Vol.

No: 29:02 Posted: 2/15/04

Disaster Preparedness and Pharmacy An Important Partnership David S. Teeter, PharmD Emergency Management Strategic Healthcare Group, Department of Veterans Affairs, Indianapolis (retired member); consultant, emergency management issues; pharmacist, Wishard Hospital, Indianapolis
Disasters and terrorist attacks are low-probability incidents, but as 9/11 proved, they can occur at any time and at any place. Private citizens, businesses, and government agencies must weigh the benefits of preparing for disasters against the cost of not planning. Pharmacy needs to be in the forefront of preparedness. Natural and manmade events that could affect a community (TABLE 1) will also deal a blow to local pharmacies and health care facilities. What can be done to ensure the continuity of pharmaceutical services and restoration of operations to predisaster levels? Today, in the United States, the standard used to deal with disasters is the Comprehensive Emergency Management model. This model analyzes the problem in four ways:

mitigationmeasures employed before an incident occurs to minimize damage. preparednessactivities conducted before disaster to improve readiness. responseactions dealing with consequences during the disaster. recoveryprocedures that help restore business operations to normal, ie, levels similar to those before the incident. It is important to realize that without mitigation and preparedness efforts, the actions taken by pharmacists and others are likely to be less effective in the response and recovery phases. Thus, pharmacy personnel should focus on activities before an incident occurs rather than waiting for

an eventunprepared and reactive.1

Enhancing Local Preparedness

A professional emergency manager's initial step is to conduct a Hazards Vulnerability Analysis to ascertain the types of threats that may exist in the area and how likely they are to occur. The manager should take into account local industries, storage facilities for hazardous materials, transportation routes, and the natural disasters that have occurred (or might occur) in the area. Then, the manager should consider the likelihood of each hazard to produce a significant incident. The list of hazards applicable to a specific location can be extensive, and it can change over time. This survey can be accomplished alone but is probably more productive if one collaborates with others, eg, health care colleagues, facility risk managers, county/state emergency management officials, and insurance agents. Identify measures that could minimize risk for anticipated threats: Examples of disaster preparedness activities that could lessen negative effects include the following: If earthquakes are a threat, secure or strap inventory, light fixtures, computers, references, etc, so they are less likely to fall and cause injury. To minimize damage from collapsed structures, buildings can be strengthened to withstand earthquakes, winds, etc. If there is a warning period before the disaster, eg, a slow-moving hurricane, windows of businesses and houses can be protected by boards. Because pharmacies rely on information technology, systems to back up data are vital. Portable electric generators and battery-powered devices can restore electricity. Some mitigation efforts have become incorporated in newer building codes and land use management plans. General information regarding mitigation for houses and businesses can be accessed easily and at no cost through Internet sites such as those of the Federal Emergency Management Agency (www.fema.gov) and the American Red Cross (www.redcross.org).2 Disaster preparedness starts locally. Pharmacy is a key component in the emergency preparedness process and should be involved with developing the disaster operation plans in each locality and county. Emergency plans should be regularly reviewed and updated. Pharmacists can provide valuable information on pharmaceutical issues to disaster-related committees. By collaborating with local community-based committees, health care facilities, emergency management teams, and public health and other relevant groups can determine the approaches needed to enhance area preparedness. Once the disaster plan has been formulated, it needs to be evaluated. Disaster committees also focus on exercise design and implementation. Exercising the disaster plan is vital to test it and allow responders to gain experience working together. Pharmacy personnel are encouraged to actively participate in disaster exercises. At the facility level, exercising allows the health care providers and other staff to rehearse their individual responsibilities as well as team roles. Ideally, health care personnel will be involved in the community's disaster exercises, rather than participating in isolation. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires health care facilities to participate in two "external" exercises each year, whereby facility staff interact with appropriate entities and agencies in the community. Typically, formal After Action Reviews (AARs) are completed at the conclusion of an exercise. These AARs allow participants to evaluate issues and recommend improvements to the emergency plan. By taking an active role in emergency planning and exercises, pharmacy personnel can become integral members of the response team. They can gain experience with the overall emergency plan and players long before an actual emergency occurs.3 Pharmacy personnel should be prepared for medical management of anticipated injuries and illnesses. This could range from assisting with trauma and burns to medical care for victims of chemical, radiological, and biological terrorism. Various publications and Internet sites can be used to obtain detailed information after the incident. Some written material or information stored

on a PDA or computer hard drive should be accessible in case Internet access is interrupted. Coordinate activities with area college(s) of pharmacy and local, state, and national pharmacy associations, as well as county and state emergency management agencies. Look for opportunities to participate in collaborative efforts and to apply for funding grants. One example is a state task force involved in a federal initiative, such as the Health Resources and Services Administration (HRSA) Hospital Bioterrorism Preparedness Program. These federal grants make it possible to allow states to assess their state of readiness, education, and training, as well as improve surveillance, epidemiology, biological/chemical lab capacity, communications technology, and health information dissemination. Pharmacists can usually access task forces such as the HRSA grant program through the county emergency management office.4

Response and Recovery

Today, most pharmacies operate under just-in-time inventory practices. A recent survey showed that wholesaler on-time delivery of pharmaceuticals met or exceeded 91% of pharmacists' expectations. Could this level of service be sustained after a disaster? Pharmacists should join forces with their primary vendor and establish procedures for postdisaster ordering and delivery. Provisions for contacting the vendor by telephone, Intranet, or other means should be established before the disaster. Normal means of communication could be disrupted temporarily. A related issue is pharmaceutical stockpiling. Each pharmacy will have to make an individual decision on whether to stockpile medications, as well as selection and amounts to store. This involves consideration for the money to initially purchase the inventory, space to store it, and time spent to rotate the stock. If a pharmacy does develop a stockpile, it should collaborate with the local emergency management agency so that the needs of the entire community are considered. On-hand levels, local stockpiles, and postevent wholesale delivery will be the community's initial working inventory for pharmaceuticals. Pharmacies should plan to be on their own for at least two days. By this time, federal assets might be in place for dispensing medications to individual patients. A prominent federal resource for pharmaceutical resupply is the Strategic National Stockpile (SNS), available through the Department of Homeland Security (DHS). A governor who determines that state resources of pharmaceuticals are becoming overwhelmed can request help from the SNS. This reserve of specialized supplies was formerly known as the CDC's National Pharmaceutical Stockpile. The 50-ton Push Packages contain pharmaceuticals and medical supplies useful in airway management, IV fluid administration, antibiotics and antitoxins for treating casualties of various bioterrorism acts, antidotes for exposures to certain chemicals such as organophosphates, and agents for internal exposure to radionuclides such as Iodine-131. Pharmaceuticals for primary care (eg, diabetes, hypertension) are not part of the SNS Push Packages. Pharmacies should plan for the local acquisition of these types of pharmaceuticals, since the need will exist postdisaster. If the exact threat is known, the state may receive specific pharmaceuticals through the SNS's Vendor Managed Inventory (VMI) program rather than the large multipurpose Push Package. An example: Terrorists release anthrax spores; governor requests federal assistance; CDC deploys the VMI; and the state receives appropriate antibiotics in bulk and/or unit-of-use packaging. Various federal agencies routinely evaluate the domestic threats and make adjustments in the composition of the stockpile. A new concept within the SNS, the chempack pilot project, is an attempt to place chemical antidotes closer to the disaster site. This is necessary since the onset of symptoms from chemical exposure is usually rapid. Therefore, local supplies of antidotes to control the symptoms could be depleted sooner. Pharmacists need to be involved at the local and state levels to ensure that the SNS can effectively be accessed. Issues that pharmacists

need to consider regarding the receipt of the SNS are outlined in TABLE 2. A CD-ROM to help state officials plan for the receipt of the SNS is accessible on the National Association of County and City Health Officials Web site, www.naccho.org. In addition, general information regarding the SNS can be obtained at CDC's Web site, www.cdc.gov.5,6

Under President Bush's Freedom Corps Initiative, pharmacists and pharmacy technicians can become trained responders for their community by joining a hometown team. One such response unit is the Medical Reserve Corps. These responders create a local resource, not designed for deployment outside the community. They would strengthen the community by becoming part of the local public health and medical response. Any citizen, pharmacist or not, can become involved by joining another group, the Community Emergency Response Team. This local unit serves as the front line in a "neighbor-helping-neighbor" effort. Members are available moments after a disaster occurs. Research findings demonstrate that often the first responders are victims who survived the disaster. They help rescue people from collapsed structures and administer first aid before EMS or fire rescue units arrive. Additional information regarding this initiative can be obtained through the county emergency management office or at www.citizenscorp.gov.8. Pharmacy personnel can be involved with federal plans to enhance national capability. These might require deployment outside the local community. One established program is the Disaster Medical Assistance Team (DMAT). The National Disaster Medical System (NDMS), a partnership of the DHS, Health and Human Services, and Veterans Affairs, along with the private sector, manages this resource. Nonfederal pharmacists and pharmacy technicians are eligible to join a DMAT. These teams are located across the country. They consist of locally sponsored cadres of 30 or more health care providers and administrative support personnel. DMAT functions include triage of victims at the disaster site, providing medical care, and maintaining casualty clearing near the site of the disaster. If deployed, the NDMS can temporarily federalize DMAT members. This affords liability protection, addresses workman compensation issues, provides payment for services and travel,

and eliminates issues of licensure outside the home state. Deployments are anticipated to last no longer than two weeks. To maintain readiness, DMATs participate in specialized training and exercising at both the team level and during local and national exercises. Information regarding DMATs can be obtained at www.dhs.gov.9-11 A new program, also forming under the leadership of the DHS, is the National Pharmacist Response Teams (NPRTs). On December 8, 2003, at the American Society of Health-System Pharmacists Midyear Clinical Meeting in New Orleans, the DHS and the six organizations in the Joint Commission of Pharmacy Practitioners Working Group on Emergency Preparedness (see TABLE 3) signed an agreement. Pharmacy personnel who join an NPRT will participate on a team based in one of 10 regions across the country. Each team may consist of as many as 200 members. This large number allows for rotation during a prolonged response and also recognizes that some individuals may not be able to deploy immediately. If activated and/or deployed, private sector personnel can be temporarily federalized similar to the procedures discussed for a DMAT. Additional facts regarding NPRTs can be obtained at www.dhs.gov, and an application form is available at www.oep.ndms.dhhs.gov/forms.html.12

Business continuity, ie, returning to normal operations in a timely manner, is a goal necessary for the survival of the organization. Some structural damage, loss of revenue, and/or interruption of patient care might occur. Pharmacy personnel must pay particular attention to minimize compromises in patient care. Pharmacy managers and owners should develop plans for alternate sites to deliver services, eg, establishing a contract with a local company to rent a mobile office (trailer). These types of arrangements should be initiated prior to a disaster. After an incident, many businesses and individuals will attempt to obtain similar resources. Demand could outpace supply. Escalating financial losses from disasters are leading to a greater emphasis on mitigation efforts and obtaining hazard insurance to minimize any loss. Insurance can help financial recovery, but appropriate coverage must be in force before the disaster. Often riders specifically for floods, earthquakes, etc, are necessary to ensure coverage. Civil unrest may not be part of some insurance contracts. Acts of terrorism are usually included under this definition and have generally been excluded. After the attacks on 9/11, the federal government mandated that the insurance industry provide coverage for terrorism. The Terrorism Risk Insurance Act of 2002 established a program with the Department of Treasury, under which the federal government shares with the insurance industry the risk of loss from future terrorist attacks. The insurance industry is required to offer coverage for this exposure, and the insured has the option of rejecting it. There are many sources for further information on business continuity and insurance. Additional assistance is available through several governmental Web sites. Two examples are the National Conference of State Legislators (www.ncsl.org) and Santa Clara County (www.sccgov.org). Nongovernmental Web sites also offer guidance, including www.phmic. com,

www.iii.org, www.drj.com, and www.thebci. org. Many companies offer business continuity planning for a fee.13

Conclusion
Only a few organizations and agencies have made emergency management a priority. Most businesses consider disaster-related matters as peripheral issues. Regardless of the practice setting, pharmacists, pharmacy technicians, and pharmacy students often have little time available to devote to preparing for disasters and terrorism. Managers and CEOs might not appreciate the need for expending money and staff time or having inventory tied up to prepare for low-probability incidents. However, consider the cost of not preparing. By becoming a proactive disaster responder, pharmacists will be prepared to help provide their patients with pharmaceutical services during a disaster. Disaster victims deserve the same treatment during disaster response and recovery as do patients in normal times. Mitigation measures and emergency preparedness activities are vital to the continuity of pharmaceutical services should a disaster disrupt normalcy. Those in the pharmacy profession should look for ways to take appropriate measures that are cost-effective. Pharmacy has an obligation to the local community and nation to share expertise in preparing for and managing the medical consequences of disasters.

REFERENCES
1. Gordon J. Comprehensive Emergency Management for Local Governments Demystifying Emergency Planning, Rothstein Associates, 4 Arapaho Rd, Brookfield, CT 06804, 2002, pp 1015. 2. Mileti D. Disasters by DesignA Reassessment of Natural Hazards in the United States, Joseph Henry Press, 2101 Constitution Ave, Washington, DC 20418, 1999, pp 215-218. 3. ASHP Statement on the role of the Health-System Pharmacist in Emergency Preparedness, Statements on Medication Therapy and Patient Care: Specific Practice Areas, Dec. 18, 2003, p 219. 4. Health Resources and Services Administration Bioterrorism Grant Process, available at www.hrsa.gov. 5. Strategic National Stockpile, CDC, available at www.bt.cdc.gov. 6. Are Wholesalers Delivering the Goods?, Drug Topics Survey, Drug Topics, Nov. 3, 2003, p 70. 7. The Critical Incident Stress Management Pamphlet, International Critical Incident Stress Foundation, available at www.icisf.org, pp 1-2. 8. Community Emergency Response Teams and Medical Reserve Corps, available at www.usafreedomcorps.gov. 9. Hejik K. Pharmacy responds to terrorist attacks, Pharmacy Today, available at pharmacy.com/articles/h_ts_0001.cfm. 10. Delehanty R. The Emergency Nurse and Disaster Medical Assistance Teams. Journal of Emergency Nursing. 1999;22:184-186. 11. Disaster Medical Assistance Teams, available at www.oep.ndms.dhhs.gov. 12. Homeland Security Formalizes Pharmacist Response Teams, ASHP Midyear Clinical Meeting News and Views, American Society of Health-System Pharmacists, Dec. 9, 2003, pp 1 & 3. 13. Tierney K, Lindell M, et al. Facing the UnexpectedDisaster Preparedness and Response in the United States, Joseph Henry Press, 2101 Constitution Ave, Washington, DC 20418, 2001, pp 119, 221-223.