Medical Consumables During a COVID-19 Surge

Medical consumables are necessary supplies for health systems to provide care within a hospital or surgical environment. Consumables include gloves, gowns, masks, syringes, needles, sutures, staples, IV tubing, catheters, and adhesives for wound dressing, in addition to other tools needed by doctors and nurses to provide care. During a sustained patient surge in infectious disease, hospitals will need a strategy to manage their medical consumables, and having adequate resources will require adjustments along the hospital supply chain. China and Italy have experienced high utilization of medical consumables, disruption of the supply chain, and intermittent breakdown in the ability to deliver care. In anticipation of a surge in COVID-19 patients, hospitals should engage in early discussions regarding the use of consumables, and the following strategy could be considered:

Engage Central Supply early. Central Supply must work with providers to identify consumable shortages and must define emergency plans for requesting medical supplies during disruptions to the supply chain. Phase 1 could include the following steps:

1. Increase hospital Periodic Automatic Replacement (PAR) levels. A PAR level system determines the minimum level of inventory necessary to be on hand for a specific period and requires automatic replenishment if the level of inventory falls below that level. Internally, adjustments in the hospital PAR levels will be needed as staff will be asking for more supplies.
   1. Resource Allocation. Look at the level of current resource utilization by examining existing internal data. Central Supply should see what the current level of use of consumables is, what the surplus has been in the past year, and then change PAR levels accordingly. Central Supply should evaluate each department’s use of consumables; identify high-use, high-turnover consumables; and anticipate different costs for these items during a sustained surge.
      1. Commonly needed supplies must be anticipated, and hospitals should consider caching or increasing levels of those supplies (space and shelf-life permitting). An example would be to stockpile nonmedical products that are not available from suppliers in large quantities (e.g., hazmat suits).
      2. Change the ordering numbers based on current and projected resource utilization.
      3. In the week before a surge happens, the hospital should consider shifting surplus supplies from storage in surplus areas to the areas that will need them.

2. Have more frequent and earlier notification of suppliers, with faster internal closed-loop communication about high-use supplies between Central Supply and service departments.
   1. Hospitals should be ready for anticipated shortages because of supply chain interruptions.
   2. It will be impossible to have the full resource supply chain picture during a surge, but hospitals can prepare by identifying stock versus non-stock items and identifying which non-stock items may slow delivery of stocked consumables.
   3. Identify alternative mechanisms for ordering, receiving and tracking supplies, such as seeking out alternate suppliers.
   4. Identify multiple delivery locations if multiple health care facilities require extra medical supplies simultaneously.
   5. The United States has a Strategic National Stockpile: Consider accessing for supplies.

3. Suspend elective surgery cases and transition outpatient visits as much as possible to telemedicine visits to conserve necessary supplies and resources.
   1. Suspending elective surgery cases will save endotracheal tubes and other consumables for COVID-19 surge patients and for patients with emergent non–COVID-19 issues.
4. Define medical consumable rationing plans in the event that medical consumables run out during a surge.
   1. Define thresholds (e.g., levels of medical supplies) needed prior to activating emergency plans.
   2. Define triggers and thresholds for changes to standards of care. Crisis standards should be a last resort, but planning for these conditions is important and can affect supply orders.
   3. Work with key stakeholders (including ethics committees) to establish memoranda of understanding (MoU) or memoranda of agreement (MoA) to manage stakeholders’ expectations during an emergency.

2. Response Phase

Hospitals will need to be able to provide an optimal level of care for as long as it can based on planning during Phase 1. This requires forecasting needs (e.g., using epidemiological data) and altering supply chain practices as needed to support a surge in demand. Rationing, substitution, adaptation and reallocation may be required if the Phase 1 effort was not sufficient in terms of stockpiling and finding alternative suppliers.

2. Considerations in this phase include:
   1. conserving and using substitute medical and nonmedical supplies;
   2. using substitution, consideration, adaptation, re-use and/or reallocation of supplies (if possible);
   3. looking for options to obtaining resources from parent or “sister” facilities;
   4. planning for workforce shortages and obtain alternative supply, warehouse and distribution channels;
   5. maintaining partnerships across all relevant supply chains; and
   6. coordinating with public sector responders.
   8. Consider rationing high-use items:
      1. To conserve personal protective equipment (PPE):
         1. Refer to the FDA’s “Surgical Mask and Gown Conservation Strategies – Letter to Healthcare Providers”
         2. Consider limiting the number of providers with direct exposure to COVID-19 patients.
         3. Consider potentially keeping on PPE for a shift if providing care in-unit with only COVID-19–positive patients.
         4. To reduce in-and-out PPE use, for any patient with suspected or confirmed COVID-19 who needs intubation, consider placing a central line and an arterial line at the same time in order to make it easier for nurses and respiratory therapists to get access and arterial blood gases. Many of these COVID-19-positive patients who get intubated become hypotensive and require pressors.
            1. Consider putting central lines in the left internal jugular vein. Doing so may allow utilization of 20-cm central line kits and reserve the right internal jugular vein for dialysis lines.
         5. Clinical care teams should not open supplies in the ICU until they are actually ready to use them.
      2. Consider invoking “crisis standards of care” if resources are direly low.
      3. For lab draws, adhere to “Choosing Wisely Guidelines” to save resources. Daily labs should answer specific clinical questions for the clinical care team.

3. Follow-up and Recovery Phase

In the recovery phase, providers can return to normal operations, including normal supply chain strategies. This phase will require dissemination of supply chain disruption situation reports to relevant stakeholders; coordination with distributors and others on product substitutions and transitions (e.g., going back to a primary product if the coronavirus event caused a shortage); and working with distributors to resume normal operations, distribution volumes and schedules.

1. Quarantine existing COVID-19 patients, and limit contact and unnecessary exposure to COVID-19 patients.
   1. For a period of time, continue dedicated OR and hospital rooms to handle patients with active COVID-19.
2. Based on lessons learned, have a plan in place for management of medical consumables for future pandemics.
   1. Stockpiles and rationing should be present in future plans.

Suggested Resources

1. Strategic National Stockpile. www.phe.gov/ about/ sns/ Pages/ default.aspx.
2. Surgical Mask and Gown Conservation Strategies – Letter to Healthcare Providers. www.fda.gov/ medical-devices/ letters-health-care-providers/ surgical-mask-and-gown-conservation-strategies-letter-healthcare-providers?utm_campaign=3-12-2020%20-%20Surgical%20Mask&utm_medium=email&utm_source=Eloqua.
3. Choosing Wisely Guidelines. www.choosingwisely.org/ clinician-lists/ critical-care-societies-collaborative-regular-diagnostic-tests/ .
4. U.S. Department of Health and Human Services. Assistant Secretary for Preparedness and Response. Goal 4: Enhancing the Medical Countermeasures Enterprise. www.phe.gov/ about/ aspr/ Pages/ innovative-mrc.aspx
5. TRACIE Healthcare Information Gateway (2019). Partnering with the Healthcare Supply Chain During Disasters. https://files.asprtracie.hhs.gov/ documents/ aspr-tracie-partnering-with-the-healthcare-supply-chain-during-disasters.pdf
6. https://www.ncbi.nlm.nih.gov/ books/ NBK201071/ #_NBK201071_pubdet_