title: Supply chain management for maggot debridement therapy in compromised healthcare settings
Creators: name: Stadler, Frank
Publisher: name: Griffith University
Year: 2018
Subjects: subject: Supply chain management
subject: Maggot debridement therapy
subject: Compromised healthcare settings
subject: Wounds
subject: Fasciotomies
subject: Compartment syndrome
subject: Amputations

description: BACKGROUND A growing body of literature and nearly a century of modern clinical use have established maggot therapy as an efficacious and safe wound care modality. Indeed, even before the introduction of maggot debridement therapy (MDT) to modern medicine, the wound healing properties of fly maggots were recognised by many cultures including Aboriginal Australians. This and the beneficial outcomes seen in wounded and fly-blown soldiers in past wars raises the question why MDT has not been used to treat wounds in contemporary compromised healthcare settings such as in disaster medical response, the theatre of war, or in development aid. The critical importance of supply chain management in the provision of goods and services suggests that there may be a mix of supply chain barriers that have prevented healthcare providers to offer MDT services in compromised healthcare settings. With this in mind, this study sought to answer the following research questions: 1) What is the wound burden in compromised healthcare settings; 2) is MDT a feasible therapy for wounds in compromised healthcare settings; 3) what are the characteristics of MDT supply chains in compromised healthcare settings; and 4) what are the enablers of, and barriers to, affordable, responsive, secure, sustainable, resilient and innovative MDT supply chains in contemporary compromised healthcare settings? METHODS In order to answer these research questions, a mixed methods approach was used including desktop literature reviews, optimising scenario development, and a case study with qualitative research methodology. The qualitative research was conducted with observations, a stakeholder workshop and semi-structured interviews which, in turn, were held either face-to-face, online or via email. A set of analytical tools were applied to the data, such as the rephrasing of transcripts according to the documentary method, coding of interview data, and logic model evaluation. The question as to what the burden of wounds in compromised healthcare systems might be was answered with a systematised literature review of the wound burden in the East African Community (EAC). In order to determine whether MDT is a feasible therapy for wounds in compromised healthcare settings, a narrative literature review of MDT in disaster medicine was conducted. The question what the characteristics of MDT supply chains in compromised healthcare settings are had two sub-questions that sought to determine a) what the theoretical characteristics of affordable, responsive, secure, sustainable, resilient and innovative MDT supply chains in compromised healthcare settings are and b) what the actual characteristics of contemporary MDT supply chains in compromised healthcare settings are. An optimised MDT supply chain scenario for the EAC was developed utilising the information provided by the main literature review, and additional literature as needed. What an actual MDT supply chain in a compromised healthcare system looks like was explored with a case study of the Kenyan MDT and MDT-like supply chains. Semi-structured interviews were held, for the most part remotely via Skype or email, and these were analysed with a process of rephrasing as is employed in the documentary research method and subsequent coding of rephrased data. These results were then synthesised into a coherent description of the actual Kenyan MDT supply chain from production of medicinal maggots to disposal of used dressings. Both, the optimised supply chain scenario and the qualitative research results, were modelled with logic model methodology which permitted internal evaluation of the actual MDT supply chain and comparison with the optimised scenario, and consequently the identification of the enablers of, and barriers to, MDT supply chains in Kenya. Melnyk and colleagues’ concept of outcome-driven supply chains provided the conceptual framework for the analysis of the theoretical and actual MDT supply chains. FINDINGS The systematised review found that, although it was not possible to comprehensively quantify the burden of wound in the East African Community, there was evidence to suggest that the wound prevalence is high and that it must place a significant burden on communities and fragile healthcare systems. The narrative review of MDT in disaster medicine found that natural and man-made technological disasters frequently lead to a surge of casualties that can overwhelm first responders and medical assistance teams and that MDT can play a significant role in meeting this wound care challenge in disaster medical aid. MDT is highly precise, controls a broad spectrum of microbes in the wound, stimulates wound healing and prepares the wound bed for grafting or closure. In addition, MDT can be performed by nurses without the need of a physician. Moreover, MDT could provide a larger window for time-critical interventions such as fasciotomies to treat compartment syndrome and amputations, in cases of life-threatening wound infection. The main literature review of maggot therapy supply chain management revealed that there is virtually no literature on the use of MDT in disaster or other humanitarian aid, and that there is a bi-modal distribution with most literature discussing production-related or MDT-related issues and only very few papers, and some industry resources, touching on medicinal maggot distribution issues. This review of academic papers, grey literature and industry information represents the most comprehensive portrait of MDT supply chains and their management to date. It laid the groundwork for the development of an optimised supply chain scenario. The optimised MDT supply chain scenario provided the first theory of what an optimal MDT supply chain in a compromised healthcare setting could look like, and the benchmark for evaluation of the actual Kenyan MDT supply chain. It also informed the development of recommendations for the management of the Kenyan MDT supply chain. Program logic analysis allowed for an assessment of supply chain outcomes. In contrast, the actual Kenyan case study provided a comprehensive picture of an actual MDT supply chain in a compromised healthcare setting. From the analysis of cost drivers in the contemporary Kenyan MDT supply chain, it appears that the cost of medicinal maggots, including delivery, to the patient could be too high, thus making MDT less affordable. This is because of inefficient low-volume production, and in-house rather than outsourced delivery. Responsiveness is significantly curtailed under current Kenyan MDT-SC conditions, and the current MDT program is vulnerable to future supply interruption and regulatory uncertainty. Overall, there is good indication that the Kenyan producer can produce medicinal maggots that are safe for the environment and patients provided best practice operating procedures and quality management are adopted. Opportunities also exist where environmental sustainability goes hand in hand with resource poverty and cost reduction, for example in the implementation of reverse logistics for cool chain packaging. The lack of preparedness regarding distribution planning and demand management further increases the medicinal maggot producer’s vulnerability and reduces the supply chain’s responsiveness. However, there are increasingly sophisticated courier companies operating across the country which could provide distribution services. There is little evidence of innovation in the Kenyan MDT supply chain, apart from the establishment of the medicinal maggot production facility and the fledgling MDT program, even though the host organisation for medicinal maggot production in Kenya is a research organisation and should therefore be in a good position to pursue product innovation. Research Question 4 sought to identify the enablers of, and barriers to affordable, responsive, secure, sustainable, resilient and innovative MDT supply chains in contemporary compromised healthcare settings. On one hand, there are numerous barriers that largely relate to institutional governance and regulatory limitations, but none are perceived to be insurmountable. On the other hand, there are significant enablers that support or facilitate the delivery of MDT services. They relate mainly to existing Kenyan research expertise and MDT-expertise transfer, a highly flexible and resourceful commerce and logistics environment, and a diverse healthcare system with NGOs and faith-based organisations complementing public healthcare provision. These enablers of, and barriers to, the MDT supply chain in Kenya can be divided into those over which the focal organisation has influence, and those that are imposed by the wider SC including external political, economic and social factors. CONCLUSIONS This research generated a wealth of new and original knowledge and new theory regarding the prevalence of wounds, the feasibility of MDT, and its supply chain management in compromised healthcare settings. Indeed, the literature review of MDT supply chain management is the first coherent theory of MDT supply chain management and thereby it lays the foundation for the future study, and ongoing revision of, MDT supply chain management. Another significant contribution is the successful demonstration of several new or rarely used methods in supply chain management research, thereby significantly increasing the tool box available for researchers and practitioners. For example, the study successfully employed a qualitative research approach and the use of program logic evaluation methodology to assess the performance of supply chains. It could be demonstrated that the program logic analysis of inputs, activities, outputs and outcomes of a product supply chain, rather than a conventional social program, is possible and deserves greater exposure in the academic and practitioner SC literature. The findings also provide tangible guidance for Kenyan MDT supply chain managers and for the provision of MDT services elsewhere. The findings of this study should assist practitioners in the design of MDT supply chains that deliver life- and limb-saving wound care.