RDF PHS-1 College Station, Texas FMS Pharmacy

3. 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 You may note a slightly more lighthearted approach to my presentation. Some of the best tools to use on deployment is a positive attitude, a sense of humor, and an ability to find solutions that may not be ideal, maybe unorthodox, but address the issue and enable the team to fulfill the mission.You may note a slightly more lighthearted approach to my presentation. Some of the best tools to use on deployment is a positive attitude, a sense of humor, and an ability to find solutions that may not be ideal, maybe unorthodox, but address the issue and enable the team to fulfill the mission.

4. Getting to know you…. Worked - The RDF PHS-1 team was divided, then reunited, then augmented all the in space of 3-4 days. Our Team was divided into two, then 4 groups. When we were in our “down” time, LCDR Pierce and I polled our team members to identify the skills each team member would contribute to the pharmacy branch. We used this time to determine those members who were uncomfortable with a sole clinical role and slated those members to serve alternate roles initially.The RDF PHS-1 team was divided, then reunited, then augmented all the in space of 3-4 days. Our Team was divided into two, then 4 groups. When we were in our “down” time, LCDR Pierce and I polled our team members to identify the skills each team member would contribute to the pharmacy branch. We used this time to determine those members who were uncomfortable with a sole clinical role and slated those members to serve alternate roles initially.

5. 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

6. 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 Because the pharmacy roles in any deployment are dynamic and every changing, each member’s strengths were found to be valuable. Our team members who had strong administrative or management background, became invaluable when we needed to set up alternate Medication Administration Records and Medication Distribution Records. Pharmacy forms, both origination and editing, inventory and purchasing, Schedule medications control and accountability, were all areas their skills were utilized and appreciated.Because the pharmacy roles in any deployment are dynamic and every changing, each member’s strengths were found to be valuable. Our team members who had strong administrative or management background, became invaluable when we needed to set up alternate Medication Administration Records and Medication Distribution Records. Pharmacy forms, both origination and editing, inventory and purchasing, Schedule medications control and accountability, were all areas their skills were utilized and appreciated.

7. “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

8. First lesson…. Designate….. RDF PHS-1 travelled with 2 “Go-bags” intended for team use in route and prior to FMS set-up. We found it helpful for minor ailments, but were concerned with the new airline regulations. Fortunately, neither bag received an extra charge. However, one half of the team was a bit over diligent and retrieved both bag from the baggage claim area. After a bit of a panic, the mix-up was resolved, but lessons learned – designate one person per team to be solely responsible for the bag to assure accountability.RDF PHS-1 travelled with 2 “Go-bags” intended for team use in route and prior to FMS set-up. We found it helpful for minor ailments, but were concerned with the new airline regulations. Fortunately, neither bag received an extra charge. However, one half of the team was a bit over diligent and retrieved both bag from the baggage claim area. After a bit of a panic, the mix-up was resolved, but lessons learned – designate one person per team to be solely responsible for the bag to assure accountability.

9. Reed Arena, College Station, Texas

11. 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 Worked – Concession stand with opening to main floor of the arena provided an excellent venue for the placement of the pharmacy. The addition of Texas A&M security at the door added extra safety. There was a question of access to the restroom in the area, which were separated froom the pharmacy area by screens, not necessarily ideal, but proved to be adequate to keep personnel from wandering through the active pharmacy area. Worked – Concession stand with opening to main floor of the arena provided an excellent venue for the placement of the pharmacy. The addition of Texas A&M security at the door added extra safety. There was a question of access to the restroom in the area, which were separated froom the pharmacy area by screens, not necessarily ideal, but proved to be adequate to keep personnel from wandering through the active pharmacy area.

12. The door in the back lead into the hallway and was closed to all but pharmacy personnel. All providers, and those patients able to administer their own insulin, were instructed to address the pharmacy at the door leading into the arena. In the lower picture you can see our answer to access to two of the limited number of rest rooms available to the team.The door in the back lead into the hallway and was closed to all but pharmacy personnel. All providers, and those patients able to administer their own insulin, were instructed to address the pharmacy at the door leading into the arena. In the lower picture you can see our answer to access to two of the limited number of rest rooms available to the team.

13. Limited access 24 hour security Using the concession stand as the pharmacy base had another advantage discovered in the early morning hours – the door could be closed to avoid light disturbing the residents, and discouraged late night visits, yet kept the pharmacy accessible to providers. 24 hour security was also provided at our open door. Using the concession stand as the pharmacy base had another advantage discovered in the early morning hours – the door could be closed to avoid light disturbing the residents, and discouraged late night visits, yet kept the pharmacy accessible to providers. 24 hour security was also provided at our open door.

14. Pharmacy set-up – Community resources and Network Designate primary = Team commander IRCT Facility contacts Janitorial Volunteers Administration Community Community pharmacies Hospitals

15. 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, When setting up the pharmacy area, your actual hard resources may be limited. In this case we started with one layer of tables and placed all medication in alphabetical order by generic name, by consensus. The arrangement would change 2-3 more times with the addition of a second layer of “shelves” (tables), and arranging the medications as our patient population changed and work-flow issues were addressed.When setting up the pharmacy area, your actual hard resources may be limited. In this case we started with one layer of tables and placed all medication in alphabetical order by generic name, by consensus. The arrangement would change 2-3 more times with the addition of a second layer of “shelves” (tables), and arranging the medications as our patient population changed and work-flow issues were addressed.

16. 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 Development of a standardized FMS blueprint for pharmacy work flow (e.g., supplies/storage, processing station, fill station, checking station, and “will-call” area). One lockable storage cabinet adequate to store pharmacy controlled medications, DEA forms, C-II prescriptions, packing lists, inventories, and provider lists of DEA numbers. Development of a standardized FMS blueprint for pharmacy work flow (e.g., supplies/storage, processing station, fill station, checking station, and “will-call” area). One lockable storage cabinet adequate to store pharmacy controlled medications, DEA forms, C-II prescriptions, packing lists, inventories, and provider lists of DEA numbers.

17. Pharmacy – PHS-1College Station Texas Pharmacy set-up – continued to evolve as work flow and conditions changed

18. This is probably the fourth configuration of the pharmacy area -

19. EMR station in front – one EMR close to window for ease of consulting with providers, and others moved out of immediate contact area to provide privacy and uninterrupted work space.EMR station in front – one EMR close to window for ease of consulting with providers, and others moved out of immediate contact area to provide privacy and uninterrupted work space.

20. 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 We were expecting the full FMS cache, unfortunately these were depleted due to prior hurricanes, so the wholesaler sent items from the FMS formulary with out any accompanying invoice or packing list. Inventory of the stock revealed many shortfalls and caused considerable concern with some of the missing items. Fortunately, in our set-up, LCDR Pierce had identified resources and avenues to address our needs. Both Texas A&M, the IRCT and the local community were supportive and worked to assist our efforts to accomadate our patient populations’ needs. the PHS-1 RDF team arrived onsite. Controlled substance inventory lists were included, but NDC numbers did not match the medications delivered, and one listed controlled medication was not included in the initial delivery. PHS-1 RDF-CS needed to order additional controlled medications within the first few days due to a critical shortage of oral and injectable immediate acting benzodiazepines (lorazepam) for seizure control. When the DMAT Pharmacy Cache and FMS pharmacy cache were added together, several high acuity patient medication needs were efficiently addressed. i. The DMAT pharmacy cache compartmentalization, totes, indexing, and inventory forms were optimal. The FMS Pharmacy cache should be modeled after the current DMAT pharmacy cache format. The medication lists indexed alphabetically and by drug/therapeutic class were efficient for therapeutic drug selection. We were expecting the full FMS cache, unfortunately these were depleted due to prior hurricanes, so the wholesaler sent items from the FMS formulary with out any accompanying invoice or packing list. Inventory of the stock revealed many shortfalls and caused considerable concern with some of the missing items. Fortunately, in our set-up, LCDR Pierce had identified resources and avenues to address our needs. Both Texas A&M, the IRCT and the local community were supportive and worked to assist our efforts to accomadate our patient populations’ needs. the PHS-1 RDF team arrived onsite. Controlled substance inventory lists were included, but NDC numbers did not match the medications delivered, and one listed controlled medication was not included in the initial delivery. PHS-1 RDF-CS needed to order additional controlled medications within the first few days due to a critical shortage of oral and injectable immediate acting benzodiazepines (lorazepam) for seizure control. When the DMAT Pharmacy Cache and FMS pharmacy cache were added together, several high acuity patient medication needs were efficiently addressed. i. The DMAT pharmacy cache compartmentalization, totes, indexing, and inventory forms were optimal. The FMS Pharmacy cache should be modeled after the current DMAT pharmacy cache format. The medication lists indexed alphabetically and by drug/therapeutic class were efficient for therapeutic drug selection.

21. 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 Many patient came with their medications, in various “packages”, bottles, bags and boxes. Pharmacists often needed to identify medications simply labeled as “blue blood pressure pill” . We were faced with the challenge of getting the proper medication, in the proper dose, to the right patient, at the right time, and do it for a large quantity of patients.Many patient came with their medications, in various “packages”, bottles, bags and boxes. Pharmacists often needed to identify medications simply labeled as “blue blood pressure pill” . We were faced with the challenge of getting the proper medication, in the proper dose, to the right patient, at the right time, and do it for a large quantity of patients.

22. Electronic Medical Record (EMR)

23. 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 We were one of the first FMS to fully utilize the EMS system. While this system may be adequate for a DMAT unit, it did not seemed to be designed for the workload the health care providers encountered. Medications were not entered or reviewed expeditiously on intake, thereby leaving many opportunities for error or mediation mishap.We were one of the first FMS to fully utilize the EMS system. While this system may be adequate for a DMAT unit, it did not seemed to be designed for the workload the health care providers encountered. Medications were not entered or reviewed expeditiously on intake, thereby leaving many opportunities for error or mediation mishap.

24. 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 Electronic Medical Record (EMR) a. Pharmacy operations were negatively impacted by numerous EMR work-arounds required to complete basic medication dispensing operations. We strongly recommend the EMR Pharmacy module be implemented, as soon as possible, by immediately beta testing the EMR pharmacy module with participation from deployment experienced pharmacists (RDF and other sources), medical providers, and nursing staff. b. Voluminous EMR order entry adjudications were necessary during this mission. It is critical that the EMR include pre-loaded drug formularies and improved pharmacy physician order entry functions. We strongly recommend preloaded FMS and DMAT formularies in the EMR to improve the accuracy of pharmacy orders. This step alone would significantly improve order entry accuracy and reduce the burden on pharmacy order adjudication. c. We recommend development of an EMR User Manual that includes guidance on the following issues: Repeat Dose Medication Administration Patients Own Medication Patients that can self-administer medications versus those that cannot FMS team member medications Stat (or emergency medication) orders Floor stock medication distribution Discharge medications and order entry Cancelled or modified pharmacy orders d. Two EMR Panasonic Toughbooks were insufficient to maintain pharmacy operations during peak medication order entry and dispensing times. 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). e. Due to significant EMR order tracking issues for repeat dose medications (e.g., every 6 hours, every 8 hours, every 12 hours), and for medications dispensed from patients own medication supply, somewhat redundant paper medication dispensing records (MDR) and Medication Administration Records (MAR) were required and implemented. Electronic Medical Record (EMR) a. Pharmacy operations were negatively impacted by numerous EMR work-arounds required to complete basic medication dispensing operations. We strongly recommend the EMR Pharmacy module be implemented, as soon as possible, by immediately beta testing the EMR pharmacy module with participation from deployment experienced pharmacists (RDF and other sources), medical providers, and nursing staff. b. Voluminous EMR order entry adjudications were necessary during this mission. It is critical that the EMR include pre-loaded drug formularies and improved pharmacy physician order entry functions. We strongly recommend preloaded FMS and DMAT formularies in the EMR to improve the accuracy of pharmacy orders. This step alone would significantly improve order entry accuracy and reduce the burden on pharmacy order adjudication. c. We recommend development of an EMR User Manual that includes guidance on the following issues: Repeat Dose Medication Administration Patients Own Medication Patients that can self-administer medications versus those that cannot FMS team member medications Stat (or emergency medication) orders Floor stock medication distribution Discharge medications and order entry Cancelled or modified pharmacy orders d. Two EMR Panasonic Toughbooks were insufficient to maintain pharmacy operations during peak medication order entry and dispensing times. 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). e. Due to significant EMR order tracking issues for repeat dose medications (e.g., every 6 hours, every 8 hours, every 12 hours), and for medications dispensed from patients own medication supply, somewhat redundant paper medication dispensing records (MDR) and Medication Administration Records (MAR) were required and implemented.

25. 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) We also recommend a non EMR computer and printer be designated for the pharmacy. Several forms, references and other essential communications were only available to the pharmacy through the generous use of our pharmacy team members personal computers. However, a change in shifts when also cause a loss of computer use.We also recommend a non EMR computer and printer be designated for the pharmacy. Several forms, references and other essential communications were only available to the pharmacy through the generous use of our pharmacy team members personal computers. However, a change in shifts when also cause a loss of computer use.

26. Preparing the days doses *

27.

28. 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 The EMR was incapable of making Rx labels or transferring the information to our self-developed program, therefore we were hand wrting labels. The workload for this step alone was intensive in this population. The EMR was incapable of making Rx labels or transferring the information to our self-developed program, therefore we were hand wrting labels. The workload for this step alone was intensive in this population.

29. More unit dose packaging….

30. 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 The daunting task of managing the medications for our population caused was one of our greatest challenges. We developed a system similar to that found in a long-term care facility to deliver and track those medications the patients had provided upon intake. Let me describe the process for you and the reasons for each, using one of our more memorable intakes. This patient’s medication came to the pharmacy wjhat looked to be an Army issue laundry bag. When open, there was a combination of “bingo card” packaged medications, meds in vials, some in a 7-day pill pack and others in expired prescription bottles. This was accompanied by medication instructions sheets which contradicted each other in a few places. The medications were reviewed, patient interviewed, and several lf the pharmacies contacted for clarification of medicatin doses and identities. These verified orders were then entered on both a Medication Administration Record – for the nursing station- and a Medication Distribution Record, for accountability in the pharmacy. Packets were created for each dosing period (ex. If pt. took a medication 4 times a day, four packets were made). These were filled from the patients own medication stock each day and delivered to the nursing station for each dosing time period.The daunting task of managing the medications for our population caused was one of our greatest challenges. We developed a system similar to that found in a long-term care facility to deliver and track those medications the patients had provided upon intake. Let me describe the process for you and the reasons for each, using one of our more memorable intakes. This patient’s medication came to the pharmacy wjhat looked to be an Army issue laundry bag. When open, there was a combination of “bingo card” packaged medications, meds in vials, some in a 7-day pill pack and others in expired prescription bottles. This was accompanied by medication instructions sheets which contradicted each other in a few places. The medications were reviewed, patient interviewed, and several lf the pharmacies contacted for clarification of medicatin doses and identities. These verified orders were then entered on both a Medication Administration Record – for the nursing station- and a Medication Distribution Record, for accountability in the pharmacy. Packets were created for each dosing period (ex. If pt. took a medication 4 times a day, four packets were made). These were filled from the patients own medication stock each day and delivered to the nursing station for each dosing time period.

31. Shift Briefings

32. 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

33. 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. 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 priority1. 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

34. 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. 2. Patient has own meds, has C2-4 pain medication and can self medicate or has competent care provider. - Non-narcotic schedule medications not entered in EMR as pharmacy orders. - C2-4 pain medications counted in presence of patient (if feasible) and nurse/provider takes medication to pharmacy. Alternatively, 2 pharmacists will verify count. - Pharmacy enters EMR orders for C2-4 pain medication and completes order; nurse/provider evaluates order. - Pharmacy prepares 3-day supply for patient and nurse/provider picks up. For overflow patients, medications are stored in the lockbox, from which individual doses are provided to the patient. - Pharmacy considers medication history in EMR to be a low priority. 3. Patient does not have medications and can self-medicate/has competent care provider. - Nurse/provider enters EMR order for all medications, both scheduled and non-scheduled. - Pharmacy fills prescription and completes order in EMR – dispenses 3 days or antibiotic to 10 days. - Pharmacists place prescriptions in bins at nursing station (organized by patient last name). For overflow patients, C2-C4 pain medications are stored in the lockbox, from which individual doses are provided to the patient. - Nurse/provider evaluates the order and completes the order. - Pharmacy considers medication history in EMR to be a high priority.2. Patient has own meds, has C2-4 pain medication and can self medicate or has competent care provider. - Non-narcotic schedule medications not entered in EMR as pharmacy orders. - C2-4 pain medications counted in presence of patient (if feasible) and nurse/provider takes medication to pharmacy. Alternatively, 2 pharmacists will verify count. - Pharmacy enters EMR orders for C2-4 pain medication and completes order; nurse/provider evaluates order. - Pharmacy prepares 3-day supply for patient and nurse/provider picks up. For overflow patients, medications are stored in the lockbox, from which individual doses are provided to the patient. - Pharmacy considers medication history in EMR to be a low priority. 3. Patient does not have medications and can self-medicate/has competent care provider. - Nurse/provider enters EMR order for all medications, both scheduled and non-scheduled. - Pharmacy fills prescription and completes order in EMR – dispenses 3 days or antibiotic to 10 days. - Pharmacists place prescriptions in bins at nursing station (organized by patient last name). For overflow patients, C2-C4 pain medications are stored in the lockbox, from which individual doses are provided to the patient. - Nurse/provider evaluates the order and completes the order. - Pharmacy considers medication history in EMR to be a high priority.

35. 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 . 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 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.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 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.

36. 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

37. 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. 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.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.

38. 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 Staffing Requirements: Twelve pharmacists per shift were adequate to meet pharmacy operational needs in most cases. Twelve hour shifts were used to support these staffing numbers early in the FMS operation, primarily due to a high number of patients being admitted within short timeframes. Pharmacy setup, integration of new pharmacy teams, and team meetings occasionally required pharmacists to work greater than 12 hour shifts. During these times, significant fatigue was present in team members due to suboptimal sleep conditions and extended deployment times. Later in the deployment, after things moved into a maintenance mode, the pharmacy went to 8-hour shifts. Specialized Pharmacy Staffing: A designated control medication pharmacist should be assigned for each shift to manage and process controlled medication dispensing and inventory. A high number of patients were on chronic narcotic pain medications. A high number of the patients also had their own medications, but could not self administer, so pharmacy was required to secure and manage large quantities of these patient’s control medications. A designated procurement, inventory and distribution pharmacist should be assigned for each shift to manage and process drug ordering, drug inventory, pharmacy supplies, and non-formulary drug requests. FMS Code Team Pharmacists: Pharmacists were pre-assigned to RDF Code teams for each shift and provided pharmacy assistance by responding to medical code operations. We also designate 2 pharmacist per shift or time period to address issues with prescriptions, or serve as liaison with provider and nursing staff. Staffing Requirements: Twelve pharmacists per shift were adequate to meet pharmacy operational needs in most cases. Twelve hour shifts were used to support these staffing numbers early in the FMS operation, primarily due to a high number of patients being admitted within short timeframes. Pharmacy setup, integration of new pharmacy teams, and team meetings occasionally required pharmacists to work greater than 12 hour shifts. During these times, significant fatigue was present in team members due to suboptimal sleep conditions and extended deployment times. Later in the deployment, after things moved into a maintenance mode, the pharmacy went to 8-hour shifts. Specialized Pharmacy Staffing: A designated control medication pharmacist should be assigned for each shift to manage and process controlled medication dispensing and inventory. A high number of patients were on chronic narcotic pain medications. A high number of the patients also had their own medications, but could not self administer, so pharmacy was required to secure and manage large quantities of these patient’s control medications. A designated procurement, inventory and distribution pharmacist should be assigned for each shift to manage and process drug ordering, drug inventory, pharmacy supplies, and non-formulary drug requests. FMS Code Team Pharmacists: Pharmacists were pre-assigned to RDF Code teams for each shift and provided pharmacy assistance by responding to medical code operations. We also designate 2 pharmacist per shift or time period to address issues with prescriptions, or serve as liaison with provider and nursing staff.

40. “If I never see a MAR or one of these bins again, I will be a happy pharmacist…. Overall, pharmacy operations at the Reed Arena FMS at College Station, Texas were effective and enabled PHS healthcare providers to administer adequate pharmacy care to special needs patients. Pharmacists deployed to the Reed Arena FMS took every available opportunity to optimize pharmacy operations, and patient care, and worked effectively within the available FMS system. Overall, pharmacy operations at the Reed Arena FMS at College Station, Texas were effective and enabled PHS healthcare providers to administer adequate pharmacy care to special needs patients. Pharmacists deployed to the Reed Arena FMS took every available opportunity to optimize pharmacy operations, and patient care, and worked effectively within the available FMS system.

41. 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. One lockable storage cabinet adequate to store pharmacy controlled medications, DEA forms, C-II prescriptions, packing lists, inventories, and provider lists of DEA numbers. One additional small refrigerator for storage of patients own medications that require refrigeration. One additional small refrigerator for storage of laboratory reagents and analysis equipment. A dedicated pharmacy laptop with a preloaded basic drug labeling program, PharmPAC approved pharmacy forms, email access, and FMS pharmacy policies and procedures. A dedicated printer, toner cartridges, and labels for pharmacy label printing and printing drug information, medication instruction sheets, and medication guides (required by law). [Label printing (or handwriting) is a significant rate-limiting step in normal pharmacy operations. Currently, pharmacists are unable to efficiently print labels or provide adequate directions for use to patients receiving medications for outpatient use One lockable storage cabinet adequate to store pharmacy controlled medications, DEA forms, C-II prescriptions, packing lists, inventories, and provider lists of DEA numbers. One additional small refrigerator for storage of patients own medications that require refrigeration. One additional small refrigerator for storage of laboratory reagents and analysis equipment. A dedicated pharmacy laptop with a preloaded basic drug labeling program, PharmPAC approved pharmacy forms, email access, and FMS pharmacy policies and procedures. A dedicated printer, toner cartridges, and labels for pharmacy label printing and printing drug information, medication instruction sheets, and medication guides (required by law). [Label printing (or handwriting) is a significant rate-limiting step in normal pharmacy operations. Currently, pharmacists are unable to efficiently print labels or provide adequate directions for use to patients receiving medications for outpatient use

42. 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. Fax/copier [Standard retail pharmacy equipment to transfer prescriptions.] At least two mortars and two pestles to crush medications for tube feeds and compounding. 8. Medication storage carts for cart fill operations in special needs shelter operations. 9. Shred bins and shredder for confidential patient information. Fax/copier [Standard retail pharmacy equipment to transfer prescriptions.] At least two mortars and two pestles to crush medications for tube feeds and compounding. 8. Medication storage carts for cart fill operations in special needs shelter operations. 9. Shred bins and shredder for confidential patient information.

43. 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)

45. First flight – Pharmacy 2009RDF PHS-1 College Station, Texas

46. Inauguration – Point of Distribution exercise (POD) “Pick-up” area For a completely different look at the science of medication dispensing, this is a short summary of the activities of the POD exercise during the Presidential Inauguration. This Point of Distribution was successfully “deployed” in the parking basement of the Humphrey building on the day of the Inauguration. The intent of the exercise was to establish a plausible baseline for mass distribution of medication.For a completely different look at the science of medication dispensing, this is a short summary of the activities of the POD exercise during the Presidential Inauguration. This Point of Distribution was successfully “deployed” in the parking basement of the Humphrey building on the day of the Inauguration. The intent of the exercise was to establish a plausible baseline for mass distribution of medication.

47. VIP Visitor ** RADM Vanderwagen stopped by to say hello and observe the operation. All the “victims” were federal volunteers for this experimental run.RADM Vanderwagen stopped by to say hello and observe the operation. All the “victims” were federal volunteers for this experimental run.

48. Interview area for POD The exercise was deemed successful, and several new insights were taken from the day. The exercise was deemed successful, and several new insights were taken from the day.

49. 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