Abstract
Stockpiles can aid with healthcare surge that occurs after a disaster, and experts recommend that these caches be assessed at least annually to ensure supply integrity. The purpose of this study was to assess a regional stockpile to determine its viability and readiness. An assessment was performed in the summer and fall of 2016 on a regionally funded stockpile that was decentralized through a regional network of 15 local hospitals. Each supply was assessed to determine whether the correct amount was present, if it was in a safe and usable condition (ie, deployable), and whether it had expired. Stockpiled materials were categorized by the type of supply or equipment for analysis. The percent of deployable materials was calculated for each item, each category of supplies, and for the entire cache. Almost all sites (93.3%, n = 14) reported that they inventory their cache at least once a year. On average, 60.1% of each site's cache materials were present and deployable (range: 22.1%-87.5%). The best-maintained supplies included personal protective equipment (79.4% deployable) and general medical supplies (73.5% deployable). Decontamination equipment and pediatric supplies had the lowest percentages of deployability (29.0% and 37.7%, respectively). Although almost all sites claimed to assess the stockpile annually, results from this study indicate that almost half of the supplies are either missing or in an unusable condition. This not only represents wasted resources, but it could also hinder disaster response, leading to increased morbidity and mortality. Facilities may need to invest in infrastructure to maintain stockpiled materials after purchase to ensure viability.
Stockpiles can aid with healthcare surge that occurs after a disaster, and experts recommend that these caches be assessed at least annually to ensure supply integrity. This study assessed a regional stockpile to determine its viability and readiness. Results indicated that almost half of the supplies were either missing or in an unusable condition.
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A common solution to these challenges is to develop local or regional stockpiles of supplies, equipment, and medications. Research indicates that many hospitals have begun stockpiling medications and supplies for mass casualty incidents, though these caches have been found insufficient to meet the facility's surge capacity needs.5-7 Some healthcare systems 8 and geographical jurisdictions or regions 9 have also invested in stockpiles to augment federal resources and those maintained by individual facilities.
Stockpiles can aid in surge capacity, but they are expensive to establish and maintain. 10 Purchasing materials for the cache is just one upfront cost involved in setting up a stockpile. Additional investment is needed to keep the supplies well maintained and ready to be deployed when needed. For example, there are personnel infrastructure costs associated with maintaining a stockpile. One or more individuals are needed to inventory and track the cache materials, and a team may be needed to deploy the stockpile during an event. 11 In addition to personnel costs, there are likely to be fees associated with storing the stockpiled materials, 12 and this can be quite costly. 1
Other costs associated with maintaining a stockpile include the fees associated with replacing equipment or supplies when the shelf life of a product expires. For example, the Israeli national strategic stockpile estimated that it would have cost about $6 million to replace ciprofloxacin 3 years after initial purchase due to the short shelf life of that medication if they had not instituted a shelf-life extension program. 13 The US's Shelf-Life Extension Program has aided in reducing costs related to medication rotation, 14 but many nonpharmaceutical supplies also can expire and require replacement, which contributes to the costs of sustaining caches. There can also be replacement costs when supply integrity is lost due to environmental exposure or some other type of damage. 1
Replacement of used, removed, damaged, or expired stockpiled materials should be done as soon as feasible to ensure the cache can be fully deployed when needed. To ensure deployability, stockpile managers need to be aware of the cache's integrity. Federal law dictates that the US SNS must be assessed and inventoried at least once per year. 15 No such laws govern local or regional stockpiles, but researchers have recommended, at a minimum, an annual assessment and inventory of these caches. 10 This article summarizes findings from an inventory and assessment of a regionally funded but decentralized stockpile to determine the status of the cache materials in terms of the amount of viable and/or deployable supplies. A secondary aim is to identify determinants of better management of the decentralized stockpiled materials by examining hospital characteristics, policies, and procedures.
Methods
Stockpile that Was Assessed
An assessment was performed in the summer and fall of 2016 on a regionally funded stockpile that was decentralized to 15 local hospitals. The stockpile was purchased by a single region using federal preparedness funding. The region had purchased medical supplies and equipment over a period of 5 to 6 years and distributed it to local hospitals to be managed; the regionally funded stockpile did not include medications or vaccines. Hosting sites were chosen based on location (ie, spread throughout the region so that supplies could be mobilized throughout the area) and willingness to manage their allocation of the cache. Before being sent to host hospitals, cache materials were organized into a standardized set of supplies and equipment, and trailers were purchased in which to store the materials. Prior to release of the materials, hosting hospitals were sent a memorandum of understanding (MOU) that outlined the site's responsibility to maintain the inventory and sustain its deployment readiness. In addition, each hospital was instructed to identify 1 individual who would be responsible for managing the cache and developing protocols for when and how to assess and inventory the stockpiled materials. The MOU dictated that sites were to perform an annual assessment and report findings to the region, but the region did not hold sites accountable and did not follow through on this.
The inventory lists used during assessment were developed based on the standardized list of supplies and equipment purchased for each type of trailer. Each supply or piece of equipment was assessed in 2 ways: (1) whether the correct number of each item was present, and (2) whether the item was deployable. “Deployable” was defined as being wholly intact, not expired, and in a safe and usable condition, regardless of whether the site followed the manufacturer's guidelines in terms of storage or maintenance schedule. Expiration dates were determined by the manufacturer's guidelines or the date listed on the item. In addition to checking for expiration, supply integrity was also assessed by examining the cache materials for signs of damage that would render the item unsafe or unusable. Members of the research team conducted the assessments in pairs, and both individuals had to agree about supply integrity before marking an item as being expired or undeployable.
In addition to the physical assessment taken of the stockpiled materials, a 21-question survey was distributed electronically to each site's cache manager prior to the team's performing the inventory. The questionnaire was designed to ascertain the following information: (1) existence of written policies related to cache management and assessment (5 items), (2) current practices in place related to cache management or assessment (10 items), (3) perceived resources to maintain or deploy the cache (5 items), and (4) perceived challenges faced by the facility in relation to managing or sustaining the cache (1 item). Host site demographics were also collected.
Data Analysis
The research team categorized the cache materials into the following groups by type of supply or equipment: (1) personal protective equipment (PPE); (2) first aid and wound care; (3) general medical supplies, such as stethoscopes, syringes, tongue depressors, and the like; (4) pediatric supplies, such as bottles and pacifiers; (5) personal hygiene supplies; (6) cots, bedding, and linens; (7) decontamination equipment; (8) decontamination clothing and PPE; (9) power, fuel, and tools; and (10) storage trailer (the unit in which the supplies were stored). The percentage of deployable materials was calculated for each item or piece of equipment, for each category of supplies, and for the entire cache. Wilcoxon signed rank was used to assess differences between the perceived time to deploy the cache internally versus externally. An independent t-test was used to compare the amount of deployable cache materials found during the assessment between sites with and without an onsite vehicle.
A regional cache management perceived preparedness score (ie, host perceived preparedness score) was calculated for each hospital by assigning 1 point for each of 13 items that the site indicated were in place: (1) have a current trailer license and insurance for the cache (1 item); (2) have written procedures to inventory, track, store, maintain, replenish, deploy, or dispose of materials (6 items); (3) perform annual inventory (1 item); (4) maintain a list of expiration dates for materials (1 item); (5) have a designated person responsible for the cache (1 item); (6) provide any amount of training for the individual(s) responsible for the cache (1 item); (7) have a vehicle on site to transfer or deploy the trailer (1 item); and (8) report the perception that the hospital has the resources to maintain the cache (1 item). Host perceived preparedness scores could range from 0 to 13 (ie, 1 point for each of the 13 items).
Results
All 15 sites (100% response rate) completed a survey summarizing their stockpile management practices and policies and the cache manager's perceived resources to manage and maintain the stockpile. The hosting hospitals ranged in size and location; a full list of hospital demographics is outlined in Table 1. Six of the hospitals (40.0%) were large (≥351 licensed beds). Just under half (40.0%, n = 6) were either pediatric hospitals or provided care to pediatric patients. Most hospitals were in rural or suburban areas (40.0% for each; n = 6). Just under half (46.7%, n = 7) have at least 1 full-time employee whose job is dedicated to hospital emergency management. Two-thirds (66.7%, n = 10) reported that their hospital emergency preparedness committee meets quarterly. Half of the hospitals (53.3%, n = 8) reported holding an internal disaster exercise once a year. About half (46.7%, n = 7) participated in more than 1 regional disaster exercise during the last year.
Demographics of the Hosting Hospitals
FTE = full-time equivalent.
Written Policies
The sites were asked if they have written procedures related to inventorying and tracking, deploying, maintaining and replenishing, storing, and disposing of cache materials. Almost all sites (93.3%, n = 14) had written policies related to inventorying and tracking the cache. Three-quarters (73.3%, n = 11) had deployment policies, and 60.0% (n = 9) had written storage procedures. About half had polices for maintaining, replenishing, and disposing of supplies (53.3%, n = 8 for both).
Current Practices in Place
Almost all sites (93.3%, n = 14) reported that they inventory their cache at least once a year; three-quarters (73.3%, n = 11) claim to keep written records of such assessments. Only a third (33.3%, n = 5) maintain a list of supply expiration dates. Most sites (80.0%, n = 12) claim to have current license and insurance documents for their storage trailer(s). Most sites (86.7%, n = 13) reported allowing multiple hospital staff to have access to cache materials, with about half (53.3%, n = 8) indicating that 3 to 10 individuals had such access. Two sites (13.3%) reported that they had used cache materials for routine duties or a past healthcare surge; both indicated that the supplies had been replaced less than a month after removal.
Most sites (80.0%, n = 12) had a designated person responsible for managing the cache. More than half (60.0%, n = 9) reported that no training had been provided to the individual(s) responsible for inventorying and managing the cache. Of those that have been provided training (n = 6), half (n = 3) had received 1 hour or less. Two sites (33.3%) had provided more than 3 hours of on-the-job training for the cache manager; 1 (16.7%) had received more than 9 hours of on-the-job, online, and formal classroom education related to inventorying and managing a stockpile. A third of the sites (33.3%, n = 5) reported that all incident command system (ICS) staff know the stockpile location; the rest indicated that some ICS staff know the cache location. Most reported that some ICS staff know the content of the stockpile and how to access it during an emergency (80.0% for both, n = 12) and how to move or relocate the materials (86.7%, n = 13). One site (6.7%) indicated that no ICS staff know how to move the cache.
Perceived Resources
Two-thirds (66.7%, n = 10) reported having an onsite vehicle that could transfer the trailer storing the cache if needed for regional deployment. More than half (60.0%, n = 9) indicated that their hospital provides ongoing funding to maintain or sustain the cache. Half (46.7%, n = 7) reported believing that their facility has the resources in terms of personnel and funding needed to maintain or sustain the stockpile. When asked how soon the hospital could deploy the stockpiled materials internally versus externally, sites reported needing significantly less time to deploy the cache internally versus externally: ≤30 minutes (internal) compared to ≥1 hour (external) (p < .001).
Host Site Preparedness
A host perceived preparedness score was calculated for each site based on whether it had reported having 13 factors related to cache management, including having written policies and procedures, conducting an annual assessment, having a designated person to manage the cache, providing training on cache management, having a vehicle to deploy the stockpile externally, and believing the hospital has the resources to maintain the stockpile. Host preparedness scores could range from 0 to 13 (1 point for each of the 13 items). The average host perceived preparedness score was 8.5 (range: 3-13). A list of the preparedness indicators and the percentages of sites that had each item are outlined in Table 2. There were no differences in perceived preparedness when comparing hospital size, location, number of supplies managed by a site, or availability of internal funding to support cache management.
Percentage of Hospitals that Reported Having Each of the Site Preparedness Indicators
Of the stockpiled materials found during the assessment, over 99% of the supplies and equipment were being stored in the trailers purchased by the region for this purpose. A quarter of the sites (26.7%, n = 4) had moved some stockpile materials to an inside location for storage, but only 1 site had stored more than a few items indoors. The site that had moved the most supplies inside was storing less than 1% of the materials in an inside location. The inventory and assessment of the decentralized stockpile found that, on average, 60.1% of each site's cache materials were present and deployable (range: 22.1% to 87.5%). When examining deployability of the supplies by category, the best-maintained supplies included personal protective equipment (79.4% deployable) and general medical supplies (73.5% deployable) (Figure 1). Decontamination equipment and pediatric supplies had the lowest percentages of deployability (29.0% and 37.7%, respectively). The most common reason why supplies and equipment were not deployable was because they were missing at the time of the assessment (71% of the undeployable supplies). In addition, 15% of undeployable supplies were damaged beyond the point of use. Multiple causes of degradation were observed; presumed environmental degradation due to a lack of humidity and temperature control was the most common. Finally, 14% of the supplies had expired years before the assessment. The percentage of stockpiled materials that were deployable, damaged, expired, or missing in each category is outlined in Figure 1.
Percentage of Stockpiled Materials that Were Deployable, Damaged, Expired, or Missing by Category of the Supply or Equipment
There was no relationship between the site's perceived preparedness scores compared to the actual amount of deployable materials found during the assessment. There was also no relationship between the number of supplies managed by a site, the amount of training the cache manager had received, hospital size, location, or availability of internal funding to support cache management and the amount of deployable supplies found during the assessment. Sites that reported having an onsite vehicle that could be used to transport the cache externally had significantly more deployable supplies compared to sites that did not have a vehicle (67.4% vs 39.4% deployable materials, t = –3.2, p < .01). Pediatric hospitals had significantly less deployable supplies compared to adult hospitals (41.1% vs 66.6% deployable respectively, t = 3.6, p < .01).
Challenges to Maintaining the Stockpile
Host sites were asked 1 open-ended, qualitative question: Please describe any challenges your facility has experienced in efforts to maintain or sustain your cache. Resulting comments were summarized in 2 themes or areas in need of improvement: (1) processes and organization, and (2) funding. Cache site managers reported that they faced major challenges in developing processes to replenish supplies and organize the storage trailers. More specifically, organization of the trailers that would maximize item retrieval was seen as challenging. One site commented that staff turnover proved challenging, especially when the new cache manager wanted to clean out and replace expired and damaged supplies while others at the site preferred the previous manager's approach of simply letting the cache sit untouched and unchecked. In addition to necessary improvements in organization and administrative processes, the cache managers identified a lack of resources as a major challenge. Over half of the site managers commented that their facility lacked the personnel or funding to adequately maintain the cache.
Discussion
Findings from this study indicate that host sites tasked with managing and maintaining a regionally funded stockpile faced many challenges, resulting in a large portion of the cache becoming unusable. Though most sites reported following many cache management procedures correctly, such as having written cache management policies in place, the overall integrity of the stockpiled materials was quite poor. Only 60% of the supplies from the regional stockpile were found to be deployable when an inventory was taken and items were assessed for integrity. Many supplies were simply missing, and many others had expired or been damaged because of inadequate storage conditions, rendering them useless. Furthermore, the supplies that had deteriorated were often intermixed with viable resources. This could cause a delay during a disaster when responders will be forced to individually assess cache contents for deployability.
It is unclear why sites were continuing to store damaged and expired supplies if they had truly been conducting annual assessments. One possible explanation is that hosting sites may not have known what to do with supplies that had expired or lost their integrity; only half of the sites indicated that they had written procedures for disposing of or replacing expired or damaged cache materials. Because the sites were only managing the stockpiled materials but did not own the supplies themselves, perhaps they were unsure of whose responsibility it was to replace materials. The Department of Veterans Affairs, which owns a very large stockpile for their healthcare system, has a policy that requires a written report to be submitted to the director within a week of their annual cache inventory; then a follow-up report is written, outlining corrective action to address the deficiencies found during the assessment. 8 This type of process is likely to have prevented the large amount of missing, damaged, and expired supplies found during the current study, and it is a protocol that other hospitals, healthcare systems, or regions that own a stockpile should consider implementing. One option for managing a stockpile is to use a tracking system like CDC's Inventory and Management Tracking System (IMATS). 16 At this time, facilities and regions must develop or purchase their own tracking system, as IMATS is available for use only by local and state public health departments.
Another possible reason why hospitals in this study were not replacing missing, damaged, or expired supplies is a lack of funding. Though 60% of the stockpile managers assessed in this study reported that their hospital provides some level of ongoing funding to maintain or sustain the cache, half of them also reported that they believe their facility does not have the resources in terms of personnel or funding needed to maintain the stockpile. This indicates that hosting sites lack the resources needed to adequately maintain the cache for which they are responsible, even though the hosting hospitals appear to be contributing at least some funding. It is critical that stockpile management include funding for replacing used, damaged, or expired materials.1,17 Many medical supplies can expire, rendering them unusable to hospitals. One option to minimize costs is to establish a rotation schedule that allows supplies to be used by the hospital for routine duties before they expire and then be replaced. 1 Implementing this type of rotation schedule also requires developing and maintaining a list of supply expiration dates. 1 In this study, only a third of the sites maintained such a list, which helps explain why 14% of the supplies in the stockpile had expired years earlier without being removed or replaced.
In addition to funding for supply replacement, facilities or regions that own a stockpile should invest in the infrastructure or resources to maintain the cache. 10 For example, important components of cache management include having at least 1 dedicated person to manage the stockpile and having that person receive training.1,10 Though 80% of the sites in this study reported having a designated person who is responsible for managing the cache, 60% of those had provided no training to the stockpile manager.
Cache managers and/or hosting sites need to accept some responsibility for the stockpiled supplies. Without an investment in supply replacement, infrastructure to manage the stockpile, and increased accountability, it is likely that the cache will lose value as more supplies expire without replacement or are damaged beyond the point of usefulness. The need to invest in infrastructure and supply replacement is critical for any hospital, healthcare system, or region that has purchased materials for a stockpile, regardless of whether the materials are decentralized or the size of the cache.1,8,10 Findings from this study indicate that host sites had difficulty managing their assigned stockpile, regardless of the size of the hospital or the amount of cache distributed to them. Increasing accountability for the hosting site could potentially address this issue.
An interesting finding from this study is that some categories of supplies, such as personal protective equipment for biological events and general medical supplies, were well maintained, while other materials, such as chemical decontamination equipment and pediatric supplies, were not. Although the reason for this is unclear, one contributing factor may be the storage methods for the supplies. Stockpiled materials that are not stored properly can become damaged beyond the point of use. 18 In this study, many stockpiled items—especially pediatric supplies—were damaged by being stored in a non–temperature-controlled trailer. Pediatric supplies, such as baby wipes and lotion, are easily damaged by high temperatures. If these supplies had been stored inside a building or in a space with adequate temperature control, they might not all have been damaged beyond use. 1 A related finding from this study was that pediatric supplies were poorly maintained—even in comparison to other types of supplies—and this left the pediatric hospitals with a lower percentage of deployable supplies than adult hospitals. It is vital that pediatric supplies and equipment are well maintained in stockpiles, because pediatric surge capacity is critical to successful disaster response.3,19-25
Although it is more expensive to store supplies in a temperature-controlled area than in a trailer, this practice could pay for itself over time by negating the need to replace supplies due to lost integrity. Inside storage might also decrease the time needed to deploy, depending on whether the supplies are stored on site or off site. Each region or facility would need to conduct a cost-benefit analysis to determine whether it is cost-effective to store their stockpile, or aspects of their cache, in a temperature-controlled environment. In addition, rental space may be needed to store the stockpile if facilities do not have the space to keep the supplies on site. For large healthcare facilities or regions, renting a temperature-controlled space may be a cost-effective approach owing in part to the sheer number of supplies to be stored. For example, the Veterans Administration healthcare system uses a 10,000-square-foot temperature-controlled facility for their stockpile, which has been estimated to cost from $100,000 to $140,000 in rent annually. 8 Other systems or regions may not need such a large space, and they may be able to store the stockpile at hosting sites or in smaller centralized locations, so their storage costs would be expected to be lower.
Regardless of the reasons that hospitals in this study had not disposed of unusable supplies or replaced removed, damaged, or expired items, the result is that the size of the deployable stockpile is not what the region anticipated. Findings from this study indicate that successful deployment of the stockpile in its current state, in whole or part, would be challenging due to the remaining amount of viable supplies and the condition of the storage trailers that would be used for deployment.
This has implications not only for the assessed region, but for hospitals, healthcare systems, and other regions as well. Stockpiles can aid in surge capacity, but only if the supplies are well maintained and able to be deployed when needed.1,10 Regular assessment of stockpiled materials is necessary to ensure that items are present and in good condition. For decentralized stockpiles, relying on a host site's policies indicating that these assessments are taking place and involve replacement of removed, expired, or damaged supplies may not be a reliable indicator of a stockpile's deployability. An external quality control check may provide a more accurate picture of the supplies' viability. Healthcare surge capacity could be severely negatively affected if a large portion of a stockpile's supplies were missing or unusable when deployed during a disaster.
The strength of this study is that it is the first to examine both the existence of a site's policies and procedures to manage a decentralized stockpile and also the actual amount of deployable supplies in the cache at each site. One limitation of this study was the small sample size, which may have prevented finding statistical differences between sites in terms of their policies and procedures and their actual management of the stockpiled materials. Another limitation is that the definition of “expired supplies” did not differentiate between those at higher risk of causing an infection (ie, supplies used for invasive procedures) versus those at lower risk (ie, supplies used for noninvasive procedures, such as providing first aid). Despite these limitations, this study provides strong evidence of the importance of performing regular assessments of stockpiled materials to ensure that supplies are not expired or losing their integrity due to inadequate storage procedures or a clear process for replacement.
Conclusion
This study examined one region's management of a decentralized stockpile in terms of existing policies and practices in place to manage the cache and the deployability of the supplies. Findings indicate that the vast majority of host sites reported that appropriate stockpile management policies and practices were in place, yet a large proportion of the cache was missing or unusable. Proper stockpile management is required to maintain the value of stockpiled materials and enhance healthcare surge capacity during a disaster. More funding needs to be dedicated to cache replacement and infrastructure to manage the cache to minimize costs associated with supply loss through damage or expiration. Other healthcare systems or regions should consider conducting a similar external assessment or quality control check to gain an accurate measure of stockpile deployability.