, ie, “burn rate” for the care of COVID-19 patients in different circumstances. In the example of PPE, this would include facemasks, eye protection, gowns and gloves, and respirators (eg, N95 mask or PAPR) for aerosol-generating procedures.3 The calculated utilization should account for anticipated clinical care for the expected duration of hospitalization for a single patient, a few patients, and in the setting of a community outbreak, as well as consider the product need for preparedness activities (eg, fit testing for PPE). The impact of various interventions should also be analyzed, such as product conservation strategies and patient cohorting. Strategies for optimizing PPE supply are available at the Centers for Disease Control and Prevention (CDC).4 An understanding of current inventories, normal product utilization, the impact of intervention strategies, and the current epidemiology of the outbreak can help a facility to optimize the timing of its interventions.5  A sample PPE utilization calculator is available.

Engagement with distributors, manufacturers, and health-care coalitions

In the setting of supply chain disruptions, medical centers should actively engage with their distributors and manufacturers (if purchased directly) to have a mutual understanding of facility needs, as well as the nature of and the anticipated duration of the disruption. Hospitals should engage with local and regional health- care coalitions to establish memoranda of understanding and processes to share resources in times of shortage.

Fractional, intermittent stockpile maintenance

It is strongly recommended not to stockpile medical products during a shortage, as this will only worsen the situation by putting further strain on regional product availability for facilities in need.6 After supply chain disruptions have resolved, institutions should replenish inventories of critical products following the fractional, intermittent maintenance approach.7,8 For example, if a product has a 5-year shelf life, replenishment of the stockpile in annual 20% or biannual 10% increments can help to stabilize the supply chain for the product and provide increased manufacturing capacity if adopted broadly. This strategy can also help the individual health-care facility by having their fractional allocation during shortage more accurately reflect their usage and needs. Using an inventory control system, product use during routine medical care should come from products in the stockpile in its final year of shelf life to avoid unnecessary waste.

External supply chain risk assessment

In order to help institutions better anticipate future supply chain disruptions, health-care organizations create or join existing programs to incorporate external supply chain risks into institutional supply chain decisions.9,10 This involves an understanding of where critical products are manufactured, as well as the source of raw materials, and incorporates a broad range of external risks, including meteorologic, epidemiologic, and geopolitical. Deep analytics can help integrate these external risks with supply chain vulnerabilities to provide an institution with actionable intelligence regarding impending shortages and lead to interventions, such as identification of alternative products or early adoption of conservation strategies.

References

  1. Tosh PK, Feldman H, Christian MD, et al. Business and continuity of operations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e103S- 117S.
  2. Shih SC, Rivers PA, Hsu HY. Strategic information technology alliances for effective health-care supply chain management. Health Serv Manage Res. 2009;22(3):140-150.
  3. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus disease 2019 (COVID-19). https://www.cdc.gov/. Accessed 03/14/2020.
  4. Centers for Disease Control and Prevention. Checklist for healthcare facilities: strategies for optimizing the supply of N95 respirators during the COVID-19 response. https://www.cdc.gov/coronavirus/2019-ncov/hcp/checklist-n95-strategy.html. Accessed 03/14/2020.
  5. Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3(2 Suppl):S59-S67.
  6. Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm. 2018;75(21):1742-1750.
  7. Abramovich MN, Hershey JC, Callies B, Adalja AA, Tosh PK, Toner ES. Hospital influenza pandemic stockpiling needs: a computer simulation. Am J Infect Control. 2017;45(3):272-277.
  8. Manolakis M. Ethical integrity in managing drug shortages. Am J Health Syst Pharm. 2012;69(1):17.
  9. Blos MF, Wee HM, Yang J. Analysing the external supply chain risk driver competitiveness: a risk mitigation framework and business continuity plan. J Bus Contin Emer Plan. 2010;4(4):368-374.
  10. HIRC. Healthcare Industry Resilience Collaborative. https://hircstrong.com/. Accessed March 14, 2020.

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