Disaster Pharmacy: Hospital and Field Operations

1. Disaster Pharmacy: Hospital and Field Operations Laura C. Block, PharmD and Amanda Miller, RPh GA-3 DMAT

2. Disaster Pharmacy: Hospital Operations Laura Block, PharmD GA-3 DMAT

3. 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

4. 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?

5. 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 • “It’ll never happen here...” • Pharmacy had limited money to “play” with • One brave pharmacy director gave the go-ahead

6. The DeKalb Medical Center Experience: Cyanide Antidote Kits • Why do these things cost so much? Is it the tubing? Hospitals have tubing… • It’s 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

7. The DeKalb Medical Center Experience • There’s got to be another way… • Sodium nitrate granules, non-pharmaceutical grade • 500 grams is $34.62 • More than enough to treat 30 patients, but it’s extremely caustic • How to reconstitute? No published guidance • See www.ohanet.com for unpublished guidance

8. 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?

9. 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

10. The DeKalb Medical Center Experience: Cost of our Cyanide Kits • Known costs: • Drugs:$23.01 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…

11. The DeKalb Medical Center Experience: Organophosphate Antidote • Bulk Atropine Powder • Reconstitution per published paper • Ann Emerg Med. 2003;41:453-456. • Treat as chemo for reconstitution • Cost: $9.44 for 5 gram bottle • 2-PAM • Cost: $503.81 for 6 vials

12. The DeKalb Medical Center Experience: Potassium Iodide for Radiological Events • Iosat Tablets • Can you even get it if you’re not a Fed? • Yes, it’s an OTC product • Is this wise? • But it’ll cost you: retail $9.95 for 9 tablets, wholesale $4.23/9 tablets

13. 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 dose=more than 1600 doses • Cost of amber PO 0.5ml syringes: $0.39 per syringe from HCL • Total cost per dose: $0.40

14. 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

15. 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”

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

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

18. 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)

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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 don’t have these records things become more difficult later

25. 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

26. 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

27. What You Have • If acquired in the field • Source uncertain • If you’re not 100% sure of who gave them to you and why, don’t 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

28. 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

29. 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

30. 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 items…if you don’t the work will all have to be done again

31. 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”

32. What is left over • Destruction • Credit from guaranteed returns • Controlled substances? (no DEA #)

33. 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

34. Looming Questions

35. Thank You