Introduction
The Supply Chain and Pharmacy breakout session focused on participants’ real-world experience with supply chain and pharmaceutical needs for their alternate care facility (ACF). This included details around acquisition and utilization of durable medical equipment, personal protective equipment (PPE), consumables, and pharmacy stock. Participants were encouraged to discuss supply chain management considerations, resource allocation and acquisition, and influencing factors that impacted these topics. Participants explored various approaches to obtain medical supplies and pharmaceuticals, including leveraging existing vendor relationships and establishing climate-controlled storage spaces, while emphasizing the importance of electronic tracking systems and documentation. The goal was to focus on what participants did and how deficiencies were managed. The discussion covered challenges in health care coordination during disasters, including supply chain issues, the management of unsolicited donations and volunteers, and the need for innovative solutions like drones and alternative medical applications, concluding with reflections on regulatory oversight and opportunities for process and systems improvements. The group identified several key gaps in emergency response systems, particularly the disconnect between emergency management agencies and health care systems, while emphasizing the need for qualified liaisons, just-in-time training, and systematic approaches to ensure effective medical resource management during crises. Clinical Operations were discussed in a separate breakout session summary.
Facilitators used the following questions to prompt and guide participants:
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• How were supply chain and pharmacy needs managed at your ACF?
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• Provide specific examples.
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• Describe some of the successes with your supply chain and pharmacy processes.
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• How did you sustain these?
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• Describe some of the challenges with your supply chain and pharmacy processes.
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• How were these addressed?
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• Do you have any best practice recommendations for ACF supply chain and pharmacy management?
To encourage further detailed discussions, additional questions were available for facilitators. These questions could be asked if group discussions slowed during the 50 minutes and if time allowed. Some groups discussed some of these questions while others did not have time:
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• Did the supply chain and pharmacy processes change over time while your ACF was operating?
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• What specific supply chain strategies or partnerships were most effective in rapidly standing up the ACF?
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• How did pre-existing vendor relationships or group purchasing agreements contribute to timely procurement?
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• Were there any examples of resource-sharing (i.e., between hospitals or agencies) that significantly improved ACF readiness?
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• What were the most significant bottlenecks in sourcing critical equipment (i.e., ventilators, monitors, oxygen delivery systems)?
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• Were there challenges in aligning the ACF’s equipment standards with hospital-level care requirements (e.g., regulatory compliance, compatibility)?
From PPE to pharmaceuticals to ventilator tubing/connections, disruptions expose how fragile and fragmented health care logistics can be. Experiences from hurricanes, pandemics, and field deployments highlighted that supplies are often stored in the wrong places, contracts lack flexibility, and burn rates are poorly tracked. Successful ACF operations integrated supply chain leaders into command structures, emphasized conservation strategies, and leveraged local, regional, and state partnerships. The overarching lesson: resilience requires pre-positioned contracts, transparent tracking systems, and recognition that supply chain management is as central to patient care as medicine itself.
Theme 1: What Was Done
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• Disruptions and Stockpile Gaps: Past incidents revealed that centralizing equipment risks loss (i.e., from flooding) and that stockpiles frequently lacked essential components (i.e., fittings and connectors). Quality assurance for medical supplies is critical during emergencies.
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• Improvised Pharmacy Function: Pharmacy services required extreme adaptation, shifting from traditional models to “refreshment stands converted into pharmacies” within the ACF, requiring new protocols for sterile storage and dispensing.
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• Courier-Based Fulfillment: Logistical solutions included establishing complex, time-sensitive courier systems for once-daily lab draws and transporting compounded medications (i.e., IV infusions) from remote partner hospital pharmacies to the ACF.
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• Data-Driven Sourcing: The lack of accurate tracking for specialized items (i.e., oxygen concentrators) meant that procurement relied on anecdotal reports and clinical expertise rather than quantifiable burn-rate data to inform state-level purchasing decisions.
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• Vendor Partnership for Controlled Substances: To manage high-liability inventory like controlled substances, ACFs relied on pre-negotiated agreements with commercial partners (i.e., CVS/Walgreens) to handle secure dispensing and accountability, which traditional ACF models lacked. Traditional ACF models typically use hospital pharmacies or stockpiles.
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• Communication: Significant challenges were identified in navigating multiple supply reporting structures and overlapping requests from different government entities during the COVID-19 response, which created confusion and inefficiencies. The participants emphasized the importance of clarifying information requirements and establishing clear communication channels to avoid duplicate requests and improve resource allocation.
Theme 2: Successes and Sustainment of the Supply Chain in an ACF
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• The Role of Centralized Procurement: Centralized state procurement bodies were essential for leveraging purchasing power and preventing local hospital competition.
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• Centralized State Logistics: To prevent local competition, states reported utilizing centralized logistics (i.e., one warehouse being central supply). A central warehouse became a staging point, reducing the need for ACFs to manage complex acquisition logistics.
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• Supply Chain Oversight: Embedding supply chain leaders in the ACF leadership team improved visibility and decision-making. Reliable supply chain officers acted like “air traffic controllers,” balancing competing needs and contracts. Military experience in logistics and supply chain management proved valuable during the emergency response.
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• Data Driven PPE Distribution: The use of dashboards and reporting tools (i.e., ventilator tracking, PPE burn-rate models) enabled proactive management of supplies. Centralizing PPE and redistributing by need, rather than on first-come-first-served, improved fairness in allocation.
Theme 3: Challenges and Mitigation Efforts
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• Fragmented Logistics: Supply lines for pharmaceuticals, respiratory equipment, and general medical supplies operated in separate silos, complicating procurement and inventory tracking.
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• Contractual Lock-in and Vendor Leverage: Rigid vendor contracts allowed private companies to cancel services if hospitals sought alternate sourcing, exposing the system to financial manipulation and supply control during a crisis.
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• Inventory Tracking: Hospitals relied on a “just-in-time” model, compounded by staff hoarding essential items in “floor-level stashes hidden outside central supply” (i.e., PPE), hich masked true inventory and consumption rates. Expiration dates created challenges for stockpiled supplies.
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• Vendor Price Inflation and Fraud: The high demand for essential goods led to vendor price gouging, and the implementation of waivers resulted in fraud, waste, and abuse as vendors aggressively pursued reimbursement for unnecessary or non-existent equipment.
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• The Scarcity of Respiratory Resources: The need for items like sterile water, ventilator tubing, and high-flow nasal cannula circuits was consistently underestimated, highlighting that respiratory supplies, along with staff, often become the true rate-limiting factors in high-acuity surges.
Theme 4: Potential Future Directions
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• Alternative Financial Leverage: Exploring financial programs, such as leveraging the 340B prescription drug program for eligible hospital partners, was recognized as a potential strategy to offset the high cost of pharmaceuticals and maintain robust stockpiles.
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• Embedded Supply Chain Expertise: Embed dedicated supply chain and logistics experts into the ACF management structure upon activation, as their role would be to manage procurement and track burn rates in real time to identify sourcing alternatives. Build on existing supply chains—don’t reinvent during a crisis. Pre-established relationships are more effective than creating them during emergencies.
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• Legal Regulations: Legislative frameworks must be established to ensure that existing contracts cannot be unilaterally canceled without a formal review process during disaster declarations. Pre-establishing comprehensive vendor contracts can assist in safeguarding against opportunistic cancellations. This should also be supported by a legal framework that prevents price gouging and exploitation, ensuring fair distribution of supplies to hospitals.
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• Formulary and Cache: A defined cache for pediatric and specialty supplies is often overlooked in planning and should be part of ACFs. It is also important to create training for staff on alternative equipment, supplies, and ACF pharmacy formulary and cache lists. It is advised to train regularly on cache and conduct exercises/case scenarios on the equipment. Leaders should have a plan for resupply to the ACF.
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• Health care Coalitions: Cross-collaboration among clinicians and the establishment of expert coalitions to improve situational awareness and resource allocation is critical.
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• Innovations: Integrating emerging technologies such as the usage of drones for delivery and utilizing public and private supply chains (i.e., Walmart) will modernize response capabilities.
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• Communication Infrastructure: ACF plans should prioritize infrastructure resilience by including alternative and redundant communication methods for when traditional communication infrastructure fails.
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• Supply Chain Teams: Supply chain teams should implement robust tracking systems to monitor burn rates and consumption patterns of medical supplies, utilizing standardized reporting to maintain visibility across all health care facilities and ACFs. Teams should anticipate single-source vendor dependencies for critical medical supplies.
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• Conservation: There is a need to address conservation strategies in a way that focuses on using resources more efficiently rather than simply using less, while navigating the challenges of supply chain strategies at a national level. Standardizing protocols for high-demand items, implementing checks and balances for supply use, and collaborating with subject matter experts to address shortages are important due to the importance of clinical judgment in medication substitution and the need to decentralize supply management across different departments.
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• Reducing variability by standardizing equipment and pharmaceuticals is essential to ease substitution and tracking.
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• Expert assessment of expired supplies can prevent unnecessary waste. There is a secondary need for clear protocols regarding the use of supplies beyond labeled expiration dates.
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• Storage conditions are critical for maintaining supply quality and requires consideration.
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• Crisis Standards: Experiences with drug rationing and prioritization, particularly during the COVID-19 pandemic, highlighted the challenges of implementing such measures in real-time. An example of a three-tiered approach to managing finite resources, from conventional use to contingency and crisis scenarios, with specific trigger points and metrics to guide decision-making is advised. Development of algorithms for prioritizing treatments like monoclonal antibodies and ventilators should emphasize the need for data-driven approaches and collaboration with subject matter experts and ethicists. Supply chain and resource allocation apply to all health care settings, not just hospitals, as smaller facilities often lack expertise in ordering medical supplies.
Summary
Supply chain and pharmacy operations revealed significant systemic fragility in health care preparedness assumptions. Symposium participants documented that stockpiles frequently lacked essential components, vendor contracts were inflexible and vulnerable to price gouging, and hidden inventory practices masked true consumption rates. ACF pharmacy operations required extreme adaptation, including improvised dispensing locations, courier-based fulfillment systems, and commercial partnerships to handle controlled substances.
Supply chains will remain a limiting factor for ACFs. Building resilience means embedding supply chain leaders in command structures, reducing variability, standardizing contracts, and implementing transparent burn-rate tracking. Supplies must be treated as critical clinical infrastructure—without them, even the best-designed ACFs cannot function.
Competing interests
None.
