For every ambulance on the street there is a store somewhere containing equipment and possibly medications to fill up that vehicle when it returns from its run. The management of this store, whether it looks after one ambulance or 100, can be the cause of financial hemorrhage and litigation risk without tight logistics management.
While preparation and planning is always encouraged, when it comes to expensive medical equipment and supplies, stock on the shelf represents hard cash. If such equipment and supplies spend their entire shelf lives on the shelf, then you might as well throw your dollars away.
The key to good stock control is the creation of a system and processes that ensure efficiency and accountability are maintained at all times. After payroll, medical stock and equipment is one of the largest expenses an organization has to deal with, so constant attention is required.
Where to Begin
To best manage your stock, you need to understand usage and flow from the store, or point of ordering, onto the ambulance or into the med pack, and how it is dispensed during the patient episode.
This understanding identifies the par, or stock level required to keep the organization moving. Moving is a key term, as analysis of stores consumed identifies items that move through the logistics system faster than others and consequently must be replenished more frequently.
Once the par is identified, the time it takes a supplier to go from order received to stock on the shelf must be factored in. Par levels may need to be adjusted or stores ordered once they hit a certain level in order to maintain system flow.
Having identified all of the above, a scientific approach to stock control can be adopted with the goal of having enough in stock to deal with normal operations, but not so much that you risk it going out of date before use. This process is known as “just-in-time supply.”
The Richmond Ambulance Authority (RAA) employs this system and can offer some best practices to aid both logistics management and stock flow.
When tracking supplies, using an electronic inventory management system enhances the ability to see what supplies are used most and how much money is spent in each individual category (e.g., oxygen, medical equipment, medical supplies and medications).
Such systems can be either bar code reader-based or radio frequency identification (RFID) systems. RAA employs a bar code system that reads directly into a central database that identifies stock usage against the par and stocks to be electronically ordered. If it is not practical to implement an electronic inventory management system, Excel spreadsheets are useful, particularly when trying to track expiration dates.
The RAA system has identified that a week’s worth of fast-moving supplies (e.g., IV supplies, nonrebreathers, nasal cannulas, ECG pads and nebulizers) is required. Conversely, slower-moving stock (e.g., defibrillation pads, endotracheal tubes and decompression needles) can last 7–10 days before reorder. Do not overstock on these supplies; pay attention to expiration dates.
When ordering supplies, it is best to set aside a specific day of the week to place orders. This allows for a good working relationship between the EMS agency and its supplier. The supplier and its warehouse will know when to expect orders and what supplies are needed. This will help to avoid back orders. RAA’s logisticians set aside early Monday morning for placing supply orders, allowing the orders to be delivered by midweek (based on knowledge of delivery lag times). After the supplies are received, a midweek order is also placed.
Using a sealed-bin speed-loading system eliminates ambulances being over- or understocked and allows for consistency on each ambulance. Sealed bins are loaded by logistics staff by commodity or treatment (identified by logistics and vehicle-stocking standard operating procedures). Stores are heat-sealed into packs and placed on every ambulance in the same position, providing a uniformity that makes spot-checking easy. From an accountability perspective, as stock is taken from the storage area and sealed into bins, it is classified as used and the par level adjusted, which in turn cues reorder.
For the binning system to be successful, there has to be a level of trust between logistics and field personnel. Field personnel need to be confident that when they open their bins, everything that is supposed to be there is in fact there. The binning system is most successful when staff are dedicated to stocking the bins.
The sealed-bin system allows for the logistics department to successfully manage just-in-time stock control measures. Personnel dedicated to binning have the greatest knowledge about how fast supplies are used. Their knowledge of how quickly supplies move allows for accurate orders to be placed when in a nonautomated stock control system.
Leveraging External Relationships
It is important for EMS agencies to have strong working relationships with their local hospitals. Ask if it’s possible to rotate equipment through and/or have a one-for-one stock exchange. For example, if a nonrebreather, ECG pads and IV lock set are used on a patient, could those supplies be replaced on patient handover? Sign an agreement so both parties understand what is expected. There may also be a requirement to have a one-for-one stock exchange with first response agencies. If they use a nonrebreather, the transporting agency will give them a nonrebreather because it can then be replaced at the hospital. This allows the first response agency to maintain its bag and readiness.
Logistics staff serve a crucial role in ensuring smooth operations. RAA logistics staff not only clean and stock ambulances so they are ready for field crews, they also visit area hospitals and pick up equipment left by field crews after patent handovers. This equipment is brought back to logistics and cleaned prior to being placed back in service. This helps improve hospital turnaround times—crews aren’t tied up cleaning equipment. Each ambulance is deep-cleaned monthly. All bins are removed from the ambulance and replaced with fresh ones. Cabinets are emptied and wiped down. Floors are scrubbed with a heavy-duty cleaner. Logistics staff can also be used for lifting assistance, which avoids the need to take another ambulance or first response fire apparatus out of service.
Stores equal cash on the shelf. A just-in-time supply system keeps stock moving at the appropriate rate of both affordability and consumption.
Best Practices for Stock Control
Don’t overorder: Track what’s used most often and keep enough stock on the shelf for one week. This should provide enough time to place an order with your supplier and have items delivered.
Only order relevant stock: Don’t favor supplies or toys that are outside your EMS agency’s scope of practice. Your OMD can recommend what supplies and equipment work best.
Appoint a lead: Having one person in charge of ordering supplies avoids the potential for double orders or orders being missed.
Implement checks and balances: Check supplies regularly. Complete a thorough walk-through of all supplies needed at least once a week, although we recommend doing it twice.
Manage shelf stocking: When new supplies arrive, place them behind the old stock. This will rotate the stock that needs to be used before expiration.
Stay oxygenated: Sending unused O2 back in cylinders returned for refill is wasteful. Keep an eye on how often oxygen is being exchanged and set a standard for when it should be changed out. RAA uses 500 lbs. for the main oxygen and 700 lbs. for its portable oxygen. RAA is an inner-city system with relatively short transport times; rural system may want to allow for greater minimums.