Best Practices for Healthcare Facility and Regional Stockpile Maintenance and Sustainment: A Literature Review

Abstract

Preparing for mass casualty incidents is essential to maximizing community resilience. Many US-based organizations and regions have developed stockpiles of medications, supplies, and equipment for mass casualty incident preparedness. The Centers for Disease Control and Prevention (CDC) assess and manage federally stockpiled materials, but hospitals, healthcare systems, and regional organizations are responsible for maintaining locally owned caches. The CDC has protocols for assessing and managing the Strategic National Stockpile, but no such guidance exists for local or geographical/regional stockpiles. This article outlines best practices and recommendations identified in the literature related to maintaining and sustaining a local or regional stockpile. Recommendations are provided on the timing and procedures for assessing, inventorying, storing, managing, tracking, and deploying materials stockpiled on site, in a trailer, or in a warehouse. In addition, alternative approaches for maintaining a local or regional cache, such as vendor- or user-managed inventory methods, are addressed. Management of local or regional caches requires an investment in infrastructure and training but is necessary to ensure the integrity of stockpiled medication and supplies and to enable rapid and appropriate activation during a mass casualty incident. Hospitals, healthcare systems, businesses, academic institutions, public health agencies, organizations, and regions can use the recommendations here to develop protocols or policies to properly manage their existing stockpiles, which should minimize costs related to damaged supplies.

The CDC has protocols for assessing and managing the Strategic National Stockpile, but no such guidance exists for local or regional stockpiles. This article outlines best practices and recommendations identified in the literature related to maintaining and sustaining a local or regional stockpile. Recommendations are provided on the timing and procedures for assessing, inventorying, storing, managing, tracking, and deploying materials stockpiled on site, in a trailer, or in a warehouse.

Mass casualty incidents, especially those involving biological events, such as bioterrorism attacks, outbreaks of an emerging pathogen, or a pandemic, could quickly overwhelm medical and public health systems and result in supply and medication shortages.^1-3 For example, more than $1 million was spent on personal protective equipment (PPE) supplies during the first weeks of Toronto's response to the outbreak of severe acute respiratory syndrome Coronavirus (SARS Co-V).¹ In the United States, many hospitals reported running out of respirators early in the response to the 2009 H1N1 influenza pandemic.⁴ During that same pandemic, hospitals in Mexico had a surge of patients requiring mechanical ventilation that exceeded their intensive care unit capacity.⁵ In the United States, on the federal level, the Centers for Disease Control and Prevention (CDC) has established the Strategic National Stockpile (SNS) to aid jurisdictions in responding to mass casualty incidents. However, the SNS is intended to supplement local resources; there are not sufficient supplies and equipment in the SNS to aid the entire nation if a mass casualty incident occurs.^2,6 Healthcare facilities need to have access to medical supplies during a mass casualty incident to ensure an optimal response.

To plan for events resulting in limited resources, many strategies have been employed to increase the response capacity. In many urban areas, a regional approach to building surge capacity has been used; this has been driven by mutual aid agreements, political partnerships, and grant-based federal funding. As an example, the Wisconsin Division of Public Health has developed a statewide cache of PPE called the Hospital PPE Stockpile, which can be accessed by local hospitals through an established memorandum of understanding with their regional hospital emergency preparedness board.⁷ These regional efforts augment the medical surge planning undertaken by individual providers. In cases where traditional medical surge practices prove inadequate, healthcare facilities are likely to deplete their supplies due to minimal local inventories, just-in-time materials management practices, and limitations in supplier production systems, such as just-in-time purchasing and production systems.⁸

For the purposes of this article, the term “region” will refer to geographical jurisdictions that have formed an official disaster planning entity, which could consist of multiple counties within a single state, multiple counties that cross state lines, or even multiple states. Examples of such regions include the Mid-America Regional Council Emergency Rescue (MARCER) in Kansas City, Kansas and Missouri, and the East-West Gateway Council of Governments' St. Louis Area Regional Response System (STARS) in St. Louis, MO. Here the term “organization” will refer to healthcare facilities (such as hospitals), healthcare systems, or other agencies or entities, such as academic institutions or health departments, that may wish to purchase or maintain a stockpile.

Existing recommendations regarding who should develop a stockpile and the contents of such a cache have been found to vary. More organizations and researchers assert that hospitals develop a cache versus suggesting that regions invest in such stockpiles. For example, researchers have asserted that hospitals need to consider stockpiling antimicrobials and other pharmaceuticals, medical equipment, and supplies to be ready to respond to a mass casualty incident,^5,8,9 as pre-event stockpiling increases surge capacity.¹⁰ It has also been suggested that regions consider stockpiling essential supplies prior to an event, so that resources can quickly be deployed after an event occurs.³ Oversight, coordination, and management of regional cache materials is considered an essential component of the larger programmatic approach required of emergency management to address the underlying issue of surge support and resource shortage.¹⁰

The purpose of this article is to address the programmatic considerations of cache program management, to include best practices and guidance related to assessing, inventorying, maintaining, and sustaining a local or regional stockpile. “Best practices” as defined here include recommendations and/or guidance identified through a systematic literature review that can be used by a local or regional organization to develop protocols or policies for managing their cache materials. SNS supplies or assets are federally funded and managed and therefore outside the scope of this article.^11-13 SNS management protocols could be applicable to local or regional disaster planners, but they are not currently available for use in managing these caches. Recommendations related to quality assurance guidelines for the acceptance of donated supplies for international humanitarian aid are also beyond the scope of this article but can be found through the Partnership for Quality Medical Donations.¹⁴

Methods

A literature review was conducted in June through August 2016 using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Healthstar, Psych Info, PubMed, and Medline databases for years 1996 through 2016 by the entire research team. The following terms were used as keyword searches: stockpile, cache, surge capacity, medical countermeasures, medical supplies, medical equipment, integrity, storage, maintenance, assessment, pandemic, and bioterrorism. Only English-language articles in peer-reviewed journals were used. An internet search was also conducted in June through August 2016, using the same search terms as above to identify existing reports or guidelines from response or government organizations, book chapters, industry standards, regulatory documents, and other relevant materials related to stockpile management and/or medical equipment, supplies, or pharmaceutical storage. The snowballing technique was also used to identify sources that were not found through the literature or internet searches.

Lastly, the research team reached out to colleagues working in public health and hospital preparedness and to SNS coordinators, requesting information regarding existing policies, protocols, guidelines, or standards that their organization used to assess their stockpile or cache. All relevant documents identified through these search approaches were included. The authors divided document review and data extraction. The data were collated and evaluated for conflicting recommendations, with the intent of having the team discuss how to address conflicting guidance; however, no contradictory recommendations were found. Next, the primary author drafted the written recommendations related to best practices identified in the literature, which the team then reviewed and edited.

Purchase Decision Making

Multiple agencies, organizations, and researchers have examined and discussed the types and amounts of medication, supplies, and equipment that should be considered when establishing a local or regional stockpile or cache.^{1,3,5,8,10,15-19} Readers may refer to these sources for detailed information; a comprehensive discussion of the types and amounts of medication, supplies, and equipment to be stockpiled is outside the scope of this article. Despite the plethora of recommendations and studies surrounding the types and amounts of medication, supplies, and equipment that should be considered when making stockpile purchasing decisions, there are currently no standards or consensus on exactly what and how much of each type of item should be purchased or maintained.¹⁵ It has been recommended that hospitals consider stockpiling sufficient antimicrobials in preparation for a biological event,²⁰ and states have been directed to stockpile antiviral medications,²¹ but there have been no such guidelines developed for organizations wishing to establish a regional stockpile.¹⁵ Though no official guidelines exist, the after-action report from a tabletop exercise in Spokane, Washington, indicated that, if financially feasible, communities should consider stockpiling antimicrobials and other supplies to ensure the region is self-sufficient for at least 24 hours.²⁰ In addition to antimicrobials, researchers have recommended that hospitals stockpile respiratory protective devices, such as N95 respirators or powered air-purifying respirators (PAPRs)^17,22 and ventilators,³ for a future pandemic. However, no such recommendations have been suggested for regional stockpiles.

The exact contents of a local or regional stockpile will depend on availability of resources and identified need in individual organizations or jurisdictions.^3,16 Purchasing decisions should be multidisciplinary decisions and should incorporate information from local and regional hazard assessments.¹⁰ It is critical that an organization or region make purchasing decisions based on an established goal, such as the Joint Commission standard indicating that hospitals be self-sustaining (meaning having the ability to continue providing medical services) with no outside help for a 96-hour surge.²³ In addition, purchasing decisions must consider how and where the supply/item will be stored. The complexity of this decision process is further compounded through the regional structure by which many procurement decisions are made. While leveraging multiple stakeholders' resources toward a clearly defined goal is logical and reinforced by real-world experiences, the complexities of authority, ownership, and sustainability are compounded.

Because of the high cost of purchasing, maintaining, and resupplying expendable supplies, equipment, and medication for a local or regional stockpile, researchers have recommended that organizations prioritize purchasing decisions based on availability of funding, with the goal of continuously building and maintaining the stockpile.¹⁶ A vital consideration when deciding the types and amounts of medication, supplies, and equipment to stockpile is that the initial purchase is only one component of the overall price of having a cache. Costs are incurred in inventorying, maintaining, and sustaining the supplies once purchased; on providing training to staff on specialized equipment in the cache; and on destruction or disposal of expired or damaged supplies.^13,15,24

Federal funding from the Department of Defense for biosecurity has been dropping in the past few years, though it is projected to remain flat for FY2017.²⁵ However, funding for pandemic and emerging infectious disease preparedness is expected to increase during FY2017, in large part because of an increase in the Department of Health and Human Services' (HHS) investment in these areas.²⁵ However, it is not known exactly how much of this HHS funding will be available for jurisdictions to purchase or maintain regional caches. Historically, federal funding has been available for the purchase of stockpile materials but not for infrastructure costs related to maintaining the cache, such as staff time to monitor, rotate, or replace items, or time for training staff on how to access and use equipment in the stockpile.²⁴ Researchers have asserted that recent decreased funding is a major barrier for sustaining a local or regional stockpile.¹³ During times of limited funding, organizations or regions may need to stop building existing stockpiles, find alternative ways to maintain existing materials, and/or not replace expired supplies.

Decisions about building, minimizing, and maintaining existing stockpiles should be a multidisciplinary decision based on a cost-benefit analysis. Groups that should be involved in these decisions include emergency managers, front-line clinicians who will use the cache materials, and materials management or central supply professionals. Other stakeholders to involve in decision making should be chosen based on the supply or item being purchased, the type of event for which the cache will likely be deployed, who will maintain the cache material, and who will deploy it. For example, respiratory therapists should be consulted when making purchasing decisions regarding ventilators. Careful management of a cache can help organizations or regions maximize existing stockpiled materials, even when funding is limited.

Storage of Supplies and Equipment

Organizations or regions that invest in large stockpiles may also have to allocate substantial funds to provide appropriate storage of the cache materials, given the limited space at most healthcare facilities. This could include the purchase of trailers or other storage containers, dedicated space or room(s) inside the building, or access to a warehouse or other facility.¹⁶ Depending on the size of the stockpile, storage could easily cost hundreds of thousands of dollars each year to maintain. For example, the VA health system reported that a 10,000-square-foot facility was estimated to cost between $100,000 and $140,000 per year for rent.¹⁶

In addition to size, location is also an important factor to consider when selecting a storage site. If a centralized storage approach is used, as it is for the VA health system or the Capital Region Metropolitan Medical Response System, the site needs to be easily accessible for rapid deployment of cache materials to local hospitals.^16,26 Availability of a temperature-controlled area needs to be considered for those medical supplies and equipment that are affected by changes in temperature.^16,26 For example, medications, lotions, batteries, and most liquid-based items are damaged by extreme temperatures and need to be stored in an environmentally controlled area. Most consumable medical supplies have ideal temperature ranges recommended by the manufacturer. The storage facility, whether a trailer, container, or building, also needs to be routinely assessed for environmental damage or pest infestation. Flooding, water damage, or mold growth can damage medical supplies or compromise their integrity.

Medications that are part of a local or regional cache should be stored and managed following all applicable state and federal regulations,²⁶ regardless of whether they are stored in a central location or integrated into an organization's routine stocks. One model for storage of antivirals is for organizations or regions to use Roche^®'s pandemic stockpiling program, which consists of having Roche^® store, secure, and rotate antivirals on behalf of an entity or jurisdiction for an annual fee.²⁷ If or when the medication is needed, Roche^® will deliver the product to the area. Organizations and regions have the option of renewing the contract every year. Organizations and regions should investigate other third-party programs similar to Roche^®'s and choose the program that is the best fit for them. A major advantage to this program is that it allows for the safe storage and availability of antimicrobials without the hassle of having to manage the stockpiled supplies.²⁷

Though standards exist for storage and management of stockpiled pharmaceuticals, no guidelines have been published for storage of other types of medical supplies and equipment in local or regional stockpiles. However, the VA system outlines their protocols and specifications of their cache storage facilities, which other organizations or regions could use as a template.²⁸

Management of a Local or Regional Stockpile

Organizations and regions need to invest resources in managing cache materials to ensure the integrity of medication and supplies and to enable rapid and appropriate activation during an event. Proper management of existing stockpiles may be a better investment than purchasing new materials. However, funding is often not specified for the administrative infrastructure needed to manage local or regional stockpiles. No studies have been conducted to determine how or to what extent regional stockpiles are managed, but researchers have asserted that hospitals have had difficulty shouldering the costs associated with managing, storing, and providing training for their staff on maintaining the local cache.²⁴

Each organization or region must have at least 1 designated individual who will be responsible for managing the stockpile,¹⁶ and there must be policies and protocols in place for managing the cache materials.^21,26 Any individuals who will be responsible for securing, storing, or handling stockpile materials prior to deployment must be trained.²⁹ In addition, organization and regional emergency management staff must be trained on how to use cache equipment, especially that which is not used during routine duties, such as decontamination supplies or auto-injectors for organophosphate-related chemical terrorism attacks.^24,26

For regional stockpiles, it is vital that community stakeholders understand the contents of the regional stockpile before an event occurs,³ even if the stockpiled supplies are stored in a central or otherwise off-site location. Community stakeholders include not only hospital disaster planners and administrators, but also those who will use the cache materials, such as security guards, materials managers, and clinicians. This will maximize situational awareness for organizations in the region and enable more rapid communication of needs between the organization and the regional cache manager during an event. For regions that have a stockpile, it is also vital to have a plan in place for deploying and transporting regional cache supplies.^3,10,16,29 Regional disaster planners should consider using existing guidance on the transportation of materials from the SNS¹² as a starting point for developing protocols for their local or regional caches.

Critical aspects of stockpile management include tracking, inventorying, assessing, and providing preventive service to the cache materials. Stockpiles should be considered more than simply assets; they require a programmatic approach. Regulatory agencies, such as the Centers for Medicare and Medicaid Services (CMS),³⁰ mandate that hospitals maintain medical equipment and devices for quality and safety, including equipment used for mass casualty incidents. CMS-required maintenance includes regular testing and calibrating of medical equipment by a qualified individual.³⁰ Some medical equipment, such as ventilators, requires periodic preventive servicing to maintain their functioning, and this must be built into cache management protocols.⁶ In addition to medical equipment, other cache contents need to be evaluated regularly,¹⁰ because pharmaceuticals and some supplies expire¹⁶ and because stockpile levels change when items are deployed during an event.³¹ In addition, the integrity of supplies can be compromised by environmental hazards, such as extreme temperatures, water infiltration, or pest infestation.

Tracking Cache Materials

Researchers recommend that local and regional cache materials be carefully managed and tracked before and after deployment.^3,10 Stockpile tracking consists of both inventory management (ie, documenting current cache amounts, descriptions, and expiration dates) and asset tracking (ie, documenting the location of cache assets both before and after deployment). Tracking is essential for operations management of the cache as well as situational awareness during an incident. For regional caches, stockpile tracking includes development of a centralized inventory database of all supplies and their expiration dates.³ Tracking of cache materials prior to deployment consists of documented routine inventorying and assessment to ensure that supplies have not been removed from the cache or are no longer usable due to deterioration or expiration.

The extent to which deployed cache materials are tracked depends on whether the items are expendable or reusable, if the supply will require replacement, and if a funding agency requires tracking for reimbursement purposes. Tracking of deployed expendable supplies, such as PPE, is less critical than reusable medical equipment, such as ventilators. This is because the vast majority of deployed expendable cache supplies will be used and unable to be returned to the stockpile. Tracking of those materials will consist primarily of noting the number of items deployed and to which location. Unused expendable supplies may be returned to the cache, or the region may elect to allow the receiving hospital to integrate the unused supplies into the hospital's stocks.

Tracking of reusable equipment will be more complex, primarily because the items will need to be returned to the cache after an event, but also because these supplies are more likely to be more expensive than expendable items. No recommendations regarding best practices for tracking of reusable equipment were found. One study examined the use of radio frequency identification (RFID) for equipment tracking and found that, although the active systems that transmit a radio signal are effective, they are expensive: between $10 and $200 per RFID tag.³² Passive systems that lack battery power were found to be less expensive (between 5¢ and $1 per tag) but had a limited range of only 3 feet.³² The use of RFID systems would be cost prohibitive for most stockpiles consisting of hundreds or thousands of pieces of equipment. However, organizations or regions may consider purchasing RFID systems for only the larger and more valuable pieces of equipment, such as ventilators.

Timeline for Inventorying Supplies and Equipment

At the federal level, the SNS is legally mandated to have an annual assessment;^11,13 however, no such standards exist regarding the expected timeline for assessing or inventorying all aspects of local or regional caches unless it is included in the funding guidelines under which the items were originally procured. CMS regulations require that medical equipment and devices used in hospitals be tested according to manufacturer's guidelines at least yearly, though maintenance schedules for these items may vary.³⁰ CMS does not outline a timeline for assessing other types of medical supplies that might be used during a mass casualty incident, except to indicate that manufacturers' recommendations must be followed.³⁰ Though CMS regulates only hospitals and not regional emergency management, it would be prudent for community disaster planners to follow CMS recommendations when managing regional caches. This will ensure that hospitals that receive deployed materials are provided medical equipment and supplies that meet CMS regulatory requirements, even during mass casualty incidents.

Though there are no organizations or researchers that provide recommendations for routine assessment and inventorying timelines of local or regional caches, there are 2 agencies that discuss actually performing this task. The Illinois Department of Public Health has reported that they collect a weekly survey from all health departments and 156 hospitals in their state regarding the number of antivirals and PPE the agencies have distributed and still have on hand. This program provides situational awareness in near real-time for PPE and antiviral stocks in the state, but it does not assess nor recommend a time frame for evaluating the status of any other stockpiled materials. The VA conducts annual assessments of their healthcare system's cache, including a report outlining the status of supplies and areas for improvement.³³ Though these 2 agencies discuss their stockpile assessment protocols, neither provides recommendations regarding how other organizations or regions should monitor or maintain their own cache.

Despite the lack of published guidance for local or regional stockpile assessment, it seems prudent to recommend an annual inventory at the minimum, with additional evaluations performed as needed. Some regions may elect to implement an electronic survey program like Illinois's, which provides more timely evaluations of on-hand medications, PPE, or other supplies throughout the region or state. Doing so allows for more rapid and accurate deployment of SNS materials during an event.³¹

How to Assess Supply Integrity

Local and regional caches often consist of a diverse combination of consumable supplies, durable medical equipment, pharmaceuticals, and other consumer goods. While quality assurance resources exist for the component parts of the cache, such as pharmaceuticals and the United States Pharmacopoeia/National Formulary, little information could be found regarding recommended processes for assessing the integrity of local or regional cache supplies and equipment. However, CMS requires that medical equipment, devices, and supplies used in hospitals, even during mass casualty incidents, need to have appropriate safety and quality.³⁰ Verifying supply integrity is essential to this, though CMS provides no specific recommendations regarding how to do this other than indicating that facilities must follow manufacturers' recommendations or use an alternative equipment maintenance (AEM) program approved by the American National Standards Institute/Association for the Advancement of Medical Instrumentation.^30,34

Researchers have suggested that organizations managing a stockpile should maintain an inventory of all cache materials, including documenting supply expiration dates³ and other relevant information, such as maintenance schedules and environmental considerations; this information should be noted at the time of item purchase and incorporated into the inventory management program. The process of assessing supply integrity will be different for various types of cache materials. At a minimum, expiration dates should be followed, and timelines for assessing supply integrity should be based on manufacturers' guidelines and/or local, state, or federal law whenever applicable. If supplies are stored in a non–temperature-controlled environment, such as a trailer without air conditioning, additional assessments may need to be conducted to ensure integrity of the items. For example, a sample of gloves stored in a non–temperature-controlled area may need to be assessed, because their integrity can be compromised by heat or light.³⁵

Stock Rotation and/or Destruction

Supplies or medications that have expired or have compromised integrity need to be removed from the cache and destroyed.^16,21 Destruction of cache materials amounts to waste and should be avoided whenever possible. One way to prevent the need to destroy stockpiled supplies or medication is to maintain a list of expiration dates and rotate items out for use prior to that date. Ordering of replacement supplies or equipment needs to be done far in advance of when the items are expected to expire, so that the stockpile never contains expired materials nor is missing vital assets.¹⁶ It should be noted that the ordering time will vary for different supplies, medications, and equipment. For example, 6- to 9-month delays in obtaining PPE have been reported,¹⁶ and this could greatly limit availability of PPE during a mass casualty incident.

Accepting and Integrating Regional Resources

Prior to a mass casualty incident, hospitals should develop plans for accepting and integrating medical supplies or equipment from outside sources into their facility.⁵ Researchers have recommended that regional cache material purchasing decisions be made collaboratively with local healthcare organizations so that supplies are interoperable and compatible with all cooperating facilities.¹⁰ This allows for consistency and sharing of resources across the region; it also enables communitywide training and exercises using the cache materials. Without this pre-purchasing planning, it is unlikely that the brand of supplies from outside sources will be the same as that used routinely by the receiving hospital. Though this does not create an issue for most medical supplies, accommodations must be made for some items when the brand is not the same. For example, fit-testing for N95 respirators is specific to a brand and size. If hospitals receive a different brand of respirators during a mass casualty incident, their staff will need to be re-fit-tested using the new brand before they can safely wear the N95s; this was reported to be a very time-consuming and expensive process when it occurred during the H1N1 pandemic.⁴

Vendor-Managed Inventory

One potential option for managing a local or regional cache is to use a vendor-managed inventory (VMI) system, a model that is similar to Roche^®'s pandemic stockpiling program. In a vendor-managed inventory system, cache materials are stored in an organization-owned or regionally owned container at the vendor. Medication or supplies that are nearing expiration can be rotated out of the vendor-managed inventory and sold commercially; the vendor would then replace the materials with new stock.¹³ This would reduce the amount of cache supplies or medication needing to be destroyed due to expiration, which would minimize stock replacement costs. Vendor-managed inventory also has the advantages of not requiring the organization or region to find the space or establish the infrastructure to maintain a large cache—barriers for many local and regional jurisdictions.¹³ Despite these advantages, not all medications or supplies would work in a such a system. In order for vendor-managed inventory to be cost-effective, there must be sufficient commercial use for the cache materials.¹³ Examples of pharmaceuticals that might be included in a local or regional stockpile that might not be cost-effective in a vendor-managed inventory include organophosphate antidote and avian influenza vaccine. If an organization or region chooses to use a vendor-managed inventory system, stakeholders need to be aware of similar agreements made with other organizations and the vendor's capability to meet all total obligations if activated simultaneously.

User-Managed Inventory

One option for managing a regional cache is to pre-position some or all medication and supplies in healthcare facilities across the region. The medication or supplies are not stockpiled in the traditional sense of being stored in the facility until deployed during a future event; instead, they are integrated into the hospitals' routine stocks for routine practice.^16,24 Cache materials would be used by the facility as part of routine duties when typical surges occur (for durable equipment) and/or cycled through the facility on a first-in, first-out basis (for expendable materials or medications); this would virtually eliminate the risk of supplies and medications being stored past their expiration.

This approach is known as “user-managed inventory” and has multiple advantages over traditional stockpiling methods.³⁶ User-managed inventory should reduce the amount of supplies or medication needing to be destroyed, assuming that the expiration dates are monitored and items are rotated in a timely manner. Another advantage is that regional cache materials would be stored in individual facilities, making them immediately available during a healthcare surge and eliminating the need to purchase trailers or off-site storage space. User-managed inventory also minimizes the time and administrative hassle of needing to deploy the cache from external storage areas to the hospitals.³⁶

If regions wish to implement user-managed inventory, community disaster planners and hospital administrators need to work closely together to ensure that policies and protocols are in place to document the assessment, rotation, use, and replacement of supplies. In addition, it may be beneficial for the region to purchase supplies or equipment that can be integrated seamlessly into the hospital, such as purchasing the hospital's brand of supplies, to ensure that facilities are able to use the regional resources during routine practice.¹⁰ This is most critical for products that necessitate fit-testing (ie, N-95 respirators) or special training (ie, needleless or safety devices, IV pump machines, or decontamination equipment).²⁴

Researchers have described approaches for implementing user-managed inventory for medical countermeasures (MCM).³⁶ It seems prudent to consider forward placement of other resources routinely used by hospitals as well, provided that certain criteria are met. User-managed inventory should be considered for medication or supplies that are expensive and have a short life, because traditional stockpiling of those products incurs high costs due to the need to replace expired materials.^21,36 However, this is not an absolute recommendation for selecting products for user-managed inventory; the frequency of routine use should also be considered. If a hospital is unlikely to use much of that item, placing it in user-managed inventory would not eliminate the need to replace the stocks due to expiration. User-managed inventory is most cost-effective for products whose shelf life is sufficiently long to allow the medication or supply to be used by the hospital before it would expire.³⁶ It may also be advantageous to select products for user-managed inventory that are frequently used by the hospital and are known to have a delayed time after ordering, such as PPE. The VA health system, which maintains a substantial stockpile, has reported that their cache has been very beneficial to the organization, because it has occasionally been used to address local pharmaceutical shortfalls.¹³

Although user-managed inventory provides cost-savings by minimizing or eliminating the need to destroy expired materials, there are costs associated with implementing this type of system. The exact costs depend on how many and the type of products chosen for integration, but researchers have estimated that user-managed inventory costs would be substantially lower than the costs associated with traditional stockpiling methods, such as warehouse storage.³⁶

Other Considerations

Although the focus of this article has been the discussion of best practices related to establishing and maintaining a local or regional cache, it is vital to point out that stockpiling of medication, supplies, and equipment is only one component of community resilience. Communities must be able to deploy the cache quickly, regardless of the content or size of the stockpile; this includes distribution of PPE or rapid dispensing of MCM from the cache.^11,15 In fact, jurisdictions must have documented plans for mass dispensing of MCM if they are to receive federal funding for bioterrorism preparedness.¹⁵ Research examining communities' preparedness for dispensing MCM has found that fewer than half of the assessed jurisdictions have the staff needed to meet CDC's standard of dispensing oral MCM to the entire community within 48 hours through open points of dispensing (POD; those that are open to all members of the community).³⁷ Many communities are planning to use closed PODs (sites that are open only to employees and/or their families) to help relieve the burden of mass MCM dispensing. However, a national study found that there are many gaps in existing closed POD preparedness, including a lack of written plans, standing orders, and pre-event training for staff or volunteers.³⁸ This research points to serious gaps in community preparedness for a bioterrorism attack and should be another consideration for regional response.

Another important aspect of community resilience is the performance of drills and exercises that assess emergency management plans, including accessing and deploying stockpiled supplies and capacity to dispense MCM. Researchers have suggested that hospitals host an annual full-scale exercise that involves deployment of local and regional caches, as well as internal and external communication related to stockpile usage.³ In addition, facilities and jurisdictions should engage in exercises that evaluate their ability to mass dispense MCM. According to research, many jurisdictions are performing periodic open POD exercises, though there is room for improvement. A 2014 national study found that 64% of jurisdictions had conducted a throughput assessment and half had performed a full-scale exercise during the previous 2 years.³⁷ Among closed POD sites, 60% had conducted an exercise to test their ability to dispense MCM.³⁸ These exercises are vital to determining the ability of a community to mass dispense MCM. Having access to a stockpile will not aid community members if the jurisdiction cannot dispense the medication or administer care rapidly and accurately.¹¹ Communities must address planning, exercises, and stockpiling decisions as part of a comprehensive emergency management plan.

Conclusion

Some hospitals, healthcare systems, businesses, academic institutions, organizations, and regions are purchasing medications, medical supplies, and equipment in preparation for a mass casualty incident. Careful decisions are needed regarding what to include in these local and regional stockpiles, and a risk-based approach should be used to make purchase decisions that meet a clarified need or goal. Stockpile purchase decisions should address costs related to storing, managing, inventorying, and replacing expired or damaged materials. Community stakeholders, including clinician end-users, should be consulted when deciding on which medications, products, or equipment to purchase and how and where the stockpile will be stored and managed. Wise purchase decisions and investment in the infrastructure to maintain a stockpile can save an organization or region in the long run by reducing the amount of waste and the need to replace supplies that have lost their integrity. Though few guidelines exist on procedures to follow when managing a local or regional stockpile, the best practices identified in this document can be used to develop protocols for maintaining and sustaining local or regional caches using a programmatic approach.

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