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 (continued)
3.2.1 Fixed and Disposable Supplies and Equipment Procurement
Disposable equipment and supplies are generally delivered to hospitals daily. Although the disposable equipment and supplies market is fairly fragmented, with many companies supplying each hospital, usually one supplier provides most materials for major health-care providers.
Approximately 10% of the vendors supply 90% of the equipment and supplies.26 Since most major vendors have warehouses and nationwide distribution networks, hospitals that have existing relationships with large distributors should not have difficulty obtaining additional supplies for a surge facility within 1 week. For example, one vendor delivers five trucks of supplies to Brigham and Women's Hospital every day. When the hospital requests something new or additional, it is generally delivered within 5 hours.
For larger equipment of which supplies may be more limited, very large national suppliers have a presence in virtually every city. For example, it is unlikely that any firm warehouses more than 200 hospital beds in the Boston area. However, a nationwide supplier has a 52% nationwide market share27 and could import beds from warehouses around the country if the Boston area had a shortage; those beds would arrive during the 3-7 days preparation for opening the surge facility. Other specific supplies and equipment, such as IV pumps and defibrillators, might not be delivered in sufficient volume during this short timeframe, however. In this case, if the facility is being operated/overseen by a major hospital, that hospital could share its own inventory on a short-term basis.28 After the surge facility is set up and initially supplied, vendors could probably replenish it at a more customary pace. If there were no sponsoring/oversight hospital involved, it would be harder to meet all the short-term equipment and supply needs and open the surge facility within 3-7 days of an emergency. Again, however, vendors advised that with advance planning, faster and more complete support would be possible.
In a surge situation, if a sponsoring hospital did not have access to the customary information management tools that are used for supply ordering, such as handheld communication devices (PDAs) or Internet access, the hospital inventory management system could adapt to a process involving the manual taking of inventory for each hospital department followed by off-site data entry and electronic order submission to the major suppliers and equipment vendors. More specifically, in case there is no electronic communication, generic lists of supplies for specific hospital departments such as the medical-surgical units could be used in paper form by the hospital staff at the surge facility. Even large and sophisticated hospitals occasionally use such forms, particularly during the holiday season, and suppliers are accustomed to filling orders they receive in paper format (although there may be some delays).
Additional staff will be required at the surge facility to ensure that procurement, delivery, and distribution run smoothly. Experts we consulted suggest that perhaps 4-5 full-time employees are needed to staff the materials management department, including two skilled workers to run an electronic inventory management system if planners decide to implement one at the surge facility. The remaining three employees are non-skilled, but must have good organizational abilities, since supplies and equipment will probably be arriving at uneven intervals, sometimes without documentation, and accurate record keeping is essential.
Given the magnitude of effort required to maintain adequate inventory and the efficiencies that can be realized by tapping into vendor electronic ordering systems, many hospitals opt for an electronic data entry, inventory tracking, ordering, and reporting tool. This is called an Enterprise Reporting Portal System. These systems are fairly expensive, and complicated to deploy. If surge facility planners choose to contract with an established logistics provider (or sponsoring/oversight hospital), they may be able to tap into an existing system remotely. If not, it is recommended that all processes be paper-based as the effort to implement a system would not be warranted for the period of time the facility would use the system.
3.2.2 Biomedical Equipment Procurement
Biomedical equipment and supplies differ from general capital goods such as furniture or disposable supplies such as bandages and can require major financial outlays. In Scenario 1, the biomedical materials necessary for continued care would be very similar to those found in any community hospital's step-down unit. Within each unit one is likely to need the following biomedical equipment:
- SP02 spot testing capability.
- ECG equipment.
- Noninvasive blood pressure monitors.
- Automatic external defibrillators (airport grade).
The automatic external defibrillator is designed for use by an average individual. Medical specialists recommend more advanced code cart and defibrillators be available in the hospital within a 3-minute distance from all patients. Patients who appear likely to need such care will not be discharged from the primary care facility. However, even in step-down units, unforeseen problems do arise, and resuscitation may be necessary prior to being transported back to the primary care facility for more intensive care. Depending on the types of patients being discharged to the surge facility, the facility may require more advanced equipment such as cardiac monitoring and EKG tools. Under Scenario 2, which would include some type of infectious disease, a larger number of ventilators may be necessary for optimal patient care.
The biomedical equipment member of the core team should begin planning for biomedical needs far in advance of any potential surge needs. Loaned or leased equipment may be available from other local hospitals. The first step is to inventory current excess biomedical capacity at any volunteering or participating hospitals within several hours drive time to the surge facility. The ability of hospitals to "share" such equipment may depend on the situation at the time of the mass casualty event. If a significant outbreak of the flu should cause a declaration of surge need, for example, much of the excess ventilation capacity at existing local hospitals will be in use and not available for redeployment at the surge facility. If equipment is offered from other hospitals, it must all have appropriate documentation and a current inspection/certification if appropriate. Equipment also must meet current safety standards and be tested to the manufacturer's specifications.
Given the complexity and cost of biomedical equipment, simply identifying excess inventory is not enough. Planners must assess appropriateness of available equipment, ease of use, similarity with other tools that staff are already familiar with (to reduce training costs), and maintenance costs/expertise requirements. The planning team must weigh the ongoing maintenance costs of existing equipment with potentially cheaper costs and reduced labor burden associated with newer equipment.
The planning team will almost certainly need to supplement the excess equipment available from other currently operating facilities. The biomedical equipment listed above is expensive but does not include some of the imaging, monitoring, or nuclear medicine products that have price points in the millions. If the planning team is considering providing these medical services at a surge facility (which we do not recommend), budget allocations and additional planning could be substantial. To investigate further the possibilities for procuring this more sophisticated and costly equipment, planners should:
- Investigate the feasibility of outsourcing to a biomedical equipment service provider.
- Determine technical specifications: biomedical equipment can be complex and require significant training to operate. To reduce training costs, planners may wish to standardize equipment across one or two vendors, regardless of cost considerations.
- Upon determination of a need, quotes could be sought in advance from a select group of vendors and providers.
- Determine operating and training costs, including the cost of ancillary supplies.
- Determine appropriate procurement strategies: Planners could elect to buy, rent, lease, or finance new or used equipment.
- Create contracting vehicles/purchase orders that can be executed in an emergency.
Vendors offer a host of financing plans, including alternatives to outright purchase, to help hospitals acquire the latest equipment. These alternatives should be considered carefully, particularly given the limited time in which the surge facility will be open (30 days to 3 months). The following are among the procurement strategies to be considered.
- Used Equipment. Planners might also investigate acquisition of used biomedical equipment. Given the high value of biomedical equipment and the extreme competitive pressure hospitals feel to maintain the most advanced biomedical equipment, many pieces are taken out of service well before their useful life has ended. This equipment can be purchased outright, or potentially procured through a variety of alternative financing methods. For example, one of the largest medical equipment manufacturers claims that it can save hospitals up to 30% in biomedical equipment costs through its equipment refurbishing programs.
- Equipment Rental. Vendors understand that there are situations in which hospitals must temporarily increase their capacity to provide services. Unfortunately, only limited biomedical equipment—primarily imaging equipment—is available under this financing method. Vendors may make equipment available on a basis as short as one week. Given that vendors have equipment in stock across the country, it is reasonable to assume that they can be delivered to the health-care facility quickly.
- Lease. Leasing has become a popular financing alternative for high value capital goods in many industries, including health care. Many vendors provide flexible lease terms for new or used equipment. However, unlike equipment rentals, lease time frames are usually years, not weeks or months. For example, one vendor's capital lease program provides lease terms from 36 months to 84 months. Leasing is, therefore, a less viable option than renting.
- Lease with Service. Biomedical equipment may have parts and components that need maintenance, repair, and replacement periodically. Therefore, most vendors provide a lease option that includes a service option. This option is particularly attractive given the limited skills of staff at the surge facility and the emergency status of all other local hospitals (requiring their own staff's full-time attention) during the mass casualty event.
- Purchase and Purchase Financing. In exploring options from vendors, a variety of purchasing options are available, including off-balance sheet financing (a modified lease), tax-exempt purchase financing and purchasing, it appears few of these options are appropriate in a situation in which their useful life will be shorter than 3 months. Most goods are depreciated over 3 to 4 years. If an operational entity were to purchase such goods, a considerable effort would need to be undertaken during ramp down to off-load the equipment on the used biomedical equipment market. This process, called asset recovery, is a service provided by outsourced service providers.
Depending on the type of equipment, whether it is new or used, and the financial arrangement (renting versus buying), the equipment could arrive at the surge facility within several hours, days, or even weeks. Ordering some specialized biomedical equipment directly from suppliers may take several weeks, making it difficult to open a surge facility within 3-7 days.
Fortunately, the materials specified in this plan are not specialty items nor extraordinarily complex, and all were available for rental at a major service provider we contacted. Therefore, much of the equipment can be delivered within a day or two to the surge facility, once a contract as been executed. Some equipment will then need to be set up by trained biomedical equipment support staff. If outsourcing with a service vendor is used, the trained staff will be part of the service. Getting all biomedical equipment set up and ready is expected to take up to 1 week. This in turn implies that contracts must be pre-drawn and executable within days, so that equipment is ready when patients begin to arrive at the surge facility.
Equipment may need to be serviced during operation. All the vendors support their own equipment with service agreements. They all stock parts and supplies that can be delivered quickly for any machinery. Biomedical maintenance can be a major expense. Outsourced biomedical equipment services provide support and maintenance on their rented products.
3.2.3 Pharmaceutical Procurement
The procurement of pharmaceuticals for the surge facility poses more challenges than does the procurement of disposable equipment and supplies, food service, or environmental engineering supplies and equipment because of the legal licensing requirements for the prescription, storage, and preparation of pharmaceuticals. Conversations with pharmacy directors indicate that the surge facility would need to have up-to-date licenses to legally store pharmaceuticals, especially for controlled substances. The necessary licenses would include:
- Board of Pharmacy.
- Drug Enforcement Administration number.
- Department of Public Health license.
In addition, jurisdiction over the writing of medical orders at the surge facility would have to be addressed, because traditionally orders need to be written by a physician at the facility itself.
Like all other areas of procurement discussed in this section, if the facility does not have preexisting contracts with the pharmaceutical suppliers or prearranged purchase orders, ordering pharmaceuticals could be difficult. One solution is that the surge facility could receive pharmaceutical supplies from a sponsoring hospital facility's pharmaceutical vendor, using an arrangement similar to that for purchasing disposable equipment and supplies from major vendors. Alternatively, an advance contract with major pharmaceutical distributors could be established much like the model discussed for other services and implemented only in an emergency. With an agreement executable on day 1 of surge need, a preorder of disaster supplies needed for the surge facility would speed the acquisition of pharmaceuticals.
Because of the legal issues surrounding prescribing pharmaceuticals, a physician authorizing the prescriptions would have to be determined in advance. In addition, all medication stored at the surge facility would have to be monitored by a pharmacist, ensuring that the available space at the surge facility could adequately secure and store the medications in accordance with the legal requirements for doing so.29
The pharmacy space at the surge facility would need adequate refrigeration, freezers, sterile prep areas, and a locked area for narcotics. Dispensing would need to be carried out without the use of electronic medication dispensing machines.
3.2.4 Food and Food Service Procurement
Providing surge facility patients and staff with adequate food services will be a critical part of the surge facility's operational success. Issues to consider include adherence to Department of Public Health regulations and outsourcing food service preparation and delivery vs. an in-house kitchen.
Since clearance to serve food could occur within a day,30 the biggest decision for planners will be whether to contract with a food service company for food preparation and service. A diversified services company or a food service firm that specializes in hospitals is a reasonable option. A national or local firm might be able to provide the food service staff, dietary consulting, and food to meet all the related needs for the surge facility. Regardless of the source of the staff, food preparation workers must possess a serve-safe certification from the Food and Drug Administration known as Hazard Analysis and Critical Control Point. Vendors' staff will all be correctly certified.
Planners can estimate staffing and food service needs by gathering information from competing vendors well in advance of any emergency, without actually proceeding immediately to a contract. The food service industry uses benchmarks to calculate the quantity of food needed to serve patients and staff members. The standard measurement is meals per productive hour. In order to calculate the number of meals needed for the surge facility, planners could ask a national company to compare the surge facility to other hospitals of similar size based on the meals-per-productive-hour standard. The company performing the comparison would use a market basket analysis approach to standardize the reporting across the country. Since the surge facility will have no preexisting data about food consumption, useful information to benchmark the calculation would include: type and breadth of services offered, size of the staff, number and type of patients, and type of patient meal delivery (cold or hot food, delivered to patient rooms or served in a centralized location such as the cafeteria).
Most nationwide vendors with whom we spoke were eager to give estimates about equipment, supplies, and staffing, and it is conceivable that opening a dialogue with vendors prior to the surge event could be useful in gauging supplies and equipment needs for any segment of the surge facility. These companies do not, however, have "on call" staff available for emergency response, and it may be difficult for them to respond with only a 3-7 day notice. In fact, many food service vendors do not even have emergency expansion plans with the hospitals they currently serve. Existing hospitals instead rely on the predictability of food service needs: the frequency of food delivery at a hospital (up to three times per week for food vendors, daily from smaller food vendors and paper products vendors) and the existence of standing purchase orders with vendors eliminate the need for an emergency plan.31 In some cases, cold food may be prepared off-site and assembled, perhaps warmed, and served when it is delivered to the surge facility.
In terms of equipment and supplies for food service, room service delivery will require more staff and additional equipment and supplies, such as delivery carts and dishes rather than disposable plates and cups. Planners must decide whether hot or cold food will be served and whether the food will be prepared on-site or prepared off-site (catered) and delivered to the surge facility to be reheated. Each of these decisions affects the staffing level and the type and quantity of food service supplies needed for the surge facility.
3.2.5 Environmental Engineering—Staff, Equipment, and Supplies
With hazardous and infectious materials and exceptionally strict occupational and facility cleanliness standards for patient safety, hospital environmental engineering is a science in itself. The several hundred page Guidelines for Environmental Infection Control in Health Care Facilities is a Centers for Disease Control and Prevention document specifically aimed at environmental controls that decrease patient illness from common hospital infections at all phases of care. The environmental engineering tasks outlined in this section require some procurement of supplies and equipment. Staff and/or contractors will be needed for the following functions:
- Cleaning the surge facility to bring it to sanitary standards before admitting patients.
- Maintaining sanitary water, air, and other environment throughout the course of surge facility operation.
- Laundering uniforms, bedding, and other cloth goods.
- Disposing of hazardous materials under strict Environmental Protection Agency (EPA) guidelines.
- Disposing of medical and other waste (both solid and liquid).
In addition to staffing, the environmental services department will need to purchase or procure the following equipment:
- EPA certified detergents, disinfectants, and chemical sterilants (including tuberculoids and germicides).
- Disposable mops, cleaning cloths, sponges, and other cleaning apparatus.
- Floor buffer/polisher and carpet shampooer.
- Sweeping apparatus (Note: recommendations from EPA suggest minimizing the use of such tools as they may disturb and distribute dust into the air—use wet mops whenever possible).
- Industrial strength vacuum with HEPA filter (and replacement).
- Containers and labels for hazardous waste.
- General waste containers.
- Cleaning carts and cleaning material storage shelving.
During the planning phase, environmental engineers should accompany the team on the assessment of the selected surge facility. They should take note of the facility's current condition from a sanitation perspective. If pests or rodents are noted, planners may wish to fumigate the facility using appropriate hospital procedures prior to any declaration of surge need. Patient areas must be free of chemical residue; therefore, special precautions, specific techniques, and time must be observed. Proactive pest control will allow the hospital to open without delay. Planners will also need to consider infrastructure options for waste disposal and removal. Many hospitals have preexisting executable contracts with hazard remediation cleaners who would be appropriate to clean a facility that has had limited upkeep over several years and prepare it for patient care. During the 3-7 days prior to opening the surge facility, environmental staff will transition from a hazard remediation cleaning standard to an upkeep phase. It may be appropriate at this point to transition from cleaning contractors to other service vendors or staff familiar with general hospital sanitary operations.
For a facility of 250-300 patients, the environmental engineering staff will likely include up to 30 FTEs and 5 managers to cover all the shifts. These staff and managers should be familiar with U.S. Code pertaining to hospital cleanliness standards, OSHA regulations, Food and Drug Administration guidelines and regulations, EPA guidelines, and general best practices.
Planners may choose to pre-establish executable contracts for disaster remediation and pest control, general waste management, hazardous waste disposal, and laundry services.
Many organizations provide these services and, unlike most other contractors discussed here, they tend to be local. Waste disposal is almost always outsourced, and, in the absence of on-site laundry machines, it would be wise to outsource laundry services as well.
An environmental crew should be the first staff in the facility as soon as a department of public health has authorized its preparation for use. This disaster remediation team, noting the specific instructions based on the facility assessment, will be responsible for cleaning a facility that has not had a medical grade cleaning in several years—and bringing it to sanitary standards appropriate for patients. Cleaners will maintain the facility, prepare and clean older equipment, and keep general orderliness and cleanliness while many people enter and exit the facility during the preparation period.
Once patients are admitted and the surge facility is operating, environmental services staff will take on a role identical to that at any traditional hospital. Under Scenario 2, their role will require additional germicidal and disinfectant tools. In either scenario, the operating organization should provide both in-house staff and contractors with an expected practices list that includes text on the following items:
- General cleaning of surfaces and walls within patient areas, including wet/dry methods, timing to repetition, appropriate materials, and detergents/disinfectants.
- Mitigation of the use of mists, aerosols, and fumigants in patient areas and cleaning methods that disturb and distribute dust into patient areas.
- Cleaning areas with immunocompromised patients.
- Cleaning spills of bodily fluids.
- Special care of carpeting and other cloth furnishings.
- Special pathogen considerations.
As patients are gradually discharged and the surge facility is prepared for closure, cleaning staff can also be reduced. A core staff will remain to shut down the facility and return it to a safe shuttered state, taking special precautions to maintain standards to ease possible reopening in the future.
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