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The Impact of SARS on Healthcare Supply Chains

Sarah Friesen

Directives from the Ministry of Health and Long Term Care (MOHLTC) called for Sunnybrook and Women’s College to go beyond annual supply purchases of $50 million, to $1 million within the first week of the SARs challenge. It sounds nearly impossible to manage. But here is firsthand look at how innovative practices in logistics helped to mitigate one of the most difficult challenges to converge on Toronto.

T he recent outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto brought unprecedented challenges to hospitals. For a time, there was no business as usual, as Management and patient care staff alike focused on caring for patients with SARS while continuing to provide care to the general patient population. Layered on this activity was the added complexity of screening everyone who entered the hospitals, and wearing various levels of protective gear. I can’t begin to imagine what it must be like to be a frontline healthcare worker right now, and most especially what it was like during the height of the outbreak.

Hospital supply chains had their own taste of being on the “frontline” as we supported the directives issued by the Ministry of Health and Long Term Care (MOHLTC) to protect staff, patients and visitors. Purchasing and warehouse staff demonstrated wonderful creativity and initiative in sourcing products at odd hours and on weekends, and worked collaboratively with our suppliers and the Ministry to set up a whole new range of products in inventory. SARS tested our resourcefulness, and at the risk of sounding dramatic, created supply challenges unlike any I have experienced in my career.

The outbreak became real to many of us on March 27, 2003. I was on my way to an Ontario Hospital Association conference on Healthcare Supply Chains when I got the call to come back to Sunnybrook & Women’s immediately. All acute care hospitals in the GTA had received a directive from the Commissioner of Public Health, and we launched into battle mode. The directive required us to: limit access to the hospitals for all patients, visitors and staff; set up SARS isolation units; wear protective clothing (this included a surgical mask for all individuals entering the premises, and special protective clothing for patient care workers in high risk areas); restrict access to staff and visitors, including trades people who had worked at certain hospitals; restrict access of delivery personnel, e.g. couriers, who used to take packages directly to patient care units. At the same time, we began to cancel surgery and clinics.

The impact was immediate and significant. From a supply chain perspective, we were asked to source many products we had never carried in our inventory. We set up new supply carts with SARS related gear and created a 24-hour SARS hotline in our stores department. We changed our receiving department processes so that we could handle all the couriers that used to go direct. We informed our suppliers that regular business had been suspended, unless they were essential service personnel, and then access was severely restricted. And we wrote policies to support these new processes.

Under normal circumstances, the 12 buyers and contract specialists at Sunnybrook & Women’s put in a fairly regular workweek, sourcing products for our end user departments and meeting with suppliers. Receiving is open five days per week, and most of our replenishment activity takes place from Monday to Friday as well. Off-hour emergencies are rare, and are usually the result of the occasional manufacturing delay or missed demand forecast. Overtime is kept to a minimum as we manage tightly within our budgets.

That all changed overnight. For four to six weeks, the supply chain staff at S&W, like the staff at other healthcare facilities in the greater Toronto area, devoted most of their time to managing SARS supplies. The first few weeks were the most tense, and demand was impossible to predict. We took a very proactive approach and built inventories of supplies in anticipation, but still had many challenges to meet the needs of our more than 8,000 staff. As is often the case, most crises happened late on Friday or over the weekend. One buyer was trying to paint her house, and kept getting called down off the ladder to ask yet another supplier to open up on Sunday for some much needed supplies.

We had significant challenges finding the unique products that were required to protect our staff from SARS. Some of the products were items we used regularly, such as gloves and gowns, but suddenly we were using unprecedented quantities. For other items, such as the now famous N95 masks, we had no previous demand. Until we set up our supply lines, we visited every Home Depot and safety supply house in a wide radius looking for masks and face shields. The stakes were high; being out of stock on any of the core supplies was not an option, given the need to protect our patients, staff and visitors.

We took a very proactive approach and built inventories of supplies in anticipation, but still had many challenges to meet the needs of our more than 8,000 staff.

For perspective, we purchase approximately $50 million/year in supplies at S&W. At the beginning of the SARS outbreak, we purchased $1 million worth of supplies in the first week alone. While this activity leveled out, our daily consumption at the height of the outbreak included:

Our suppliers, both existing and new, were fantastic. They exceeded expectations, responding to our calls at odd hours, searching their global supply chains to meet our needs and personally bringing us supplies in the trunks of their cars. SARS has represented a new business opportunity for many manufacturers, and most have responded by significantly increasing global manufacturing capacity for key items such as N95 masks.

Beyond this, we had to ensure adequate supplies for the door screening process, and brought in several new tympanic thermometers (the type that go in your ear). The screeners go through thousands of probe covers every day as we take the temperature of everyone who enters the hospital. And throughout the hospital we have increased the use of alcohol based hand wash dramatically. As with the core products, the demand for these products skyrocketed overnight, placing significant strain on supply. One weekend we were counting out the bottles by unit while we waited for a rush shipment.

In early April, the MOHLTC divided the GTA into east and west to centralize and coordinate the distribution of supplies. Two healthcare organizations, St Michael’s Hospital in the east and Shared Healthcare Supply Services (representing University Health Network and Mount Sinai Hospital) in the west, were designated to manage the demand on behalf of the hospitals in their respective areas. Suppliers were instructed not to ship core products direct to hospitals, but only to the approved warehouse. We provided St Michael’s with our average daily demand, and began drawing supplies from a centralized warehouse (through the Ontario Government Pharmacy).

Although the impact of SARS was mainly felt in the GTA, plans were also put in place to ensure that all hospitals throughout Ontario had access to the necessary supplies. Regional Communication and Supply Centres were set up, and will continue to be a resource for hospitals in the event they have difficulty sourcing supplies. Regional Supply Coordinators were assigned to help the MOHLTC in monitoring demand, inventory availability and the distribution of emergency supplies. As in the GTA, hospitals were asked to provide demand forecasts to the Regional Centres, to ensure adequate supply was available.

What have we learned from SARS? We discovered we weren’t ready for a crisis of this magnitude, yet throughout the city and province (and across the country, no doubt), government officials and the management and staff of healthcare facilities came together and created processes and policies that ultimately stopped the spread of the disease. Going forward, we will build on those plans so that we can mobilize quickly in a similar situation. For example, the Ministry warehouse will continue to carry a safety stock of essential products, even after hospitals are ordering those items on their own again.

We also learned the value of good communications, as hospitals disseminated reams of information to educate and inform staff and patients, as well as to calm fears. From a supply chain perspective, we set up complex communications channels, to ensure a smooth flow of products to our end users on the frontlines.

SARS has retreated, with the last case reported on June 12, but hospitals continue to exercise vigilance to ensure we keep it that way. Some protective measures have been relaxed, and we are now focusing on our normal business activities again. Managing the SARS supplies has become a part of our daily routine, but we still screen everyone who enters the facilities, and frontline healthcare workers still don protective gear. We learned some important lessons from SARS, and are better prepared to respond should such an emergency reoccur in the future. We also learned the value of teamwork – people’s resourcefulness and responsiveness were key contributors to managing through one of the most difficult challenges of our time.