Forged In Fire

March 1, 2008

A San Diego hospital benefits from automated inventory management during the 2007 wildfires.

Southern California is renowned for the semi-arid climate that brings it abundant sunshine and average annual precipitation of less than 12 inches; but the long stretches of fair skies, warm temperatures and low humidity often come at a price. In 2007, the National Climatic Data Center of the U.S. Department of Commerce reported that long-term moisture deficits were subjecting much of the area to conditions of “severe to exceptional drought.” Often, the months of late summer and early fall bring with them strong winds called “Santa Ana” that characteristically gust through the inland mountains and coastal valleys at near hurricane force.

A San Diego hospital benefits from automated inventory management during the 2007 wildfires.

Southern California is renowned for the semi-arid climate that brings it abundant sunshine and average annual precipitation of less than 12 inches; but the long stretches of fair skies, warm temperatures and low humidity often come at a price. In 2007, the National Climatic Data Center of the U.S. Department of Commerce reported that long-term moisture deficits were subjecting much of the area to conditions of “severe to exceptional drought.” Often, the months of late summer and early fall bring with them strong winds called “Santa Ana” that characteristically gust through the inland mountains and coastal valleys at near hurricane force.

This combination of wind, dryness and heat turns the region’s dense-growing evergreens and other drought-resistant shrubs, or chaparral, into explosive fuel for wildfires. On Oct. 19, the National Weather Service issued a Red Flag Warning for the mountains and coastal valleys of San Diego County, citing strong Santa Ana winds, gusting to 80 mph in some places, very low relative humidity and warm, dry conditions. The only ingredient missing from this recipe for disaster was an ignition source; a vehicle fire, a carelessly tossed cigarette, a match. The next day, the powder keg was lit.

Five separate wildfires were raging through San Diego County (site of the two largest wildfires) by Oct. 22. Two hospitals in the northern portion of the county were forced to evacuate, or face the possibility that escape routes might later be cut off. Pomerado Hospital, in Poway, began evacuating just before 9 a.m., using school buses and ambulances to transfer patients to several area hospitals. At 3 p.m., in the nearby community of Fallbrook, emergency management officials ordered the evacuation of the city’s entire population, including that of Fallbrook Hospital. Sixteen patients found their way to Tri-City Medical Center (TCMC) in Oceanside as thick smoke from the fires choked freeways, forcing some Pomerado transfer patients elsewhere.

Because of a robust supply chain delivery and materials management system, TCMC was prepared to respond to a significant patient influx and remained operational throughout the disaster.

Prepared, Just-In-Time

As TCMC discovered during the four days of wildfires, having an efficient combination of inventory tracking, disaster planning and supply chain logistics was key to a successful response. Alan Coates, director of Supply Chain Management at TCMC, says that previously inventory was hand-counted. This slow, often inaccurate process would have created a nightmare scenario during the wildfires. “With our automated system, we receive realtime information. This supports our “just-in-time” (JIT) approach to materials management, and it’s a better method of controlling cart levels and re-order points,” says Coates.

TCMC selected the Pyxis SupplyStation system from Cardinal Health in 2000, as part of an overall effort to automate materials-management processes, including medication administration. For that particular process, TCMC uses another Pyxis product, the MedStation. To Coates, it made sense to standardize the automation of their materials management processes by using the same vendor.

A key link in their supply chain, the SupplyStation system is a secured supply storage cabinet that uses touch-to-take technology. By touching a “take” button on the cabinet when removing an item, usage, inventory and replenishment information is automatically recorded and transmitted to the hospital’s materials management inventory system (MMIS). The Pyxis system manages a network of these secure storage stations, which are located throughout the hospital, with a SupplyStation console that is, essentially, a Microsoft Windows 2000 server linked to the MMIS.

Wireless technology integrates approximately 70 of the SupplyStation units, located in 12 OR suites and on patient floors throughout the hospital, with ValueLink, the vendor’s stockless inventory-management service. ValueLink interfaces with the MMIS and provides automated order entry, par level replenishment, electronic invoicing, guaranteed fill rates and 24-hour-a-day availability. The hospital has bulk orders delivered daily and needed supplies can be delivered several times a day from the vendor’s distribution center located 90 miles away. This channels all of TCMC’s supplies through a single integrated system that breaks bulk quantities into immediately required units, enabling low unit-of-measure orders to be delivered directly to individual hospital units or other points of care.

Therefore, TCMC is constantly aware of what materials are inbound to the hospital from the vendor’s JIT warehouse – a crucial factor of their success during the wildfires. “The realtime reporting of the SupplyStations helped us to monitor, analyze and maintain the supply chain,” says Coates. “Not only did we know what was being consumed every day, but also what was coming in the next day.”

By operating as a stockless inventory-management system with their supply chain partners at Cardinal Health, TCMC mitigates the cost of storing, maintaining and distributing supplies. The vendor owns the inventory contained within the SupplyStations until it is taken out (at which point it is simultaneously recorded) and utilized at the point of consumption. “This is a benefit to our organization because those supplies then become an expense related to patient care, so it becomes more of a proportional dollar expense of consumption for that activity,” says Coates.

Leave Nothing to Chance

This realtime inventory tracking was invaluable to Coates and other TCMC staff who were tasked with keeping the hospital supplied while eight wildfires devoured countryside, homes and other structures throughout San Diego County.

Craig Lawyer, TCMC’s Environment of Care officer and incident commander during the wildfire event, ensures the hospital is prepared to respond to a mass-casualty event even before one occurs. “What I look for when developing disaster response plans are ways we can mitigate its impact to our facility,” says Lawyer. “Since we are a JIT warehouse-supplied healthcare facility, I consider the Pyxis Supply system a valuable resource to our clinicians. If they need supplies, those materials are readily available to them and they aren’t forced to wait for the distribution process to take effect.”

“The primary objective is to develop a plan with the vendor and identify supply chain needs,” he says. Lawyer and TCMC use what they call a “memo of understanding,” making the vendor aware in advance, what to have on standby. In addition, he adds, it’s important to identify supplies that are routinely consumed during mass-casualty events. These supplies are prepurchased and staged at the vendor’s JIT distribution facility, ready to go, when hospital inventories begin to be consumed more rapidly than normal.

Some of the supply chain routes frequently used by the vendor had been shut down due to the nearby wildfires. “The logistics of getting the vendor’s supplies to us needs to be preplanned as well,” says Lawyer. “Including alternate routes and airlifting, if needed.” To do this, TCMC met with all 24 San Diego County hospitals as part of their regional disaster preparedness program, identifying core supplies that would be utilized and shared in such an event.

During the four days of wildfires, the vendor supported TCMC with six materials services technicians (MST) along with a ValueLink program supervisor, to oversee every link in the supply chain. “They played an integral role during our planning process,” says Lawyer. “They ensured that I was provided with actionable information regarding what was being consumed. We knew that we were running low on albuterols for the respiratory illnesses, as well as the N95 masks,” he says, referring to the particulate respirator/surgical mask commonly worn by clinicians. “Having that kind of robust information flow, and knowing what’s going to be available in our inventory tomorrow, helped me to plan for the injection of a supply and identify needs for the next day’s response.”

Responding to Disaster

Had the automated materials management system not been in place during the wildfires, TCMC staff would have had to cycle count everything by hand. Instead, materials management personnel generated a constant stream of supply inventory reports to identify supplies that were rapidly being consumed. “During the wildfires, it was the N95 mask that we needed, because we were providing those to the public as well as to our staff,” says Lawyer.

Many of the TCMC staff themselves were forced to evacuate from their homes during the disaster. “We were wrestling not only with the patient volume increases, but also with our own staff’s difficulties getting to the hospital because they lived in the evacuation zones,” says Coates. “One member of our staff, who was evacuated from her home, took her family to the QualComm Stadium evacuation shelter and then drove another two hours back to Tri-City so she could support our activities and response to the disaster,” says Lawyer. “It really demonstrated the caring, compassionate side that Tri-City medical staff have towards each other, as well as towards our community.”

In addition to continuing to provide high-quality patient care at their own facility during the fires, TCMC sent nursing staff out to several evacuation shelters to perform patient respiratory illness assessments. A child day care site was set up at the hospital, at one point caring for 72 children, as well as a pet shelter. Meals were supplied around the clock to staff members and their families and sleeping arrangements were also provided. Additionally, TCMC set up surge capacity tents next to its ED, providing it with 60 additional beds to accommodate the 9 percent influx of patients during the event. “We were able to deploy all of our assets within about an hour of our first notification of patient transfers,” says Lawyer.

A Positive Outcome

On Nov. 6, nearly three weeks after the fires first ignited, California declared the wildfires finally under control. More than 6,000 firefighters had battled alongside U.S. Armed Forces, the National Guard and firefighters from Mexico to extinguish the rampaging blaze. Left behind in its sooty, smoldering path was half a million-acres of destruction stretching from Santa Barbara County to the U.S./Mexico border. The fires had consumed more than 1,500 homes in seven counties, killing 14 people and injuring 85 others, 61 of them firefighters.

Although they were powerless to stop the raging wildfires, Coates and Lawyer, along with the entire staff of TCMC, had been prepared to respond. Being aware of the materials they needed and having those ready at a moment’s notice, enabled them to make the crucial difference.

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