Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 3. Equipment and Supplies
Most shuttered hospitals are going to have little if any usable medical equipment or supplies on hand. The lack of appropriate equipment or supplies should not be a stumbling block, however, as the vast majority of equipment and supplies are both portable and obtainable.
This section provides a basic understanding of equipment and supplies one might expect to find at a hospital closed within the past 5 years, based on inspections of the two hospitals in the Boston area and the resources that would need to be procured. The equipment and supplies discussed here are applicable to the two mass casualty scenarios discussed above.
Patient Population Assumptions, for Purposes of Estimating Supply Needs
The specific equipment and supply needs for the two scenarios vary, but a significant amount of basic equipment must be procured for any patient population to make a shuttered hospital operational. The minimum supplies held in inventory at the hospital should ideally be sufficient to last at least 3 days per admitted patient, regardless of the patient population. It is probably not advantageous to hold larger inventory, as this would require significant storage space—space that would be better used housing patients. Many hospitals operate in a "just in time" inventory and receive supply shipments daily, allowing procurement staff to order only what is necessary and minimize expenditures and storage requirements. Although the two scenarios require the same general amount of basic supplies, patients with active infections, as in Scenario 2, would likely need higher acuity care (ICU care is not anticipated at the surge facility), so for Scenario 2 the basic list of supplies is somewhat augmented.20 Patients treated under Scenario 2 (infectious disease/isolation) would require more extensive supportive care than the general medical-surgical patients served under Scenario 1. For example, if we assume that Scenario 2 requires supplies similar to those stocked by an intensive care unit at a large urban hospital, supplemental supplies such as the following would be needed: respiratory support (tracheal tubes, respiratory solutions, and fluid resistant masks) and tubes (gastronomy, nasenteral, culture). In addition, kits such as those used for aspiration procedures, blood gas sampling, and administering intravenous central lines and a more extensive array of thoracic, suction, hemodialysis, and cardiovascular catheters (cardiovascular guide wires, injection tubing, and introducers) might need to be stocked for Scenario 2. Perhaps renal dialysis supplies, spinal needles, anti-embolic garments, and pressure monitoring systems should be available to serve patients in Scenario 2, although patients with such extreme needs might be better served by being returned to a tertiary care hospital if it is an option.
We obtained inventory lists from three operational general community hospitals in the Boston area minus those specific supplies to provide more specialized care such as surgery or obstetrics, to serve as a standard for supplies needed for a surge facility. Appendix A lists the types and amounts of supplies to run a surge facility for 30 days. We have broken out each type of equipment or supply into the amounts that are necessary for a floor or ward of 30-40 patients (shuttered hospitals of the size we examined could hold perhaps 4-8 such wards) and then considered how that inventory would be depleted over the course of a 30-day operation. In doing so, we made assumptions about the type of patients entering the facility and usage of equipment and supplies during their course of treatment.
We assume that patients would continue to be cared for in the surge facility for at least 30 days (and perhaps as many as 60 days), and we further assume that all the patients would not arrive on 1 day; their arrival would be spread out between days 8 and 11 following a mass casualty event, or spread out even more in the case of an evolving epidemic. For Scenario 1 we assume an average patient stay of 2 to 3 days; for Scenario 2 the length of stay could be 1-2 weeks. Patients would be discharged slowly, over the course of several days or weeks, until the facility is no longer needed.
For the purposes of estimating equipment and supply needs, we assume the hospital will be operating at 100% utilization (a many as 300 patients at Hospital 1) beginning 3-7 days after an emergency is declared and operating for at least 30 days. For our calculations, after 30 days, the surge hospital would continue to operate at capacity. This is an artificial endpoint. Under Scenario 1 (medically stable, general patients), we could safely assume that a surge facility could end peak operation earlier, while under Scenario 2 (infectious disease/isolation), peak operation could continue for months. Therefore, in addition to calculations for one-month supply, we've provided a 1-3 day supply calculation for a fully occupied ward of 30-40 patients that can be used for additional procurement if the hospital remains open. At day 30, we assume any remaining patients will be directed back into one of the tertiary or community hospitals for Scenario 1, and the same would probably be true by day 60 for Scenario 2 (the total supply quantities would need to be increased if the epidemic during Scenario 2 is protracted).
Supply replenishment would be dictated by the number of patients admitted and the severity of their illnesses. If illness severity is slightly higher, thereby increasing the average patient stay by 1 day, many items, including patient comfort items such as toothbrushes will not need to be replenished as frequently, while other medical supplies may be depleted at faster rates for more severely ill patients.
Reabsorbing supplies and equipment that are left over after the surge facility closes also warrants attention. Since hospitals are not able to hold more than 1 week's worth of inventory at the most, and vendors would probably not agree to reclaim unused supplies, it may be necessary to parcel out the remaining supplies to several local hospitals (including the sponsor/oversight hospital if there is one, the local public hospital, and others.)
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3.1 Shuttered Hospitals' Existing Equipment
Based on extensive tours of the two Boston area hospitals, it is clear that most usable equipment in a partially shuttered hospital will have been removed from the premises for resale or use elsewhere. However, some important pieces of infrastructure will likely remain. This section describes what may remain in a shuttered hospital, in patient rooms, nursing stations, kitchens, and other areas of the hospital.
3.1.1 Patient Rooms
- Beds. Hospital beds are both costly and difficult to procure quickly in the numbers likely to be required. During the two facility tours we noticed a total of four beds,21 and were told that neither facility stored any additional beds. While modern, electronic adjustable beds may be the ideal for patient safety and comfort, they are not absolutely necessary. Regular beds, cots, or other arrangements might suffice for the weeks of surge capacity required of a shuttered facility. Each patient would need a bedside table as well, although, again, this is not essential.
- Bed Linens. The standard amount of linen per patient is one sheet, one blanket, one disposable pillow, one gown ("Johnnie"), one pair of disposable slippers, one face cloth, and one towel. Linens would be changed up to three times for every patient every 24 hours. This too could be rationed, and linens could be changed less frequently for certain patients.
- Patient Call Buttons. Ideally, electronic patient call buttons should be available by each patient's bedside, and the call system would be operational at the nursing station in each patient ward. If the electronic system is not working or available, an alternative manual or visual system, such as a bell or buzzer, or even a nurse' aide circulating to visually monitor all patients, could be adopted.
- Bathrooms. Most patient rooms have a private bathroom, although in some cases a shared bathroom connects two patient rooms. Most bathrooms have fixtures such as toilets, showerheads, and sinks. It may be necessary to replace some showerheads or other minor plumbing fixtures.
- Optional Items. Items that are not essential to medical care but could improve patient and staff comfort include: one chair (folding) per patient room, one table or nightstand per patient, and one trash can or plastic bag for refuse per patient room. In addition, having one television or radio per patient floor could improve patient morale, although these would certainly not be necessary. Cable TV would not be operational so only limited reception would be available, should televisions be brought in.
- Storage. Some patient rooms contain built-in shelving or closet space, but where movable storage units were used and no longer exist, storage will be needed for personal effects as well as medical supplies and equipment. For personal supplies, each patient would need one small plastic bin filled with sundries such as a toothbrush, toothpaste, and comb. These supplies would be distributed throughout the patient treatment areas in bins for easy dissemination by hospital staff.
- Privacy. Most patient rooms in partially shuttered hospitals lack window shades and curtains between beds, and some lack room doors. For patient comfort and privacy, curtains could be hung on doorframes. In the event of long-term operation of the shuttered facility, doors could be reattached.
3.1.2 Nursing Stations and Common Spaces
The common spaces on general patient wards will likely be stripped of any useful material from beds to trash cans. However, most common spaces are still functional by using portable equipment and supplies.
- Nursing Station. Some nursing stations have wiring for computer and telephone hook-ups. While we cannot assume that these lines are live, they all have modern wiring technology, giving us confidence to suggest that Internet and voice service could quickly be turned on. While not part of our initial recommendations, portable laptops may be considered as part of the equipment procurement plan. A nursing station at a shuttered hospital would need telephones, computers (or a paper registration and records system), office supplies, and enough chairs for the staff on duty. We do not intend to include telephones in the patient rooms, as that is a luxury that is not essential during an emergency period.
- Utility Closets. At a minimum, at least three closets per patient floor are needed: one each for clean and dirty linen and one for equipment and supplies. While these closets may exist at a shuttered hospital, they may have been stripped of any shelving, carts, or hooks for organizing equipment and supplies. Therefore, it may be necessary to supply carts and portable shelving units for each closet.
- Clean and Soiled Linen. The hospital would need one large rolling Rubbermaid type cart to deliver clean linens to each floor, and four to five five-shelf carts (dimensions: 6 feet high by 6 feet wide x 2 feet deep) with chrome shelves (rust-proof) to store the clean linens. An identical Rubbermaid cart and 5 linen hampers would be needed for soiled linen. If closets are not available to store linens, the carts can be placed in central hallways for easy access.
Both hospitals we inspected currently have an ongoing outpatient medical mission; current occupants include walk-in clinics, a visiting nurse association office, a dialysis clinic, and hospital administrative offices such as accounts receivable. Therefore, it is possible that a limited amount of disposable and consumable medical supplies will be in place. Most of what is available (bandages, tongue depressors, blood pressure monitors, scales, cotton swabs, sterilizing alcohol, and other basic supplies and equipment) could be useful in a surge situation but would be in short supply and would be used up in the first hours of operation.
3.1.3 Ancillary Medical Service Areas
- Laboratories. In all probability, former laboratory space will be lacking modern equipment, will be used as storage for supplies or paperwork, and will not be operational without significant time and effort. It will be easier to employ bedside point of care testing for common tests and a courier service and contract with private laboratory testing companies or other hospitals for more advanced tests than to resurrect a moribund laboratory. We assume that specimens will be obtained in the facility and sent out for virtually all laboratory tests. While many currently operating hospitals do send out their lab work, under certain emergency situations, particularly under Scenario 2, shipment and transportation may be challenging. Bedside point of care lab testing is an option that provides a higher level of patient/caretaker interaction and quicker results. Portable and bedside lab capabilities are usually limited to uncomplicated tests, such as blood glucose tests, blood gas monitoring systems, and whole blood analyzers for cardiac markers, blood clotting tests, basic metabolic panels, and blood counts. It is expected that bedside lab kits will become increasingly sophisticated as technology advances over the coming years. If the hospital elects to use point-of-care lab testing, we recommend procurement of one complete lab kit per patient ward. Depending on specific patient populations and tests performed, consumable lab material may need to be reordered.
- Pharmacy. We examined the customary stock held by functioning community hospitals, which is ordinarily more than 4,000 different drugs and biologicals. Since the surge facility will not be a full-service hospital (no operating room, ICU, emergency department, or active oncology), it will not need the entire diverse formulary one finds in a community hospital. With advice from clinical experts, we have developed a preliminary 'basic' pharmacy list, which would need to be stocked at the surge facility once it opens, and which would be supplemented as needed. Go to Appendix B. One option might be to have a nearby tertiary hospital serve as the main pharmacy, with the surge facility as a 'satellite' pharmacy. The formulary does not assume delivery of Strategic National Stockpile (SNS) inventory.
3.1.4 Support Service Areas
- Central Supply Area. Since a large amount of equipment and supplies will need to be received, inventoried, stored, and dispensed, a central supply area would be helpful. A large open area, such as an atrium or auditorium could serve as central supply.
- Laundry. Both hospitals have laundry hook-ups in utility closets in general patient ward areas, but no laundry equipment exists. It would be more feasible to use vendors for laundry.
- Biohazard and Waste Disposal. Even when not treating contagious patients, it is important to properly dispose of biohazardous waste such as needles. To handle hazardous waste, six to seven large trash cans, a trash can or bag in every patient room, four to five biohazard containers per floor, a hazardous materials container remover (one to two large red carts similar to large laundry carts), and a hazardous materials outside trailer provided by the State health authorities would be needed.
- Receiving. The loading dock itself would require one pallet jack, three flatbed delivery carts for unloading supplies, and bins to hold bulk items such as patient sundries.
- Water Supply. Most shuttered facilities will have municipal water with holding tanks, but one cannot also assume that the tanks will be filled to adequate capacity to supply the 5 gallons per patient per day22 that would be required. In an emergency, the facility could make arrangements with the local government and health department for additional water or could temporarily use bottled water from a commercial supplier.
- Cafeteria. Both hospitals have operating cafeterias (Chapter 2). Both facilities appeared to have most operating equipment necessary to supply food to a full hospital, although some of the equipment was turned off and may need a thorough cleaning and re-certification. Since patient-specific dietary needs will dictate specific food orders, the hospital should be prepared with fairly generic staples based on the scenario for the first 3 days, and order as necessary thereafter. Appendix A shows the significant volume of supplies that a kitchen will use over the course of a month.
3.1.5 Miscellaneous Areas
- Visitors/Waiting/Lobby Area. If visitors will be accommodated, some minimal furniture will be needed. Furniture would also be needed for staff doing intake/admitting. Areas of former hospitals that served an administrative purpose, such as patient intake, may still have furniture and supplies. Many shuttered facilities are used as administrative space (medical records, billing, etc.) for the entities that own them, and may still contain some office furniture, computers, and even photocopier and fax machines.
- Other. Both Boston area hospitals continue to operate with medical missions, and both have basic outpatient radiology rooms still in use, although neither has a workable CT scanner, MRI, ultrasound, or other more sophisticated radiology equipment.
3.1.6 Special Equipment for Infectious Disease Scenarios
As there are multiple possible infectious disease scenarios, a significant amount of personal protective equipment may be required to safeguard the health of hospital personnel. Very little, if any, of this material is currently available in recently closed hospitals appropriate for re-opening in the case of surge needs.
Level D personal protective equipment, defined by the Department of Labor as coveralls or other work clothes, boots, and gloves, is included in the list necessary supplies for any surge scenario. Positive or negative respirators may be needed in certain infectious disease scenarios (Level C personal protective equipment as defined by the Department of Labor), and in such a scenario these materials would need to be procured.
Level B protection is used in situations in which vapor harm to the skin is lessened, but respiratory protection is still required. As defined by the Department of Labor, Level A equipment provides maximal protection against liquid and vapor. Under very specific and rare circumstances, Level A personal protection equipment may be needed. The equipment includes self-contained breathing apparatus and chemical resistant clothing, boots and gloves. These materials are more likely to be available from local, State, and Federal emergency planners—and planners should consider accordingly when preparing a surge facility equipment plan.
Go to Table 3 for a summary of expected supplies and equipment at partially shuttered hospitals.
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3.2 Procuring Equipment, Supplies, and Associated Support
Based on inspections of the two former hospitals in Boston, it appears that most such facilities will have little if any usable medical equipment or supplies on hand; equipment will have been transferred elsewhere, sold, or discarded as obsolete. These deficits should not be a stumbling block, however, since the vast majority of equipment and supplies are both portable and obtainable.
The sections below address the ability to procure equipment and supplies for a shuttered hospital for use during a surge event. Staff to deliver, maintain, and operate the equipment will also be needed. Most hospitals divide procurement and associated services across several different departments. This section is organized around the following common specialty areas of materials management:
- Fixed and Disposable Supplies and Equipment.
- Biomedical Equipment.
- Food and Food Service.
- Environmental Engineering.
The scope, magnitude, and detail necessary to supply a hospital properly cannot be underestimated. Fortunately, nearly all the equipment and supply procurement and associated services in the following sections can be outsourced to any one (or a combination) of a number of national hospital service and vendor supply firms and such organizations could be valuable partners. In each of the following sections, we outline the service capabilities, specific considerations, and specific associated challenges of such organizations.
General Planning Responsibilities
With the advice of hospital materials management experts and service vendors, we have concluded that it would be essentially impossible to open a closed facility in 3 to 7 days in a city experiencing massive casualties without previously created contracts, service agreements, and purchase orders. Processes and responsibilities to maintain adequate supplies and service levels must be in place before the surge facility needs to be opened, and these plans should be reviewed yearly to keep them up-to-date. The team responsible for equipment and supplies might consider including equipment and supply company representatives in the inspection and planning stages for the surge facility.
If the team decides to negotiate an executable contract—which would be signed only when a mass casualty event occurs—such a plan and its associated executable contracts should be reviewed regularly—perhaps once a year—and modified based on changes in disaster risk and facility or vendor status.
Suppliers and Contracts
Hospitals buy supplies and equipment either from wholesalers, distributors, or manufacturers. In general, the medical-surgical equipment and supplies market is more fragmented than the pharmaceutical market, with a larger number of vendors, more products, less customer expertise, and less standardization.23 In the health-care sector, one-stop shopping for pharmaceuticals is more common than for other supplies because of greater consolidation within the pharmaceutical industry.24
Given the myriad equipment and supplies needed by a hospital, more than one person in the hospital is usually involved in purchasing, and this can contribute to the fragmented nature of supplies and equipment procurement. The use of multiple vendors could make procuring equipment and supplies for a surge facility difficult and confusing, particularly for biomedical and disposable supplies.
Large suppliers have existing emergency plans that have proven valuable in emergency situations. The "Disaster Contingency Plan" from one distributor provides a snapshot of advance preparations that hospitals and their distributors can establish to keep operations flowing smoothly during an emergency:
- Prepare an emergency critical items list.
- Develop an updated order form (paper as well as electronic copies).
- Maximize standardization and utilization efforts between the vendors and hospital.
- Consolidate distributors and manufacturers.
- Make sure accounts payable is up to date.
- Keep accounts clean, and resolve any discrepancies or disputes.
- Establish prepayment if necessary.25
In an emergency, equipment and supply vendors will most likely assist those hospitals with which they have preexisting procurement arrangements and might be unable to suddenly support the needs of a surge facility with which they have no prior agreements or arrangements. Thus it will be essential to establish such agreements and arrangements in advance.
Large suppliers or distributors may be reluctant to enter into a new contract with a hospital or local health unit solely to operate a surge facility. If the surge facility is being overseen and operated by a hospital that has a current vendor contract, supplies and equipment could be procured through that contract. The materials management director at Brigham and Women's Hospital advises that even if BWH was the sponsoring/oversight hospital and used its own established contract in this way to meet the needs of the surge facility, it would be necessary to have signed contracts and a complete understanding from each vendor as to the expectations and need. The vendor would need to add staff and truck routes, add to food orders, and so on. Without a sponsoring hospital that already had contracts and ordering procedures in place, it night not be possible for a vendor to simply implement full support for a surge facility. When we discussed possibilities with vendors, however, we were advised that an advance contract of some sort could probably be worked out, so that the vendors would be prepared to support most (if not all) of the needs of a surge facility with a 3-7 day notice.
Every hospital in the mass casualty zone would need emergency supplies, and one might anticipate stockpiling or "hoarding" to begin as the magnitude of the event becomes clear. Fortunately, supply shortages due to hoarding are unlikely because the large equipment and supply vendors each maintain many warehouse locations—often many in a single metropolitan area—and because hospitals lack the inventory space to stockpile more than a few days worth of supplies. It might be useful, however, for area hospitals in any community to discuss the supply and equipment procurement process for a potential surge event in advance in order to avoid stockpiling and misunderstandings.
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