Hello, and welcome to today's webcast of Supply Chain Management During Outbreaks and Disasters. This educational opportunity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services. Its contents do not necessarily represent the policy of CDC or HHS and should not be considered an endorsement by the federal government. My name is Jeffrey White. I am the Director of Safety with Health Net Aeromedical Services in Charleston, West Virginia, and I will be your moderator today. A recording of this webcast will be available within five to seven business days. To access that, you can log into mysccm.org and navigate to the My Learning tab to access the recording. A few housekeeping items before we get started. There will be a Q&A at the end of the presentation. To submit questions throughout the presentations, you can type them into the question box located on your control panel. Please note the disclaimers that the material is intended for educational purposes only. The opinions expressed herein are those of the presenters and not necessarily reflect the opinions or views of SCCCM. Our presenters today are Dr. Gil Seda, who is an ICU Medical Director at Scripps Mercy Hospital in Chula Vista, California. Michelle Ralson, the Technical Director, Respiratory Therapy, Anesthesiology, and Critical Care Medicine at Memorial Sloan Kettering Cancer Center in New York. And Dr. Tony Gerlach, Clinical Pharmacist at The Ohio State University Wexner Medical School located in Columbus, Ohio. Good afternoon. My name is Dr. Seda. I'm the ICU Director at Scripps Mercy Chula Vista. Our objectives for our webinar today is to review the effects of disaster on the supply chain. We'll focus on staff, stuff, and space. We'll talk about the role of the ICU in the hospital surge plan. We'll also go over a needs assessment that includes space, staff, and stuff. We'll also recognize what are the unique infectious casualty surge requirements. And you may recognize a lot of these thinking about the COVID-19 pandemic at your hospital. It's a great way to look at how to deal with some of these things that we're going to be encountering. We'll also talk about the role of creating a contingency plan in advance. And then the third portion of our talk today will devise strategies for coping with drug shortages. So where do we begin for ICU supply chain? I think it's important before a disaster occurs to do a needs assessment of what you have at your hospital and what you'll need to cope with the disaster. And a nice way to break things down is what I have here on this slide. First of all, think about your staff, all the different staff that provide critical care services in your hospital, not just the physicians, the advanced practice providers, the critical care nurses, the ancillary staff, all those support staff, as well as the non-critical care staff in your hospital, the physicians, the nurses, the APPs that work outside of your ICU, and the other staff that support the care of the patients in your hospital. Think about the stuff in your hospital, the consumables and the non-consumables, the medications, the lines, the endotracheal tubes, IVs, as well as your equipment, your ventilators, your IV pumps, your dialysis machines. Think about what's your supply chain, and do you have a backup for supplies when there's shortages? Finally, think about space. Where is your ICU? How many ICUs do you have at your hospital? Are they available? Are they filled? Are they filled with ICU patients or non-ICU patients? Think about your ICU bed capacity in a disaster. The other thing that's important to think about is your non-ICU beds and whether they can become ICU beds. Look at your wards, your operating rooms, your post-anesthesia care units, your emergency departments, as well as your tents. So I'm going to start by talking about staff and space. One of the things I think that's important to recognize is that disasters amplify existing shortages. So I've listed here a lot of ICU staff that are in most hospitals. Think about what are the shortages you have now in your hospital. I know in my hospital, there's a real shortage of critical care nurses, and a lot of times that determines our bed availability. But think about the other staff within your hospital, your advanced practice providers, your nurse practitioners, your physician assistants, your critical care physicians, your respiratory therapists, your pharmacists, your ancillary staff, nutrition, occupational therapy, physical therapy, your social workers, case managers, chaplains, and also think about your housekeeping and maintenance. So think about what are your mitigation strategies for your staffing. It's very common in a disaster for staff roles to change. Hospitalists will be taking care of more complicated patients in a disaster due to a shortage of ICU staff. This will also be true for nurses. Nurses will be taking care of patients that may usually be managed by critical care nurses. So there's going to be some changes in expectations for your hospital staffing. Your hospital in the COVID-19 pandemic had to rely on hospitalists and non-critical care nurses, and that's going to be a common thing with disasters. You also may have taken advantage of staff from outside hospitals coming to your hospital to provide care. That's another valuable source of extra additional staffing. There may also be travel nurses, locum providers, and other temporary staff that may augment your staffing. You may also need assistance from your specialists within your hospital to help provide care. Another important resource is telecritical care services. Telecritical care services can also allow you to expand your critical care capability. With disasters, there's going to be staff shortages, and having mitigation plans before disaster occurs is going to be very important. In many textbooks, you've probably seen this before. If you haven't, this is kind of the tiered staffing for the ICU, and it's based on the notion that when you have a lot of patients, you're going to have an intensivist that's going to oversee several physicians who are overseeing some ICU patients with ICU nurses, and then some non-ICU nurses, and that allows you to care for more ICU patients. This kind of tiered staffing model where people will be out of their normal role caring for patients and caring for more complex ICU patients, but this is kind of the model that is recommended when you need to augment your staff in a disaster, surge your hospital's capacity. Some challenges that you're going to encounter when you increase your staffing and you're caring for lots of patients for a long period of time is going to be burnout and compassion fatigue. You know, burnout is where your staff are going to have that emotional exhaustion. They're going to lack that empathy for patients. And compassion fatigue is that, you know, constantly caring for patients, maybe at the expense of their own needs. Both are things that can happen, caring for patients for prolonged periods of time, and can be detrimental to a staff's resiliency. So those things you have to think about, you have to plan, and you have to have mitigation strategies for how to make sure your staff maintain their resilience and mental health. Your administration department will already authorize emergency credentialing for your staff so you can have staff from outside the hospital providing care. Other things that I listed here that I think are important is if your staff live far away from the hospital, having housing services nearby so they're not doing long drives after working long shifts, food services, pet care, other things are certainly important, daycare services if they have children, adequate sleep, very important, particularly if people are working the night shift, getting a good amount of sleep helps our mental health and resiliency. Other support groups are important. Mental health services and spiritual support I think is also very helpful. In terms of space, one of the things I would recommend to think about is how many ICU beds do you have now? What's your inventory? Do you have one ICU or are you at a larger hospital where you have several ICUs, a medical, a surgical, a neuro ICU, a burn ICU? Think about your ICU beds. Also think about how many isolation rooms your hospital has. Think about available spaces outside of your ICU where you can care for ICU patients. Can you use emergency department beds? At my hospital, the emergency department is full. They don't have many beds. They're very busy. But are there other places that can take care of ICU beds or become ICU beds in your hospital? Are there medical wards, surgical wards? Do they have telemetry? Do you have a step-down unit or a directly observed unit? A lot of times they have very similar capacity and ability like an ICU. Do you have other spaces in your hospital? Do you have an endoscopy suite, a cath lab? What's the size of your PACU, your operating rooms? You have available operating rooms that you could put patients in? Think about all those additional spaces. Things to think about in terms of ICU space. What's the proximity to your other ICU beds? Is it easy to get to in case there's the code blue or a rapid response? What's the size of the room? Is it big enough to carry equipment that we use in ICU beds? Can it fit all your ICU pumps? Is there room for a ventilator? If you need an x-ray, can the portable x-ray machine get in there? What's your source of oxygen? Is it wall? Is it an oxygen canister? Do you have negative pressure rooms if you have an infectious disease outbreak? Can they be converted to negative pressure rooms? Is it accessible? If there's a code blue and you need to get things in the room. And like I mentioned here on this last point, it's very interdependent on your staffing, your supplies. They're all interrelated. But space is another one of those things that's important. I've just listed here some other places to think about for ICU beds. The other option, you know, the last option is certainly putting people in tents or trailers. Those are things that we might have to think about if it's a significant patient capacity in your hospital or patient need. The other option, which is available too, is to transfer patients to other hospitals. In summary, know the role of your ICU and your hospital's hazard vulnerability analysis and disaster plan. Your hospital's hazard vulnerability analysis is the potential disasters in your local area that your hospital may encounter. Know the role of your ICU and those disasters. Have a plan to expand your ICU's capability. We call that surge capacity. Knowing your existing resources and what resources do you have available outside of your normal ICU. Prepare to use your in-house non-critical care staff in ways that help them augment the ICU service and critical care services. Know potential spaces in your hospital that can care for ICU patients. And when you're caring for ICU patients and you've got lots of staff, you're working long hours, recognize the risk of burnout and compassion fatigue and think of ways to take care of the resiliency of your staff. Support their resiliency, sleep, nutrition, time off, you know, all those things you have to think about. And then stay in touch with your other hospital departments as well as your administration and command center. That's going to be very important. I am now going to turn over here to Michelle, who's going to talk about stuff. All right. Thank you so much, Gail. So Gail did a great job talking about staff and space. And now we're going to talk about the stuff or the supplies. I want to review the effects of disasters on supplies in the supply chain. I want to review some definitions, some real-time pandemic responses, and then review some proposed mitigation strategies for adoption and better preparation. There are two main categories of supplies. There are consumables and there are non-consumables. These can also be described as disposables and non-disposables or durable goods. So examples of consumables are the things that are single-use, either per patient or just one-time use. For our patients, these are the tubes and lines we use, their medications, their nutrition or tube feeds, the hydrogen products we use. And they can really be most of the respiratory supplies. So this can be anything we use for the ventilator, their circuits, their filters. And for our staff, the disposable equipment we talk about is our PPE. It's our gowns, our gloves, our masks, the alcohol-based disinfectants we use, scrubs. Our non-consumables are things that we don't dispose of. It's our equipment like our ventilators, our pumps, dialysis machines, hospital beds, non-invasive ventilators, high-flow oxygen device. These are considered durable goods. It's also things that are not one-time use that may need to be reprocessed to be reused. And there has been a shift over time away from reprocessing things more towards one-time use and that has affected the supply chain. An example of that can be resuscitation bags many years ago. Those were reprocessed and reused and now those are one-time use. The overall COVID-19 effects on our supply chain consisted of inventory shortages, equipment shortages, and employee shortages. In March of 2021, I'm sure we all remember the six-day blockage of the Suez Canal by a container ship that had run aground. This was stuck for about six days, but it created shipping delays internationally that lasted months and affected the supply chain for months. Other shortages that we experienced were materials like computer chips, which affected the auto industry, and lumber, which affected construction of homes. Equipment shortages were also big things we all remember, like our PPE, our ventilators, our oxygen. There were also employee shortages that happened because of illness or shifting to work from home or even employees simply being furloughed because there was less work and companies could not pay as much and needed to lay employees off. And that all affects how facilities can manufacture if they have less staff. Most of us probably take for granted that when we turn on a flow meter in our hospital, we get oxygen. However, the pandemic really caused us to have to evaluate knowing where our oxygen comes from. Most hospitals have a bulk liquid supply, and liquid oxygen is stored kind of on our hospital facility in these big bulk refrigerated tanks. And the way that that comes into our hospital system as a gas is it is drawn through what's called a vaporizer, and heat is added, and that's how it becomes from a liquid into a gas. And what we saw happening during the pandemic was not simply a shortage of oxygen. It was this really unforeseen circumstance. What we saw was that this incredible increased usage of oxygen caused this increased rate of vaporization, so the oxygen ended up freezing the lines because it was not completely in the gaseous state when it came through the vaporizer because it did not spend enough time being warmed. So the oxygen supply was not depleted, but it was frozen. So we may have had oxygen, but we couldn't use it, so it didn't really matter. So this was a problem that we didn't foresee. This wasn't actually a problem in my hospital because what happened was really interesting. We had an attending that actually saw an article in the New York Times on this happening in Milan, and he forwarded this to myself and to our head of plumbing, and then our facilities team was actually able to monitor our vaporizers for this. And so when they saw frost accumulating, they were able to bring out industrial heaters and able to warm our vaporizers and our gas lines. And so we didn't actually experience this problem. And I was speaking to a hospital in Florida last year, and similarly, they dealt with this problem in their own way because they were in a different climate. They didn't have to use heaters. They were actually able to use their sprinkler system to warm up their lines. So it was definitely very interesting how a new universal problem had different solutions. And then similarly, there was such an increased need for oxygen that it brought about the fact that there are limited oxygen vendors geographically. So one area geographically is probably all relying on the same oxygen vendor. So let's say my hospital in one part of New York needs more oxygen. I'm going to be calling the same vendor for oxygen that the hospital across the street from me is. So we're all drawing from the same vendor. So the entire area is going to be low on supply. So that's also an issue. Another unforeseen supply issue was our PPE. We're all very well aware that N95s were extremely hard to come by. The simple fact was that these were masks that are made for single use and we weren't using them with every single patient before and all of a sudden we were. And so we had, you know, we had limited options. Do we reuse them? Do we reprocess them? My hospital chose to reuse them a limited number of times with surgical masks covering them but some hospitals chose to reprocess them using UV treatments or hydrogen peroxide vaporization, moist heat or dry heat. But it's important to remember that decontamination and reuse should really only be considered when necessary because these masks are designed for single use. What happened at my hospital was interesting. We found out that our original vendor that all of our staff had been fit tested for couldn't supply anymore. So while we were quickly able to find another vendor to supply, we had to overcome the challenge of fit testing our entire staff quickly. And in order to fit test your staff, you have to have the space to do it, the time to do it, but you also have to have people that are trained to fit test your staff. And one option when fit testing staff is bringing in a third party vendor that can fit test your staff for you. But that was challenging because we didn't want third party vendors coming into our hospital during the height of the pandemic. So we were able to do this and fit test our staff internally, but we actually had to do this more than once because the supply chain necessitated that we had to pivot from one vendor to another more than once during the pandemic. And we also ended up having a tracking system married to our inventory system to know what type of mask was available for fit testing at that very moment. So it's important that we were able to rely in real time on our information technology colleagues to kind of help us work with this ever-changing process. Finally, our experience with the National Stockpile of Ventilators was also very interesting. There was a rental company that acted as the distributor for the state stockpile. This meant that we had to log into their portal and kind of enter in our need for equipment and then they would assess, compare it to everyone else's request and get back to us. This led to a lot of quick distribution and redistribution of equipment. So one day we received 35 ventilators and within a matter of hours, they delivered. And a few hours later, we were told that we had to pack up and send those ventilators to a hospital across town that needed them more than us. So aside from having to pivot and redistribute equipment very quickly, we also had to deal with the fact that you don't get to choose what equipment you get and nor is it equipment that your staff may be familiar with. So you have to rely on vendors who could provide education, you have to rely on the internet, and the HHS.gov website also provided a lot of great information on the ventilators that were in the stockpile. But that's just the durable equipment. These ventilators also came with their own consumables, their own circuits, and filters that our staff had never seen before. So that also was a learning curve. And we hadn't prepared for this, so we didn't have any of this education developed. So in the real time that we were dealing with the logistics of getting the equipment and setting it up, we were also creating the education. So what can you do and what should you do to learn from all these things we experienced and to prepare ahead of time? You should develop contingency plans in advance of these disasters. This starts with having discussions with your management and your administration and foster their support and buy-in for why you should be prepared for any and all of these situations. You need to know your supply chain and diversify it. You have to communicate and maintain strong relationships with your vendors. For example, let's say you have product A and there's two different kinds and you choose the first kind. That doesn't mean you don't need to keep a relationship with the other vendor because there may be a shortage someday and you may need to pivot. So you always need to maintain strong relationships even if you don't routinely order something. You also should think ahead of time for a backup option. We always want to be able to order the product that we like the best and that suits our needs the best, but there's got to be a backup option when there are supply shortages. So we should choose those ahead of time so that we don't have to do that in the moment and are able to have education prepared for that ahead of time. And in doing so, we can also investigate if there are durable goods options instead of disposables. It may not be what we would like to do most of the time, but in an emergency, it could be a good backup option. You should also think about those supplies that are most critical to you and keeping a stockpile of them. This can be hard to do if you're an urban hospital like my institution because you might not have space. We don't have our own warehouse space in New York City, but we're able to partner with distributors and leverage their warehouse space. But if you're a rural hospital, you may have your own space and you should leverage that. But you also need to pay attention to expiration dates when you're doing something like that. You can also leverage your relationship with other hospitals. If you're part of a bigger system, certainly leverage your relationship within your own system if you ever need to borrow supplies. I'm not in a large system, but I have definitely called on hospitals very close by when I have run low on certain circuits for my ventilators and say, I have a delivery coming in a week and I need something today. I've definitely called and asked to borrow and offered to pay back and it's definitely paid off. You should always be looking for new vendors, new equipment, new relationships. Don't be afraid to take supply donations. We did this during the pandemic with our PPE. We took supply donations. It's really important that if you do that, you have to vet the legitimacy of what you're taking, but you should be willing to do that. Again, like I mentioned, you have the state and national stockpiles that you can take advantage of. And then once you have those contingency plans, you have to know how to operationalize them. So have criteria to enable them, leverage technology to keep track of data, keep track of your inventory. Also no forecast for what's happening with your vendors and what may be going on back order. And then have a plan for how you're going to communicate changes in supplies to your staff. So if you do go on a backup supply, have a plan to communicate that and have a plan for how you're going to disseminate that education that you've already created and that training. And then lastly, just like any other hospital response, like a code, have an after action review, have a debrief on your response, come together as a team and say, how did we do? And also once you're done and you've moved back to your normal supply, see what you can do with excess supplies. Can they be donated? Can they be redistributed within your organization or can you store them? So in summary, it's important to learn from each disaster, prepare as much as you can and know when to enact your plan. Identify product substitutes before they're needed so that you have time to develop education and remember that your relationships are invaluable. These relationships are with your administration, other institutions, vendors and your own supply chain. And now I'm going to turn it over to Tony to talk about pharmacy management. Well, thank you very much to Michelle. I think we have a lot of similar issues we'll be talking about with pharmacy supply, but both you and Gail gave some great content. And I think with drug supplies, you had another layer in there and that they're really common. And when I was putting this talk together on the 1st of August, there were more than 240 products that were on shortage for the American Society of Health System Pharmacists. And that's really a supply and demand issue. As I'll talk about in a little bit, part of this was because of a disaster, a tornado that hit a Pfizer plant that makes a lot of generic medications. And I think, especially in the United States, most of the drugs are manufactured, especially the intravenous ones, outside the continental United States, China, India, and Europe. And even when they're in the United States, a lot of them were in Puerto Rico. And with past hurricanes, that's been a problem with natural disasters, let alone much more difficult for the FDA to inspect plants. And I think as Michelle spoke so well about, 90% of drugs are distributed from free wholesale. This past Christmas holiday, I actually worked in being in Columbus, Ohio. I don't know if you remember, it was bitterly cold outside. And we were the only hospital in the state of Ohio accepting the frostbite victims. One of the drugs we tend to use is Alteplase or TPA. Having the relationship with two distributors, even though we get one mainly from Cardinal, did us a very big effect. Because we were running out, and as I left on Christmas Eve, we were down to our last dosage of TPA, and actually got the drug from Wheeling, West Virginia, versus a suburb of Columbus, where I work, much quicker. And having those relationships, especially on times of disasters, was invaluable to our patients that day. And I think a lot of that is because there's a lack of regional stockpile. And I think Michelle brought it so succinctly. In New York City, where real estate's a premium, that's not something you might have, which you might have in Columbus, Ohio, but you might not have in rural Idaho, for example. And I think, really, the supply and demand with COVID was really one of the things that we saw. And I was putting this together, and there's a lot of reasons for it. And I think early on, we were trying to do everything we can to help our patients. And thinking about some of the drug shortages, there was hydrochloroquine, or Plaquenil, that potentially was using, ivermectin, which still seems to be on. And I even saw some people using a lot of zinc. And all of those create a problem with the supply. And I think we always have to think about the unexpected. And there's a reason why we have a supply issue. There's a low cost of incentive to produce these less profitable drugs. And in addition, they seem to be produced by one plant in the whole entire world. So for my patient who was on the zinc and came in, who had intractable seizures, it was found, when we got a better history, that he was taking massive amounts of zinc. And if you remember, zinc and copper compete for the same site of absorption. And his cause of seizure was a copper deficiency. Well, back in COVID, when we had enough IV copper, it was pretty easy to treat them. But nowadays, if there was compounded by that disaster, that tornado at that Pfizer plant, it would be a lot harder to treat that patient. And these are just some of the issues that we talk about. And I think Michelle talked very well about the supply chain disruptions, especially with the ship that run aground in the Suez Canal, and really caused major problems, not only for non-medicine supplies, but for medicine supplies as well. And there's increase in demands and their effect about stockpiling. There's also surges, and not where you might see it first in Seattle, which had the COVID pandemic. Then it might have gone to New York and finally goes across the next part of America. And there's also prolonged length of stay and really utilization, like I saw, of low quality data. And I think the spread of this information on social media is something to keep in mind, as well as medical misinformation. And there's really, I think, a lot of holistic approaches that we can use to help with these issues. One is institutional, and really work in how we balance drug inventory. And realizing here is our purchasers and our drug inventory specialists really need to be at the table and be talking to the clinicians, such as myself, or get out the front line so we can develop a plan. And really having, if we need to, knowing that we have a conversation, knowing where the conversation needs to be. There might be some rotation of stock. Are there any therapeutic alternatives? So getting back to the Alteplase over Christmas, when I worked, if we had to use our last dose, my alternative, and I tried to communicate, was we probably would have used Tenecteplase because we also had that, unfortunately, and enough supplies. And really working with your purchasing people and the wholesalers to identify what drugs are at risk of shortage to really kind of looking at the bigger picture, at least in your hospital. And I think really what this is, there's also national, regional, and manufacturing issues, and really prediction models. I'm not sure they were the best during the COVID, but I think times where you might have a plan out because of a tornado, for example, that that might help us with some of these issues. Decentralization of products to multiple sites, sharing agreements, and collaborative dashboards will help. And I think, you know, in states like Ohio that are relatively small in space, geographically, that might have a big population, as there are talks going on on the regional and on level, especially with trauma patients, if we have big traumas occurring in the states. And really, I think one of the things that has done, and I know SCCM has been a part, is really recommendations and developing better lists of essential supplies and medications that we need to make sure, as well as improving the pharmaceutical process and really making sure that we engage the manufacturer and inventory management. And I think that goes to the bigger picture, which is global aspects. And we really need to have global planning for shortages and substitutions and conversion strategies, and sometimes thinking outside the box on how we were going to convert some of these patients. And they really do need to be multinational networks and recommendations on really the essential supplies, which is, I think, important, as well as what we can do for sharing agreements and getting out there. I think a lot was good in COVID that we were able to get some of these drugs from outside our traditional sources, such as China and other parts of the world, that we really need to have a more nimble effect with some of these sharing agreements. And really, the key points are to make sure that, with drug supplies, that we have the key stakeholders and make sure all areas are representative. Not only on the local level, at your own institution, what are the essential medications, but we need to think about those as the regional, national, and global issues. And I think one of the key supplies with some past shortages I've dealed with is really know where these locations and stockpiles are located. It does no one good, for example, earlier this summer, to have your ketamine, when it was on shortage, locked away in some room in the hospital that no one knows where it is on second or third shift on the week, and where they might need a drug for status epilepticus. It's not going to do the patient good. We need to know where those stockpiles are located. So, if we have to use them, we need to get them. And I think one of the things that you cannot overdo is communicate plans effectively, especially to frontline staff. And I think that's what the key stockpile is. Oh, we're in a shortage. We don't want to use it. But sometimes we might need to use the drug, especially if there are other alternatives out there. And that frontline staff really needs to know that. And I will say that was one of the things that I think I probably did being in my job for 25 years now, is communicate not only to the pharmacy staff, but the nursing staff that's in the surgical ICU that we're getting these patients, as well as the physicians taking care of them. So, we knew where everything is. And in case of shortages, we really need to develop plans for alternative medications. And ideally, if it's something that's an unfamiliar product to your staff, quickly get some education out there so they know how to use these projects quickly and get all the pieces. So, we give our patients the best care that we can. And now I think it's time for questions and answers. All right. Yes, there are a couple of questions. The first one is kind of a general question for the entire group. So, whoever would like to answer it. Did any of your institutions give emergency critical care medicine privileges to ED physicians during the pandemic? I believe this is Tony. I believe that we were close to it. I know we did early on a lot of training, not only for the ED physicians, but additional training for our anesthesia staff, as well as our general surgery staff, in case they had to cover patients. And personally, I gave a lot of education on PADIS and what to use, as well as they did develop plans on making sure that if they were using non-critical care staff to try to have experienced physician providers, such as NPs and PAs, to help out. So, they were taking care of patients the best they could. Yeah, this is Gil Ceda. I'll answer that question as well. My hospital is very small. So, we certainly have infectious disease critical care. We have anesthesia critical care. I think at our hospital during the pandemic, the emergency room was so busy. I really think they did critical care services and they housed patients when there were no beds available. And it wasn't uncommon for patients to remain in the emergency room for a long time. So, they sort of did critical care in terms of managing ventilators and taking care of patients, but they didn't come over to the ICU. They were very busy where they were at. And my hospital is quite different. We're a cancer center. And so, we don't have a typical emergency department. We have a center for oncological emergencies. So, I can't really answer this the same way. All right. Thank you all. The next one we have is for Gil. How did the travel staff, when you get a new group of travel nurses in or travel physicians or locums or whatever the case may be, how was the effect on your PPE supply and your processes that they were coming in, learning the new processes, and by the time they got it down, they're on their way out and you have a new group. Did that affect the flow in the ICU at all? It certainly did affect the care of ICU patients. They were not familiar with our unit, but I thought they learned well. They picked up how things went. And there were usually other ICU nurses they could talk to. What Michelle said was very true with our hospital as well. We didn't have enough PPE, so we ended up trying to kind of conserve what we had. We had a variety of different N95 masks in the beginning because we would run out and then we would use something else. And we usually have to stay with what we had for a long time. But when we did have travel nurses, it seemed like we had the same ones that stayed for a while, which over time became more helpful because they saw the way our unit functioned and they seemed to adapt to the way our ICU was managed. Perfect. Thank you, sir. Next is for Michelle, kind of following along those same lines of the personal protective equipment, especially being a cancer-specific center. What kind of struggle did you have or what was the process you had of finding approved PPE? There were multiple kinds of different masks and gowns and different eyewear out there, but ones that were actually certified and good to use and not just something with a label on it. We were incredibly lucky. We very early on found a vendor of N95s that could support us. And so we never had such a shortage that we had to consider reprocessing. We just had to do, you know, reuse to an effect. When it comes to other PPE, we had a lot of donations come in, and I talked about that a little bit, but we really did have, we had a lot of donations come in. We actually, I was told a story, one of our supply chain administrators actually met someone like on a street corner early in the morning to like do a deal and got some PPE. But you have to, they had to kind of vet everything when they would get, they would constantly be getting information and calls. They actually set up a hotline for staff and the public to call. And if they knew of PPE or a source or had someone that could donate, and then they had staff that could vet that information. So it was a whole, it was a whole operation and we had staff dedicated to that. And then we were very fortunate that we always had enough. All right. Thank you for that answer. One last question, and this one is for Tony. When you have those medications on backorder, you go find a suitable replacement. But during this process, how far down did you have to get to second and third replacements for those drugs that were on backorder or did it push you that far down the line? No, it did. And I think it's a little bit dependent on the drug and the patient's condition. Ideally, if you're talking about sedatives and stuff or the need for neuromuscular blockade, I think we were always robbing Peter to pay Paul as the saying goes. And luckily, similar to Michelle with the PPEs, we really never ran out of some of those medications. But I think we also did a good job as people were getting better, is switching what we could to oral medication and trying different strategies. I think in the past, with some other shortages, it's one thing if you're having a shortage of, let's say, norepinephrine, which we've dealt with a couple of times, where you have suitable alternatives, such as epinephrine or phenylephrine or dopamine, for God's sakes, that you have other options. Or steroids, where in the past, especially COVID, there were some shortages of dexamethasone, but we were able to use other agents, including oral agents, as appropriate. And those are taking it. I think the hardest one was some drugs like tocilizumab for people with severe COVID that, although especially it was on our pathways or guidelines for it, yes, there was a big price. And someone, unfortunately, and I think, thank God that we have a great staff that some of the physicians were able to come up and be one or two of them, really be the gatekeepers of some of those drugs. So there's a variety of ways to treat with it. And I think it depends, is there truly an alternative or not? Perfect. Thank you all. There were no other questions posed by the group. So this will conclude the Q&A. I do want to thank Dr. Seda, Michelle, and Dr. Gerlach for your time. I want to thank the audience for attending this presentation. And again, as a reminder, this webcast was recorded. The recording will be available to registered attendees within five to seven business days. Again, log into your mysccm.org account, navigate to the My Learning tab, and you can access the recording there. So again, thank everyone for your participation. And this will conclude our presentation today. Thank you.

supply chain management

disasters

ICU

preparedness

PPE supply

pharmacy management

communication

COVID-19 pandemic