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Laurence A Goldberg
HPE Editorial Consultant
Over 20,000 pharmacists from 47 countries attended the 40th ASHP Midyear Clinical Meeting in Las Vegas in December 2005.
Frontline emergency relief – Hurricane Katrina
Pharmacists from all levels in the healthcare system were involved in the response to Hurricane Katrina.
Marianne Billeter (Clinical Pharmacist, Ochsner Clinic Foundation Hospital, New Orleans) was a member of the hurricane team in the only hospital to remain open in the locality during the disaster period. Her primary role was to run the pharmacy services during the emergency period. The day before the hurricane was spent in preparation. Staff shifts were altered so that the pharmacy could run with fewer people than normal. Many patients were evacuated from the hospital.
Soon after the hurricane struck on Monday 29 August 2005, mains power was lost, disabling a vertical carousel drug storage unit, a laminar air flow cabinet that was used to make total parenteral nutrition solutions and the air- conditioning system. The cabinet was moved to a surgical theatre, which had an emergency power supply. Without air conditioning, computer servers could not be cooled, and soon the pharmacy computers were out of operation. A manual system was introduced for the next four days.
Dr Billeter said that it was essential to have a group of people who could react very quickly to changing situations. “In two hours you can have a new situation, there is no time for committee meetings,” she said. Finding places for staff to sleep was a major issue, because they were unable to return home during the crisis. Dr Billeter had slept in four different places, including her own office, during the emergency period. Another problem was finding showers for hospital personnel. Staff were working in 100-degree (Fahrenheit) temperatures, and showers were welcome, despite the fact that the water was usually cold and brown.
Dr Billeter said that preparation in advance had enabled them to plan for many possible scenarios. Supplies were not a problem because the pharmaceutical wholesaler was able to maintain supplies throughout, so donations were not required. In fact, donations could be a problem – at one point she had received 10,000 doses of an antibiotic that had not been heard of since 1988, and another donor sent two truckloads of insulin – equivalent to 15 years’ supply for the hospital.
Finding a typewriter for pharmacy labels was an important measure in preparation for the hurricane, according to John Smith (Director of Pharmacy, Biloxi Medical Centre Mississippi). Biloxi Medical Centre is 25 feet below sea level, so when a storm surge of 27 feet was predicted, flooding was inevitable.
In addition to running the pharmacy, Mr Smith helped out wherever he was needed. At first, he helped to board up broken windows, then, as people began to queue in the car park outside the emergency room, he went to assist with triaging patients. Later, some of the emergency room physicians became so severely dehydrated that they were unable to function, and he was drafted in to prescribe medicines. He was given a prescription pad and told to prescribe whatever was indicated – apart from narcotics. On the third day of the emergency, problems were further compounded by an outbreak of dysentery.
Charles Valencia (Ambulatory Services Pharmacist, Harborview Hospital, Seattle, Washington) is a disaster medical assistance team (DMAT) pharmacist who was deployed to the hurricane-affected area. The team was sent to the airport in New Orleans where a busy emergency hospital was established. Helicopters were arriving eight at a time bringing in casualties. Initially a pharmacy was set up in the back of a FedEx truck, but it was later relocated to a bar inside the building that became known as the “barmacy”. They dealt with 2,000 people in 36 hours and ran out of food, drugs and water. There were no showers available for three days, and the team slept in the airport’s baggage reclaim area. Supplies of medicines were short, and they had to use patients’ own medicines and donated medicines.
Captain James Bona (Office of Orphan Products Development, Food and Drugs Administration) was part of a team that was sent to a naval base in Meridian, Mississippi, to set up a 488-bed hospital in an aircraft hangar. A lockable cage, normally used to store chemicals, was identified for the pharmacy. There was no furniture, air conditioning or fridge facilities for the first three days, and one shower for 150 people. One pharmacist had brought a laptop computer, which was used to create all the required documentation. A reference book would have been useful as substitutions frequently had to be made, he noted.
A curtained-off area of concrete was where Edward Stemley (Administrative Director of Pharmacy, Harris County Hospital District, Houston, Texas) was asked to set up a pharmacy in the Houston Astrodome when 25,000 refugees from the Louisiana Superdome arrived. In the event, 90 clinics were set up served by two pharmacies. The IT department built a wireless infrastructure on site that enabled pharmacy staff to enter all prescriptions for ambulatory patients and send them off-site for dispensing; 1,600 prescriptions were processed in four days in this way. Dr Stemley stressed the need for a pharmacy manager to lead the operation and “make decisions”. There was an abundance of resources, including numerous volunteers and pallet-loads of donated drugs, but the drugs were difficult to use and the volunteers were untrained. “You need someone to explain what pharmacists can offer,” he said. One particular incident exemplified the problem: it was decided that the insulin- dependent diabetics should line up to receive insulin injections from a central point instead of the usual self- administration because someone believed that insulin had to be refrigerated. Pharmacists were immediately able to explain that it was unnecessary as insulin is stable outside a fridge for 28 days.
“Revisit your disaster plans and challenge the assumptions that you made – such as the assumption that electricity supplies would be undamaged,” advised Malcolm Broussard (Executive Director, Louisiana State Board of Pharmacy). During the emergency, the Board of Pharmacy office had four key tasks: they were to manage donation of medicines as well as volunteers, establish drug distribution systems to the shelters and assist pharmacies with dispensing of medicines to volunteers and evacuees. Much of the work of providing prescription medicines to evacuees who have no assistance at all is ongoing, with the Board functioning as a claims processor. “Millions of dollars’ worth of medicines have been given away to victims,” he said. The Board is also attempting to recover central funding for this exercise.
During the crisis he received many phone calls about “the rules” from pharmacists concerned about what was and was not permitted in an emergency situation. His advice was always the same: “Use sound professional judgement – take good care of your patient.”
Cell-based technology is urgently needed for the rapid development of vaccines to combat the threat of an avian influenza pandemic, according to Lesley Maloney (Director of Public Health and Quality, ASHP).
Should the current avian influenza virus (H5N1) mutate to a form that is transmissible between humans, then it is predicted that 25% of the population could be infected. The treatment options include both antiviral agents and vaccines. A vaccine would be more effective, but a vaccine cannot be made until the epidemic strain of the virus emerges. Currently, in the USA, there are only three vaccine manufacturers, and the technology that is used for vaccine preparation is outdated. Moreover, vaccine production relies on eggs, which may be in short supply if there is large-scale slaughtering of chickens as a disease control measure.
Neuraminidase blockers such as oseltamivir and zanamivir are active against both influenza A and B, explained Kristi Kuper (Director of Infectious Disease Outcomes, Cardinal Health). Oseltamivir has been used in both prophylaxis and treatment of human avian influenza infection, but experience with zanamivir is limited to in-vitro and animal studies. A recent WHO review of human avian influenza infection concluded that early use of neuraminidase inhibitors was likely to be beneficial (see Resources).(1) At present it is not known whether a higher dose or longer duration of treatment than for seasonal influenza is needed. Moreover, oseltamivir-resistant organisms have already been isolated from some patients.
Thermal screening of individuals to identify those with pyrexia was introduced at airports and at hospital entrances during the SARS outbreak in Singapore. Ryan Forrey (Assistant Director of Pharmacy, Ohio State Medical Centre) had been in Singapore at the time and had gained a first-hand insight into control measures for infectious disease. He explained how all hospital staff were issued with thermometers and were required to log onto a website three times daily, on work days and leave days, to record their temperatures. In the emergency department, surgical masks were worn and an electronic tracking system was introduced for all staff and visitors.
Most hospitals in Singapore have large outpatient pharmacies and, during the outbreak, off-site pick-up of medicines and home delivery arrangements were introduced to avoid unnecessary visits to the hospital.
Patients were isolated in a single hospital and visiting was restricted. In- and outpatient staff were kept apart, and the pharmacists who served the SARS wards were allowed no contact with the other in‑patient pharmacists. A pneumatic tube system was used to deliver medicines, and satellite pharmacies were used to provide ward supplies. Staff restaurants were closed.
In preparing for pandemic influenza, Dr Forrey said that his hospital had assumed that the supply of oseltamivir would be limited and would therefore be reserved for confirmed cases of the disease. All healthcare workers should be vaccinated for seasonal influenza, and those who develop pandemic influenza should receive antiviral treatment and postexposure prophylaxis. Handwashing and the use of sanitisers should also be encouraged, he noted.
Personal stockpiling of oseltamivir is to be discouraged, explained John Zarek (Director of Clinical Pharmacy Services for Swedish Medical Center in Seattle, Washington). The national stockpile of oseltamivir is inadequate for currently predicted demands, and so it might seem logical for people to hold their own supply, given that oseltamivir is widely available in the private sector for treatment of seasonal influenza. Neither the Centers for Disease Control (CDC) nor the US Department of Health and Human Services (HHS) has advised against personal stockpiling. However, personal stockpiling could cause shortages and give rise to difficulties in treating seasonal influenza. The optimal dose and effectiveness are unknown, and the drug may be used inappropriately as people may not know when to start therapy.
Representatives of several countries, including the UK, Canada, Ireland and Hong Kong, attended a meeting of the Institute for Safe Medication Practices (ISMP) to share experiences and discuss developments in medication safety.
One key development in the USA was the Patient Safety and Quality Improvement Act (2005), which includes a provision for legal protection for people who report patient safety incidents. Under the new act, both the reporter and the body that logs the report are protected, and the information cannot be used in litigation. ISMP has lobbied for this provision for many years, commented Michael Cohen (President and CEO, ISMP).
In July 2005, the Los Angeles Times had publicised the dangers of fatal accidental fentanyl overdose arising from the use of fentanyl transdermal patches. This had raised awareness of an issue that has long concerned ISMP. Ciara Kirke (Drug Safety Coordinator, Tallaght Hospital, Ireland) commented that inappropriate prescribing of fentanyl in Ireland had given rise to similar problems.
A new report entitled “The identification and prevention of medication errors” is expected from the Institute of Medicine during 2006.
Numerous initiatives are under way in Canada to improve the safe use of medicines, said David U (President and CEO, ISMP Canada). A reporting programme has been set up to collect both individual reports of incidents and aggregated data from organisations. Early analyses have shown that morphine and its analogues, warfarin and insulin, are the drugs that are most commonly implicated in medication incidents. A large element of the work at present is awareness-raising, preparation of bulletins and delivery of in-service training.
One area of interest for ISMP Canada is the provision of medicines for ambulances. At present, medicines are stored and carried in a 70-pound bag. It is difficult to retrieve the correct product in the emergency situation, and errors often occur because of lookalike, soundalike (LASA) problems. “One of our biggest problems is the definition of terms – we need clarity to distinguish between adverse drug reactions and harm as a result of medication errors,” said Sylvia Hyland (Vice President, ISMP Canada).
Medication safety monitoring is well developed in Hong Kong, and many safe-practice initiatives have been introduced. One example is the introduction of a vest bearing the words “Medicine round – do not distract”, to be worn by the nurse undertaking the medicines round. In the past, an apron with the same words had been designed but male nurses declined to wear it.
A global conference on the future of hospital pharmacy was proposed at a meeting of representatives of national and international pharmacy organisations that was facilitated by ASHP President Jill Martin and ASHP Executive Vice President and Chief Executive Officer Henri Manasse. The International Pharmaceutical Federation (FIP) has offered to coordinate the organisation of the conference. It is likely to take place immediately preceding the 2008 FIP World Congress of Pharmacy and Pharmaceutical Sciences in Basel, Switzerland, possibly on 29–30 August 2008.
Participants pointed out that the outcome of such a meeting would contribute to the World Health Organization’s work regarding the global health workforce and would be consistent with various initiatives that are designed to advance hospital pharmacy in specific regions of the world.
Centers for Disease Control and Prevention (CDC)
HHS Pandemic Influenza Plan