Hurricane Ike

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Hurricane Ike
Texas, September 3, 2008
http//www.nhc.noaa.gov/
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The following information is based on the
experience of PHS pharmacists deployed to the
Federal Medical Station (FMS) established at Reed
Arena in College Station (CS), Texas during the
month of September 2008. Purpose is to
Provide insights for future pharmacy-related
operational improvements to PHS
colleagues Present PHS RDF-CS Pharmacy Branch
Lessons Learned Summarize PHS RDF-CS Pharmacy
Branch Operations Some information was
collected during a PHS RDF CS After Action
meeting and has been submitted to OFRD, Team
Leadership and Pharmacy Leadership
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RDF PHS-1 College Station, Texas FMS Pharmacy

• What we will cover
• Some lessons learned
• Some frustrations to address
• Some best practices at least for that day
• Some things that worked
• Some that did not work
• And some that just kept changing

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Getting to know you.

• Worked -

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Pharmacist Roles

• ID team Pharmacist skill
• Clinical practice
• Ambulatory care practice
• Administrative
• Public health
• Discharge planning
• Immunization or other specialties
• Code/ ACLS/
• Comfort in clinical, dispensing or counseling role

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Designate initial roles prior to boots on the
ground

• Clinical
• Code
• Administrative
• Inventory and ordering
• Inventory and control of Schedule meds
• Pharmacy flow and design
• Community outreach and network
• Staff accountability and scheduling

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The best laid plans of mice and men

• Do plan to be surprised
• Maintain flexibility
• Re-assess and expand or contract the pharmacy
  role as required
• Remember
• Stabilize
• Maintain
• Improve status if resources available now and
  after departure

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First lesson.

• Designate..

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Reed Arena, College Station, Texas
Dr. Elsa A. Murano President, Texas AM
Texas AM University Core Values Loyalty -
Acceptance forever. Integrity - Character is
destiny. Excellence - Set the bar. Leadership -
Follow me. Selfless Service - How can I be of
service? Respect - We are the Aggies, the Aggies
are we.
Source LCDR William Pierce. September 15, 2008
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Chronology

• On-site in conjunction with planning, determine
  site for pharmacy
• Electricity
• Secure able to limit access
• Accessible to providers
• Clean and dry
• Control temperature
• Running Water

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• Limited access
  
• 24 hour security

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Pharmacy set-up Community resources and
Network

• Designate primary Team commander
• IRCT
• Facility contacts
• Janitorial
• Volunteers
• Administration
• Community
• Community pharmacies
• Hospitals

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Pharmacy set-up Designate primary Deputy team
commander

• Assess space and plan for work-flow
• Determine resources
• Computers
• Electronic Medical Record computers
• Printers
• Distributions points
• Filling points
• Check points
• Stock arrangement, availability,

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Suggestions

• Development of a standardized FMS blueprint for
  pharmacy work flow (e.g., supplies/storage,
  processing station, fill station, checking
  station, and will-call area).
• Include one lockable storage cabinet for security
  of controlled medication and accompanying
  documentation
• Verification EMR stations set up away from the
  pharmacy window
• protect patient confidentiality
• minimize risk of medication errors

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Pharmacy PHS-1College Station Texas

• Pharmacy set-up continued to evolve as work
  flow and conditions changed

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This is probably the fourth configuration of the
pharmacy area -
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Challenges

• FMS cache
• Not full cache
• No invoice or packing slip
• Stock inadequate to address unexpected rate of
  episodes of seizures
• DMAT cache added -met several high acuity
  medication needs
• DMAT Cache easy to use, compartmentalized
• Inventory forms
• Indexed alphabetically and by drug/ therapeutic
  class

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Challenges

• Patient population
• Higher acuity than expected for an FMS
• Larger volume of medications
• Lower number of care givers with patients
• Higher number of patients deemed not capable of
  self medicating
• Concern with predatory personalities among
  patient population
• Accountability for Scheduled medication for
  patient safety and accuracy of dosing

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• Electronic Medical Record (EMR)

EMR issues significantly impaired pharmacy
operations. Paper Medication Dispensing Records
(MDR) and Medication Administration Records (MAR)
were required to address several EMR medication
management issues.
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• Electronic Medical Record
• No actual pharmacy component software
• No formulary
• No allergy check
• No medication interaction check
• No ability to transfer Rx to a viable label
  program
• Ability to view only 2 of patients Rx on screen
  at a time
• Time consuming and labor intensive
• No Rx report capability

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Electronic Medical Record (EMR)

• Pharmacy operations were negatively impacted by
  numerous EMR work-arounds required to complete
  basic medication dispensing operations.
• Voluminous EMR order entry adjudications were
  necessary during this mission.
• EMR does not include pre-loaded drug formularies
  and improved pharmacy physician order entry
  functions

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EMR continued

• Two EMR Panasonic Toughbooks were insufficient
  -Recommend 3-4 Toughbooks be designated for
  pharmacy
• (e.g., one for order retrieval and filling
• one for order verification
• and at least one for pharmacist order
  adjudication
• No capability in EMR to track orders or doses
  requiring paper medication dispensing records
  (MDR) and Medication Administration Records (MAR)

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Preparing the days doses

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Flexibility, adaptation and improvise!

• Label program decision do not use
• Hand written labels set up checking station on
  second EMR request third to speed flow
• VERY labor intensive
• Multiplied exponentially by unit-dose system
  developed
• Medication delivery and accountability
• Medication Administration Records
• Medication Distribution Records
• Packaging / Repacking medication for single dose
  distribution

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• More unit dose packaging.

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Communication important!

• Process changed and evolved many times
• Initially providers picked up doses each shift
• Changed pharmacist delivered to provider
• 3rd change provided shift medications to bins
  secured on nursing station
• Control medication policy
• What worked? Collaboration and communication
  Chief medical officer, chief nurse officer of
  each shift written policy for off shift and
  repeated communication

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Shift Briefings
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Worked!

• Shift Briefing
• Pharmacy log book may need modification
• Use of varied talents
• Shift leaders
• Designated Control and inventory each shift
• Communication with Nursing and provider personnel
  at shift change and via written updates
• Mentoring gave members confidence in alternate
  roles

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RDF-1 Pharmacy Medication Procedures version
210?!

• For all patients EMR chief complaint states
  Self medicates or Cannot self-medicate.
• Principle pharmacy delivers non-C2-4 pain
  medications, nurse/provider picks up C2-4 pain
  medications.
• For patients who cannot self-medicate, pharmacy
  creates medication administration record (MAR)
  nursing records medication administration.

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• 1. Patient arrives with own medications, has no
  C2-C4 pain medication ( e.g. morphine, Vicodin,
  Darvon but not benzodiazepines), and can self
  medicate or has competent care provider.
• - Medications are not entered in EMR as pharmacy
  orders.
• - Patient is responsible for administering
  medication.
• - Pharmacy considers medication history EMR to be
  a low priority
• 2. Patient has own meds, has C2-4 pain
  medication and can self medicate or has competent
  care provider.
• 3. Patient does not have medications and can
  self-medicate/has competent care provider.

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• 4. Patient has own (not C2-4 pain) medication
  but is not competent to self-administer/has no
  competent care provider.
• - Medications are not entered in EMR as pharmacy
  orders.
• - Nurse/provider takes all medications to
  pharmacy.
• - Pharmacy creates a pharmacy medication
  distribution record (MDR) for pharmacy tracking
  only
• - Pharmacists place medications for a single dose
  (e.g. Sat 0800) in a bag, and deliver to bins at
  nursing station.
• - Nurse/provider returns the bag to pharmacy when
  the medication is administered.
• - Pharmacy considers medication history in EMR to
  be a medium priority
• .

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• 5. Patient has a new C2-4 pain medication order.
• Nurse /provider enters order into EMR, pharmacy
  completes order, nurse/provider evaluates order.
• If competent/provider pharmacy dispenses 3-day
  supply and marks EMR complete
• Nurse/provider picks up medication at pharmacy
  and delivers the 3-day supply to patient or for
  overflow patients, medications are delivered to
  the lockbox, from which individual doses are
  provided to the patient.
• If not competent/no provider pharmacy will
  create a pharmacy-based MDR for a 3-day supply.
• Nurse/provider will pick up each dose at
  pharmacy.
• Pharmacy considers medication history in EMR to
  be a high priority

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• 6. Stat or single dose order
• - Nurse/provider enters order into EMR.
• - Pharmacy prescription and marks order as
  complete.
• - Pharmacy puts non-C2-4 medications in bins
  nurse/provider picks up C2-4 pain medications
  from pharmacy.
• - Nurse/provider evaluates order.
• - Pharmacy considers medication history in EMR to
  be a high priority.
• COMMENTS
• All dose bags must be returned to pharmacy for
  accountability and security.
• Medical/nursing/ROTC/other college students may
  not pick up medications but can return empty bags.

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Staffing

• Staffing Requirements
• Twelve pharmacists per shift to meet pharmacy
  operational needs in most cases.
• Twelve hour shifts early in the FMS operation.
• Pharmacy setup, integration of new pharmacy
  teams, and team meetings occasionally required
  pharmacists to work greater than 12 hour shifts
• Specialized Pharmacy Staffing
• A designated control medication pharmacist
  assigned for each shift
• A designated procurement, inventory and
  distribution pharmacist assigned for each shift.
• FMS Code Team Pharmacists
• Roving clinical pharmacist used 2 per shift

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• If I never see a MAR or one of these bins again,
  I will be a happy pharmacist.

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Equipment addition suggested

• One lockable storage cabinet.
• Two additional small refrigerator
• for storage of patients own medications that
  require refrigeration.
• for storage of laboratory reagents and analysis
  equipment.
• A dedicated pharmacy laptop with email access
• A dedicated printer, toner cartridges, and labels
  for pharmacy label printing and printing drug
  information, medication instruction sheets, and
  medication guides
• FMS pharmacy policies and procedures.

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Needed equipment, cont

• Fax/copier
• At least two mortars and two pestles.
• Medication storage carts for cart fill operations
  in special needs shelter operations.
• Shred bins and shredder for confidential patient
  information.

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Improving Pharmacy Response Capabilities

• Communicate regularly with
• Pharmacists
• Medical team members and support staff
• Chain of Command
• IRCT Pharmacy Liaison
• Reassess pharmacy operations, record and
  prioritize issues
• Continue to optimize pharmacy care throughout
  mission
• Plan ahead (as much as possible)
• Update pharmacy operational procedures (when
  necessary or when improves pharmacy care)

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First flight Pharmacy 2009RDF PHS-1 College
Station, Texas
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Inauguration Point of Distribution exercise
(POD)

• Pick-up area

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VIP Visitor

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Interview area for POD
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Acknowledgements

• LCDR William Pierce
• RDF PHS-1 Pharmacy section lead
• RDF PHS College Station pharmacy team members for
  their input, spirit, can-do attitude, and
  imagination
• RDF PHS-1 College Station After Actions Report

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Thank you for your attention!

• CAPT Raelene Skerda, BPharm
• Health Resources and Services Administration,
  Office of Commissioned Corps Affairs
• rskerda_at_hrsa.gov