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A Tale of 2 Cities- Disaster Relief from 1,100 Miles Away

Christopher Arendt, PharmD

Pharmacotherapy Coordinator

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Disclosure

• Nothing to disclose.

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Objectives

• After attending this lecture the participant should be able to:– Describe the system used to provide

maintenance medications to disaster victims.– Understand the lessons learned in preparing

for Mass dispensing.– Recognize the importance of the chain of

command during a disaster.– Describe the ideal supply chain and distribution

system in a disaster

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The Scenario

Katrina Rita Health Recovery Week 16 Months later

Katrina Photo: Jeff Schmaltz, MODIS Rapid Response Team, NASA/GSFC

Rita Photo: Jacques Descloitres, MODIS Rapid Response Team, NASA/GSFC

Sept 21st, 2005Aug 28th 2005 Jan 28th -Feb 3rd 2007

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• Thousands of Refugee’s will be sent to Camp Ripley in Northern Minnesota in the next 3 to 5 days. Be ready to receive by September 5th, 2005.

• Need Medical attention. Primary care needs. Medications. Food. Shelter. Staff. Mental Health. Social workers. Security.

Operation “Northern Comfort”

Mayo gets a phone call from the State of Minnesota

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Mayo Responds

• Sent Computers (Guardian Rx), Printers, Labels, Office Supplies

• Sent Pharmaceuticals• Arranged Wholesaler (Cardinal)

Delivery on-Site through Carrier.

• Sent Pharmacy Supplies• Established contacts and supply

chain network• Established Pharmacist/Tech

commitment from Mayo and other MN pharmacies (MPhA)

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Mayo Responds

Operation: “Northern Comfort”

Camp Ripley

9/5/2005

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We were ready…We were ready…

……and they never came to and they never came to Minnesota.Minnesota.

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ACT 2

• The Louisiana Office of Public Health asks Mayo for assistance Sept 9th, 2005.

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The Mayo Response

• Mayo looks for volunteers in key areas– Logistics/ Security/ IT– Nurses/Care Assistants/Clerical Support– Providers/NP/MD

• Mental Health• Internal Med/Family Med/Peds• Infectious Disease

– Pharmacy• Pharmacist/Technician

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The Mayo Response• Mayo in conjunction with

University of Minnesota and College of St. Katherine's established the “Minnesota Minnesota LifelineLifeline” Medical group.

• Team 1 left Monday 9/12/05 morning w/ 9 vans

• Team 2 left -9/14/05 Wednesday on Commercial Flight out of MSP with U of M folks.

• 2 Trucks with supplies headed south 9/12/05

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The Pharmacy Response

Robust Supplies. Repackaged Alphabetically into numbered totes for ease of retrieval.

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The Pharmacy Response

Alphabetical labeling and Pharmaceuticals

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The Pharmacy Response

Code SuppliesFormulary

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The Pharmacy Response

Scheduled Drugs and ability to account for them

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The Pharmacy Response

Personal Packs

Ciprofloxacin 500 mg tabs BID x 3 days

Disp # 6

Loperamide (Imodium) 2 caps now. Then 1 cap after each loose stool. Max 16 mg/24 hrs.

Disp # 30.

Alcohol Based Sanitizer

Drug Info Sheet

If Allergy- Got If Allergy- Got Azithromycin Azithromycin (ZPak)(ZPak)

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The Pharmacy Response

• Computer system and Labeling system (Guardian Rx). Zebra Thermal Printer, Laser Printer

• Pharmacy supplies (vials, ovals, beakers)

• Misc Supplies (Calculator, pens, marker, tablet cutters, grinders, mortar and pestle, scissors, forms, drug info resources, drug info, stapler, Pharmacy tape dispense, note pads, baggies etc….)

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The Pharmacy Response

• Vaccine– Pneumococcal– Hepatitis A, B– Influenza– Tetanus– MMR

• Needle Stick Emergency Kit– Lamivudine + Zidovudine (Combivir)

Used to supplement Public Health Supplies of Vaccine

Hepatitis B confirmed

in the water supply.

Let’s Talk Do’s and Don’ts

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Pharmacy Teams

• Pharmacist + Tech– 8 Weeks of support, 4 teams ( 2 weeks/team)

• Support of department/Inst – “Whatever it takes”

• Pharmacy Job: Assembled, managed and ordered drug supplies day and night

• Helped administer at vaccination sites

• Opened a Disaster-relief Out-Patient Pharmacy out of an RV

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Where did the supplies Where did the supplies come from?come from?

•Public HealthPublic Health

•MayoMayo

•Private DonationsPrivate Donations

•ManufacturersManufacturers

•WholesalersWholesalers

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Protect your assets!

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What do you do when another disaster strikes during your relief effort?

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What is your communication back up plan?

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Lessons LearnedLessons Learned

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Communication is critical• Establish ONE phone contact number

– But always have a backup

• Calling Tree and Phone Rosters at your finger tips

• Know key players throughout your profession– Boards of Pharmacy– State Health Officials– Industry

• Suppliers• Data/IT/IS

– Have 24 hour contact lists

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Communication is critical

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• Establish collaborative agreements right away– Therapeutic Substitution – Rx Writing

• DEA List/RX Pads Info- Get info pre-deployment• Know State Requirements/Get Medicare & Medicaid Provider

info up-front

– Contact Local Pharmacies for Support• Set up time to call, facilitate communication w/in

chains. Ie…CVS, Walgreens, Wal-Mart

– Talk with the DEA right away• Suppliers need permissions up front to ship ALL

meds.

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Communication is critical

• Establish supply chain rules– Must go through one contact for all donations

and purchases of pharmaceuticals• Minimize “Dumping” of expired meds• Allows better inventory accountability• Reduces time spent (Discovery, follow-up,

disposal)

– Have a disposal plan– Have a re-distribution plan

• Ie…Charitable Pharmacy

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Team

• Send people in pairs (Buddy System).

• Send people with similar interests and personalities.

• Send people without young children.

• If it involves drugs, include pharmacy up front. [Vaccine fiasco]

• Establish sound chains of Team Command. Give everyone a copy.

• Recruit more help from others.

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Team• Help monitor each others stress and exhaustion

levels (Buddy system)• If you set up a meeting time, stick to it.• Recognize the roles and responsibilities of other

team members. Help each other if you can, or at least offer to help.

• No job is beneath any team member. No job is above any team member.

• Starting at 5AM and ending at 2AM..a really bad idea

• Mix up teams - makes greater satisfaction

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With or without walls it can become a pharmacy!

MN Comfort

Camp Ripley, MN

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With or without walls it can become a pharmacy!

Mobile Pharmacy

Lafayette LA

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If you pile it they will come…

Set up Stock rules• Entry point in ONE

Location– Wasted time tracking

down items. Some items turned up weeks later.

• Establish delivery lines and times– Fed Ex– UPS– Distributor

Heyman Center Pharmacy, LA

Camp Ripley, MN

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Totes-Push Packs and Go-Kits

• Standardize the pack

• Pack by Therapeutic class, not by drug name.

• Always use both generic and trade names to label items in the Therapeutic Class.

• Less is more

• If items require refrigeration, buy more refrigeration, coolers, make ice, and check multiple times daily to ensure it’s done.

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Totes-Push Packs and Go-Kits• Split the work between multiple people

(day/eve/night)

• Set ground rules in the beginning– You restock pack or you fill out the stock

request form (let us know what you used). – Establish “ownership” of the kit with providers– If you need something new, let me know early

so I can try to get it here by tomorrow.– Remove redundancy ( 1 item per class)

• Set up a FORMULARY• Ie..you don’t need 5 different ACE Inhibitors.

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Team Prescriptions• Personal packs

– Great idea. – Could go with Bulk Bottles to save time/effort.– Get allergy list pre-departure for Emergency– Was a method of taking attendance

• Bus Med Bag– Nausea, Headache, Travel Sickness and Back pain Kit.– Sent legend drugs (don’t get back) after c/o motion sickness

• No Legend drugs with last bus.

– Send with bus “Charge” person. Inform Team of Bag on Bus

• Employee Prescriptions– No problem, but if it requires refrigeration…No.

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Emergency Supplies

• Code Cart– Nice to have there, but not used

• Was never unwrapped from Shrink wrapping

– No one performed daily checks• Sent documentation log with modified procedure• Need self diagnostic style machines (AED Pro)

– 4 AED’s also sent out with teams• Should send AED with each team & make sure

they know how to use.• Need more AED’s• Contacted MFR…Backfilled our needs.

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Lessons for Incident Command• One person needs to coordinate the phone

list!

• More Phones and Computers for Group

• Keep the All Inclusive morning meeting

• Keep the Round Table approach to Q/A– Get a bigger table & room- Many players.

• Give the Command Structure and Contact list to EVERY Team Member (lanyard around neck)

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Pharmacy Services

• Think outside the rule laden box.• In-Patient and Out-Patient Pharmacy collaboration

achieved remarkable results.• Even the best drawn plans are merely sketches.• Be open and ready to explore alternative methods

of accomplishing a task.• Be willing to ask for help.• Having one person responsible for coordination is a

must.• Keep the staff aware of what is going on.

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The Ideal Supply Chain

• Central point of Distribution/ repackaging• Real time shipping status• Mobile Distribution units• Real Time counts/Use reports• Direct from supplier shipping 24/7• Portable med management system /Drug info

resources• Language resources• Financial support• Teamwork

WEB

PDA

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Can Technology Bridge the Gap?

…YES! But…

• Need power

• Need Communications

• Need User Understanding (JIT Training)

• When we go to a sticks and stones When we go to a sticks and stones mentality, this won’t work.mentality, this won’t work.

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Summary• Be Fluid, Flexible and try to have Fun• Communication, Communication Communication.

– Solid, scheduled and redundant.

• Know your Chain-of-Command and follow it• Pharmacy involvement early on makes the logistics

easier• While the Ideal Supply Chain does not exist, good

support can make a major difference

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Thank you!

Contact InformationChristopher Arendt, PharmDPharmacotherapy CoordinatorMayo Clinic, Saint Marys Hospital1216 2nd ST SWRochester, MN 55902507-255-0384 (w) arendt.christopher@mayo.edu