Disaster Pharmacy: Hospital and Field Operations

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Disaster Pharmacy Hospital and Field Operations

• Laura C. Block, PharmD and Amanda Miller, RPh
• GA-3 DMAT

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Disaster Pharmacy Hospital Operations

• Laura Block, PharmD
• GA-3 DMAT

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DeKalb Medical Center

• 525 acute care bed hospital
• Level III trauma center
• 74,818 ED visits in 2003
• DeKalb County population in 2000 676,976

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The DeKalb Medical Center Experience Why is
disaster pharmacy an issue in the hospital?

• Lack of financial resources
• Hospital staff pushed to their limits day-to-day
  without the extra burden of a disaster
• Many people in average hospital pharmacy are not
  disaster-savvy
• Cost of ONE cyanide antidote kit to treat ONE
  patient - 188.86
• Who can afford to be prepared for what might or
  might not happen?

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The DeKalb Medical Center Experience Disaster
Preparedness on a Shoestring Budget

• Emergency committee had no budget
• Some believe that the only purpose of
  preparedness plan is for Joint Commission
  approval
• Itll never happen here...
• Pharmacy had limited money to play with
• One brave pharmacy director gave the go-ahead

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The DeKalb Medical Center Experience Cyanide
Antidote Kits

• Why do these things cost so much? Is it the
  tubing? Hospitals have tubing
• Its the sodium nitrate!
• Unobtainable at any price from 3 months prior to
  Iraq War until December 2003
• Hope Pharmaceuticals sodium nitrate, USP
  300mg/10ml vial, 84.95 for 2 vials, enough to
  treat 1 patient

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The DeKalb Medical Center Experience

• Theres got to be another way
• Sodium nitrate granules, non-pharmaceutical grade
• 500 grams is 34.62
• More than enough to treat 30 patients, but its
  extremely caustic
• How to reconstitute? No published guidance
• See www.ohanet.com for unpublished guidance

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The DeKalb Medical Center Experience

• Unproven ideas for reconstitution of sodium
  nitrate
• Treat as chemotherapy (compound in chemo hood
  wearing chemo gloves and gown and mat)
• Reconstitute in glass conical
• Minimize contact between gloves and solution (to
  preserve integrity of barrier)
• Can we use 0.22 micron filter after adding to IV
  bags?

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The DeKalb Medical Center Experience Cyanide
Antidote Kits

• The rest was easy
• Sodium thiosulfate two 50ml vials
• 12.5 grams in 50ml
• 8.10 each
• Amyl nitrate inhalant, USP
• 0.3 ml, box of 12
• 5.65/box

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The DeKalb Medical Center Experience Cost of our
Cyanide Kits

• Known costs
• Drugs23.01 per kit
• Unknown costs
• Equipment for reconstitution
• Pharmacist time for reconstitution
• Hazmat response charge?
• New hospital building? (due to explosion? due to
  contamination?) shoot it was already a disaster
  before we started this part

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The DeKalb Medical Center Experience
Organophosphate Antidote

• Bulk Atropine Powder
• Reconstitution per published paper
• Ann Emerg Med. 200341453-456.
• Treat as chemo for reconstitution
• Cost 9.44 for 5 gram bottle
• 2-PAM
• Cost 503.81 for 6 vials

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The DeKalb Medical Center Experience Potassium
Iodide for Radiological Events

• Iosat Tablets
• Can you even get it if youre not a Fed?
• Yes, its an OTC product
• Is this wise?
• But itll cost you retail 9.95 for 9 tablets,
  wholesale 4.23/9 tablets

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The DeKalb Medical Center Experience Potassium
Iodide for Radiological Events

• SSKI
• Cheap and Easy!
• Cost per bottle 20.44 for 8 ounces
• 0.13ml/130mg dosemore than 1600 doses
• Cost of amber PO 0.5ml syringes 0.39 per
  syringe from HCL
• Total cost per dose 0.40

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The DeKalb Medical Center Experience

• Total cost for supplies to treat 30 patients for
• Cyanide 23.01
• Organophosphates 2,558.44
• Radiation 168.00
• Orange boxes 17.50
• Cart 171
• Entire package 2,937.95

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Useful References

• Biological and Chemical Terrorism (from ASHP)
• Ed. by Krenzelok
• Disaster Medicine
• Eds. Hogan and Burstein
• Management of Persons Accidentally Contaminated
  with Radionuclides
• (AKA NCRP Report 65)
• www.ohanet.org, search for antidote

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Thank You

• Lee Underwood, RPh, Director of Pharmacy, DeKalb
  Medical Center
• Mark Embry, Purchasing Technician, DeKalb Medical
  Center
• All of our staff pharmacists

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Disaster Pharmacy Field Operations
Amanda Miller, RPh GA-3 DMAT
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Field Pharmacy

• In the field, pharmaceuticals can be divided into
  three categories
• What you need
• Where is it coming from?
• What you have
• What condition is it in?
• How do you maintain it?
• Do you actually need it?
• What you have WAY too much of
• Useable or not useable?
• How do I get it outta here? (legally)

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What You Need

• Current pathway is dictated pharmaceuticals come
  from Rockville-LC
• Not everybody agrees with the formulary
• Not every disaster complies with the formulary
• But some situations call for special packaging
  which the LC can handle in advance

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What You Need

• Some teams also have MOUs
• With wholesalers
• With Hospitals
• With other government agencies
• Currently considered redundant capacity
• Some MOUs are more successful than others (e.g.
  cache from VA rarely includes pediatric meds even
  if they are part of the MOU)

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What You Need

• Field Acquisition
• Directed by OER/MST
• May come through wholesalers
• May come from other Federal agencies
• Delivery may consume considerable team-member
  work hours
• a You still may not get what you need

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What You Have

• If you brought it with you (lucky you!)
• ASAP Sort into AHFS therapeutic categories
• ASAP Inventory ensure you actually have what
  the invoice says you have
• an opportunity to visually inspect the load for
  damage
• an opportunity to begin to note what you may need
  more of based on the type of disaster

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What You Have

• If you brought it with you (lucky you!)
• Particularly need to inventory controlled
  substances (not just C-II, but C-III, C-IV and
  C-V, as well)
• MST may request a daily inventory
• best if 2 people sign this
• In 24 hour operations will need to count
  controlled substances at shift change
• Use of numbered locking tabs may reduce the time
  burden

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What You Have

• If you brought it with you (lucky you!)
• ASAP Ensure that all temperature and other
  storage recommendations are being met
• keep records of temperature, etc if you dont
  have these records things become more difficult
  later

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What You Have

• If you brought it with you (lucky you!)
• Begin immediately making note of needs and
  requesting shortfall items and replacement of
  items used
• generally, the MST wants an order first thing
  every morning
• anticipate needs it may take several days for an
  item to arrive

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What You Have

• If it was acquired in the field
• Source known (OER)
• Apply same standards as items you brought with
  you
• Source known (other)
• Many people and organizations donate drugs to
  disaster relief as a tax write-off without regard
  for the usefulness or appropriateness of the
  donated items
• Donated items may initially need to be sorted for
  appropriateness BEFORE sorting into AHFS
  therapeutic categories

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What You Have

• If acquired in the field
• Source uncertain
• If youre not 100 sure of who gave them to you
  and why, dont use them
• Risk of forgeries, adulterated meds, meds may
  have been kept in substandard conditions, and
  worst of all,
• a may be a vector of secondary attack
• Make arrangements with MST for removal of suspect
  items from theater of operations

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What You Have Way Too Much Of But Could
Potentially Use

• Be in contact with MST
• Let them know what you have too much of
• Let them know what the storage requirements for
  it are
• Request that it be removed, transferred to other
  teams, offered to other agencies in order to
  reduce maintenance burden in the field

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What You Have Way Too Much Of And Do Not Need

• Be in contact with MST
• Let them know what you have too much of
• Let them know what the storage requirements for
  it are
• Let them know why it is inappropriate or might be
  dangerous
• Make arrangements with MST for removal of
  inappropriate items from theater of operations

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When it is all over

• In most cases, the MST will reclaim the cache,
  even if it came with your team via your team MOU
• To help then out, package things reasonably for
  shipment
• This includes packaging items that are damaged or
  short-dated or out-dated separately
• Include notes or packaging lists to communicate
  your methodology to the recipients of these
  itemsif you dont the work will all have to be
  done again

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When it is all over

• An attempt is made to repackage the items for use
  at the next event
• Example.. Many leftovers from WTC were repackaged
  for the 2002 Olympics
• Really, only the items in the Pharmacy Basic Load
  will be turned around
• All of the rest will likely go to waste the best
  case scenario is that the items are returned for
  credit

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What is left over

• Destruction
• Credit from guaranteed returns
• Controlled substances? (no DEA )

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The Afghanistan Hospital Project

• There were literally TONS of pharmaceuticals left
  over when the medical mission at the WTC ended.
• Much of that was
• Given to the Mayors OEM in NYC (a back-handed
  gift)
• trashed without being destroyed

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Looming Questions
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Thank You