No matter the effort or the second guessing, you’re still not able to get the job done.

So the fissure between supply chain management and critical care widens as the former believes the latter makes too many unrealistic demands without any forecasting, while the latter feels the former simply remains out of touch with the hectic pace and unpredictability of the cardiac/coronary or intensive care units.

Experts and observers point to a lack of communication or miscommunication as the common denominator fueling the operational disconnect.

But some hospitals have bridged that gap. Healthcare Purchasing News tapped two critical care nurse managers who have successful working relationships with supply chain management to share some process innovations they developed together. Some are relatively basic and simple, but nonetheless effective.

Mary Bylone, R.N., MSM, CNML, alumnus CCRN, recalled working in one facility where they were consistently running out of the specialty catheters they stocked.

"Because we allowed for physician preference, we needed to maintain an inventory of over 15 different catheters," said Bylone, assistant vice president, Patient Care Services, The William W. Backus Hospital, Norwich, CT. "In order to do this, I always ordered in the smallest quantity I could obtain, which was five. Otherwise, I would have had thousands of dollars of inventory on the shelves for these catheters alone. Because the use was unpredictable and the time it took to reorder and restock was at least seven days, we would constantly run out of the one the physician wanted." 

Then she discovered that several other ICUs in the facility actually used some of the same catheters. So she worked with supply chain management to list all of the different catheters that were being used in this organization, uncovering that nine were used in almost all of the areas. They devised a plan to consolidate inventory usage across all areas to the extent that they could replenish in bulk rather than each unit making special orders direct from the manufacturer.

"This was a huge satisfier," Bylone said. "Not only did I have the catheters that I needed, when I needed them, but the organization was able to save a lot of money that was being spent on overnighting packages and gaining a better tier for pricing. This project was only made possible because the unit managers and the materials people came together on this."

During a monthly Emergency Care Committee meeting, Melissa L Hutchinson, MN, R.N., CCNS, CCRN-CMC, CWCN, clinical nurse specialist – MICU/CCU, VA Puget Sound Healthcare System, explored ways to improve stocking supplies and equipment in crash carts. The committee, which included physicians, nurses, biomedical engineering and supply management, looked at what each crash cart contained, expressing concerns about missing products not readily accessible that caused time delays during code situations and some stocked products that were no longer used.

"We wondered who usually reviewed the contents and who should coordinate the updates because it appeared that this had not been completed for many years," Hutchinson said. "We decided that a small group of the key players called a ‘Hot Team’ should evaluate the contents and determine what changes should be made to make improvements." This "Hot Team" would consist of the respiratory therapy manager, manager of the supply division and the clinical nurse specialist for the medical ICU.

Their first target? Intravenous supplies either were placed in different drawers or missing altogether in the carts.

"This made it difficult to obtain supplies necessary to quickly start an IV during a code blue without rummaging through several drawers," she said. "The supply manager was able to visualize how searching for supplies could negatively affect our ability to run a successful code when the carts are not arranged intuitively for the end-user. Once we all had a better understanding of each other’s point of view and needs, we were able to brainstorm what products were necessary and what might be the best approach to packaging and placement in the cart."

Their solution? "We came up with something we called ‘Quick Packs’ where everything needed was preassembled so the nurse could ‘grab-and-go,’ minimizing the time needed for searching the crash carts."

The Hot Team created Quick Packs for blood draws and for IV starts and queried the ICU nurses about the product content, organization and placement. They prepared a couple of test packs for others to review and selected the groups’ preferred pack for the final combination.

Blood draw packs were assembled in "zip lock" bags with a newly designed color-coded lab slip with the assistance of the lab supervisor so lab technicians could easily identify the critical code labs, according to Hutchinson. All of the lab draw supplies were assembled in one "zip lock" bag that could be quickly obtained from the cart, and then sent to the lab. They did the same process for IVs. "We also determined that by preparing the packs in advance it would make refilling used crash carts easier," she added.

But Hutchinson admitted that developing the Quick Packs and determining the new pick list for stocking the crash carts was the easy part. What they really needed to do was "create a plan for updating every crash cart in the hospital over a several-day time period," she said.

The Hot Team worked with pharmacy, biomedical engineering, nurse managers and quality improvement to finalize proposed updates before obtaining the green light by the Emergency Care Committee to make the changes.

The team dedicated three days to revamp 45 in-house crash carts throughout the hospital campus, according to Hutchinson. The supply and pharmacy managers and the clinical nurse specialist coordinated the schedules of the key players necessary to complete the transition.

"We developed a plan for changing over the carts, placed a bulk supplies order in advance of the changeover date, pre-assembled the Quick Packs [at] four per cart [and] 200 total, and created new documentation books for each cart," she said. "Each book illustrated, with color photos, each drawer and the contents, so staff had a reference for the new carts. Each cart took over 20 minutes to prepare – remove old supplies and replace new supplies. This was an extremely challenging task and without the participation of the three Hot Team members it would not have been a hospital success."

Bylone and Hutchinson acknowledged that critical care and supply chain management need to know each other fundamentally before they can work together and solve problems.

For Bylone, critical care has "space-time" concerns.

"Units lack storage space," she said matter-of-factly. "Nurses do not like to waste time charging for items or ordering them. Many items in critical care are needed ‘just in case.’ I think this presents enormous challenges on both sides. We need to have enough to get through the day, but have a backup to refill when needed without delay. We need a system or technology that is able to restock that doesn’t depend on nursing staff filling out slips of paper or making phone calls or completing online order sheets."  

 For Hutchinson, it’s all about communication. When supply management and nursing start to collaborate "and get to know each other, they are no longer the ‘voice on the phone,’" she said. "Establishing a good personal communication link is essential. After that it becomes very easy to dialog about other issues. I know I can pick up the phone and say ‘Hi Gilbert, can you explain to me why we run out of X, Y or Z so often? This is why I need X, Y or Z and why it is important for patient care. How can we change how this product is ordered or stocked?’"

"I believe it really comes down to improving communication and understanding how each part of the supply chain – purchaser, stocking, delivery and end-user – can either positively or negatively affect each other and the care the patient receives," she continued.

Based on personal experience, Bylone and Hutchinson offered some of what they consider to be innovative, take-it-to-the-bank, useful tips for how supply chain management can improve its relationship with and customer service to critical care nurses.

Bylone emphasized building a "trusting relationship with the manager and respect that the nurse has little idea of what supply chain management requires." It’s a simple concept that isn’t unique to critical care and supply chain management getting along, she added.

"We have one priority in mind: Improve patient outcomes," Bylone noted. "If every time the nurse went to find the supply, [and] it was there in the spot it was supposed to be… well, who could ask for more?"

Furthermore, she indicated that product purchasing decisions should be based more on clinician needs than costs with the following caveat: "I didn’t say to ignore the cost, but if they won’t use it, well, any cost is wasted."

Hutchinson urged both to participate in a multi-disciplinary committee – either the manager or other supply chain staff to "better understand how critical it can be to have appropriate, timely and correct supplies and how that can either negatively or positively affect patient outcomes."

Nurses and supply chain managers also should introduce themselves, she noted. "Supply staff should be able to ask what could be different or what the end-user appreciates. Our supply person is fabulous! She speaks to the nurses every day, even just to say ‘hi, how are you,’ and when there are issues, questions or supply changes the nurses know they can easily go to her to correct par levels and to discuss supply concerns."