Throughout the Covid-19 pandemic, the need for a stable and ever-growing source of oxygen supply regularly surfaced as a consistent threat to providing effective respiratory therapy support for the most critical of patients. As the trajectory of Covid-19 evolved into treating a younger population suffering the effects of the highly infectious Delta variant and questionable success of mechanical ventilation, treatment protocols evolved and moved towards high-flow oxygen through the use of non-invasive nasal cannula delivering a high flow of heated and humidified gas, rather than ventilators. As a result, we saw demand for bulk oxygen grow by two to three times that required to operate ventilators, as was the case in the first year of the pandemic.

In the late summer of 2021, hospitals across the Southeast, including those in south Florida were struggling to maintain a sufficient source of oxygen for managing their caseload, with the worst-hit left with only twelve to 24 hours of supply. To the further dismay of this region, as the Covid census grew, so did the conditions adversely impacting a sufficient oxygen supply. Staffing shortages – whether among the generators of oxygen or the drivers of bulk oxygen tanker trucks – created logistics headaches, as did the several gulf storms that disrupted power to the oxygen generating facilities. Seasonal weather, labor shortages and challenges to oxygen generation created a perfect storm of potential disruption during a period of doubled or tripled demand.

Premier Inc., a technology-enabled healthcare improvement and group purchasing company, employs a strategic sourcing team and subject matter experts who work with 4,400 hospitals and health systems and 225,000 other providers across the country. Premier regularly assist these provider organizations in managing through supply chain disruption and ever-changing healthcare delivery and the associated technology issues. Premier’s government affairs representatives participate in federal disaster response planning and are able to channel federal support to such emerging disasters. Throughout the entire pandemic, Premier was in touch with the White House, the Federal Emergency Management Agency and the Department of Health and Human Services – among other government organizations – keeping them apprised of the oxygen scarcity issues in the Southeast, as well as the implications of oxygen scarcity on a national level.

What Premier found in the summer and fall of 2021 was that, in addition to demand for oxygen reaching unprecedented levels in the healthcare setting (both for the treatment of Covid patients and normal and emergent surgical procedures) our need for a finite amount of oxygen was competing with a variety of industries that were being served by the same sources of supply. Among these competing uses for oxygen include the industrial sector which uses bulk oxygen for cutting, smelting and welding; the aerospace industry for liquid oxygen fuel tanks for providing the thrust to leave the earth’s gravity; and the use of bulk oxygen for waste-water treatment and decontamination. Some of these industries were just beginning to restart following a period of Covid-induced inactivity, creating a degree of competition in the market that had not previously existed.

Another logistical problem that hospitals and health systems consistently faced in getting the oxygen they needed, was around transportation. Hazardous materials – oxygen is considered one of these – have restrictions in how they can be transported within and across state lines. Moving bulk oxygen requires a massive amount of trucking support, as it cannot be flown. The tankers that transport liquid oxygen have approximately a 250 mile limit before the gas begins to degrade. There are also limits on the number of hours that drivers can work, with federally mandated break and rest times and other related safety regulations. Coupled together with there not being enough drivers – for a variety of reasons – the ‘storm’ became that much more ‘perfect’.

To give some perspective as to the scale of the issue, typically, a hospital’s on-site oxygen storage tanks are 80-90% full. During this past summer, we found that hospitals were at less than 20% capacity in their primary oxygen tanks (less than a two day supply) and oxygen availability coupled with the stretching of the supply chain resulted in deliveries that were ‘topping off’ or only getting them up to 40-50% capacity (four or five days).

We saw hospitals frequently resorting to operating out of their reserve tank – which we equated to riding on a donut tire after a flat – with a single point of failure for managing their critical patents. There was clearly too much risk for this to be a sustainable long-term strategy.

Throughout the supply chain issues, we continued to support our members’ need for consistent delivery of oxygen while addressing their ongoing concerns through the active management of oxygen delivery both on- and off-contract to ensure they had enough to get through each day. We found that daily all-hands calls between the suppliers and the members were critical to keeping everyone apprised where the most critical need was at any given moment, while ensuring alignment on timing and delivery expectations. Premier also worked with its contracted suppliers to identify supplemental sources of supply and additional oxygen suppliers who had not previously been involved in delivering for healthcare organizations. In some cases, we coached, cajoled and pressured oxygen suppliers who were not on contract and had no reason to work with us to up their game.

After many years of expecting a sufficient supply of oxygen to routinely flow from the patient headwall into a delivery device, we learned that the oxygen supply chain is a fragile and finite commodity that requires secondary and tertiary sources of supply, significant manpower to produce and deliver, and a commitment on the part of commercial companies to hold healthcare as their highest priority when there are supply constraints. Redundancy is a key to a secure oxygen delivery network. Redundancy in suppliers, in logistics, and in hospital-based equipment.

In retrospect it would be hard to imagine another supply-generated crisis that could result in NASA delaying the launch of an Atlas rocket delivering an imaging satellite to outer space.

Robert J. Karcher is Vice-President, Contract Services and Donna A. Craft, RN, MHA, SASHE, is Senior Director Facilities and Environmental Services Service Line at Premier Inc.

About Premier Inc.

Premier Inc. is a leading healthcare improvement company, uniting an alliance of more than 4,400 US hospitals and health systems and approximately 225,000 other providers and organizations to transform healthcare. With integrated data and analytics, collaboratives, supply chain solutions, and consulting and other services, Premier enables better care and outcomes at a lower cost. Premier plays a critical role in the rapidly evolving healthcare industry, collaborating with members to co-develop long-term innovations that reinvent and improve the way care is delivered to patients nationwide. Headquartered in Charlotte, North Carolina, Premier is passionate about transforming American healthcare.