Prepare for the Worst, Hope for the Best: Pharmacy Preparedness and Advanced Planning for Natural Disasters

Kate E. Reichert, PharmD BCPPS
Pediatric Oncology Clinical Pharmacy Specialist
Memorial Sloan Kettering Cancer Center
New York, NY

In 2017, the United States was plagued with memorable natural disasters, including devastating hurricanes and blazing wildfires that caused catastrophic destruction, left thousands of people stranded, and led to hundreds of deaths. The 2017 Atlantic hurricane season was extremely active, with three Category 4 hurricanes making landfall in the United States: Harvey, Irma, and Maria. (My own experience with emergency preparedness was acquired when I was working at Texas Children’s Hospital in Houston before, during, and after Hurricane Harvey.) Adding insult to injury, the immediate damage rendered by these hurricanes included Puerto Rico’s considerable pharmaceutical manufacturing industry. The downstream effects of the destruction have significantly disrupted production and continue to affect the nation’s healthcare system because of the numerous drug and supply shortages that have resulted.

Natural disasters threaten the ability to provide optimal patient care for a variety of reasons, while at the same time causing an increased demand for healthcare services. Not only do these events potentially destroy pharmacies that house vital medications and supplies, but natural disasters can inflict anything from minor injuries to severe traumas on individuals, who in turn require medical attention.¹ Furthermore, in some cases the anticipated course of a natural disaster changes direction and subsequently affects another region unexpectedly, or the timeline of the storm is prolonged compared to the initial forecast.²

The unpredictable nature of disasters makes preparation exceptionally difficult, and for that reason emergency preparedness and advanced planning are integral to navigating a pharmacy through the storm.³ Natural disasters vary according to the region of the country, so it is important to consider the location when doing advanced planning.¹ It is imperative that the different phases of natural disasters are evaluated both individually and collectively when an emergency response plan is being developed.

Phase 1: Preparation
Pharmacy leaders should be familiar with the ability of the local, state, and federal government to provide assistance, including drugs and medical supplies, during a declared natural disaster.⁴ State governors play an essential role in coordinating resources and soliciting additional aid when necessary.⁵ Further, pharmacy leadership in conjunction with the hospital administration should work closely with local distributors and wholesalers to institute an ordering process during emergencies so that the inventory of critical medications and supplies can be maintained. The disaster plan for the pharmacy should outline this procedure clearly and appropriately.³

Before developing a pharmacy disaster plan, the director of pharmacy or designee needs to clearly understand the hospital-wide emergency system for natural disasters in order to effectively align the plan for pharmacy response. During a disaster, the pharmacy often oversees the medication management and procurement for the hospital and potentially the surrounding region, depending on the location of the facility. The director of pharmacy or designee should identify key stakeholders and assign specific roles in the pharmacy disaster plan. It is common for the pharmacy disaster plan to have a designated pharmacist that works closely with the hospital administration in the event of a natural disaster, as well as a pharmacy administrator on call to be the single point of contact for the pharmacy staff. The role of this designated pharmacist is dynamic and entails several responsibilities, including, but not limited to, informing the pharmacy administrator on call when to communicate with the staff, obtaining additional medication supplies as needed, and reallocating staff members to high-demand areas in the pharmacy. Effective communication throughout the activation of a pharmacy disaster plan is crucial.³

Advanced planning should include creating a list of essential medications to have in stock, including the amount and storage location for each drug. This list should be made through collaborative, interprofessional efforts with emergency medicine and infectious disease physicians to ensure appropriateness. A reasonable inventory is considered to be a 72- to 96-hour supply on hand for the essential medications on this list. In the days or hours leading up to a potential natural disaster, the inventory should be closely inspected to ensure that the supply is not past the expiration date and that the quantity on hand is sufficient. Other considerations for medication management are having a flow diagram of assigned high-acuity areas for the stocking of emergency medications and knowing where and how the surplus inventory will be stored during the emergency, what to do in the event of a power outage or generator failure, and how to handle medication needs if the patients are evacuated.^2,3

The pharmacy disaster plan should set clear expectations for the role of each pharmacist and technician shift to allow for the continuation of efficient patient care throughout the natural disaster. Clinical pharmacists are indispensable to a staffing plan for an emergency response, as will be discussed in the section on Phase 2. Pharmacy staff members should be adequately trained on their role in the pharmacy disaster plan, and their competence in emergency preparedness should be evaluated at least annually through an assessment deemed appropriate by the department of pharmacy. Many institutions offer drills to prepare for emergencies, such as natural disasters, and pharmacists should be allowed and encouraged to participate.^2-4

Phase 2: Response
Several studies have evaluated the training that prepares practicing pharmacists to respond during natural disasters and have examined the role of pharmacists during these events and gaps in knowledge regarding emergency preparedness.⁶ Ideally, each role to be carried out by a pharmacist and the responsibilities of each shift during an emergency response will be clearly outlined in the pharmacy disaster plan. Not only does this alleviate confusion and eliminate gaps in coverage, but it gives each pharmacist the ability to focus on explicit tasks and specific responsibilities and makes every pharmacist accountable. Pharmacists should be assigned to a role they are best suited to fill. It is crucial to develop a robust training program with different competencies for each role so that pharmacists meet the requirements assigned to that shift during an emergency response.⁷

When a natural disaster strikes unexpectedly or lasts longer than expected, pharmacists play a crucial role in maintaining the medication use system so that medications can be delivered and dispensed, but unique challenges can arise. Pharmacists may need to make do with limited resources and a dwindling medication supply when shipments cannot be delivered. Pharmacists are essential to analyzing the inventory on hand and working with the medical team to determine therapeutic substitutions.⁷

Clinical pharmacists contribute an unmatched knowledge of navigating the medical record, have established relationships with their respective teams and nursing partners, and possess the critical-thinking skills required for processing the acute demands of potential mass triage situations caused by the damage of a natural disaster. Generally, the daily demands of a clinical pharmacist can be quickly translated to the need to emergently respond during a natural disaster. In addition to the traditional activities completed by a pharmacist daily, clinical pharmacists can actively participate in code response, provide direct patient care, and efficiently provide drug information in response to questions from both the medical team and patients. Many clinical pharmacists work closely with the interprofessional team to facilitate transitions of care, which is useful during a natural disaster when the census can exponentially increase with an added need to triage patients based on acute presentation.² The staffing plan in a pharmacy disaster plan should account for the need to have clinical pharmacists present for the duration of the natural disaster and involvement in each of the phases.

Phase 3: Recovery
When preparing for the recovery period following a natural disaster, it is important to be familiar with the prescribing practices of your institution and region, which can aid in planning for medication needs relevant to the patient population. It is imperative to consider the setting for which the advanced planning is taking place and then properly using multiple data sources, such as trends in medication purchases from wholesalers, to compile a list of medications that may be needed after a natural disaster.⁸ Although this is a critical part of the recovery phase, it should be accounted for during advanced planning in the preparation phase.

During this time, it is entirely possible that records for patients cannot be accessed or that there will be limited availability of physicians to write prescriptions for both acute emergency medications and vital chronic therapies. Plans should cover such an event, including a workflow for handwritten labeling and dispensing of medications and instructions on seeking reimbursement if possible after the natural disaster recovery period.¹ Again, this should be addressed in the advanced planning and be part of the pharmacy disaster plan.

It is increasingly common for emergency preparedness training to be incorporated into pharmacy school curricula. These learning experiences range from simulations of mass triage and dispensing scenarios during introductory pharmacy practice experiences (IPPEs) to participation in programs run by public health organizations. The inclusion of unique experiences like these in curricula should be considered as a valuable interprofessional learning opportunity for healthcare professional students to practice the skills necessary to work in teams during response to natural disasters.⁶

A discussion about emergency preparedness and advanced planning for natural disasters would be incomplete without stressing the importance of developing a personal plan for these potential events. Whether it is learning how to adequately prepare your home for a natural disaster or arranging care for your dependents, developing a plan for your family is just as integral as understanding the emergency response procedure at your place of employment. Several online resources are available to help formulate this plan, including those from the American Red Cross and the Department for Homeland Security and the websites of a number of insurance companies.

References

1. Melin K, Maldonado WT, Lopez-Candales A. Lessons learned from Hurricane Maria: pharmacists’ perspective. Ann Pharmacother. 2018;52:493-494.
2. Lynx DH. Preparing for forecastable disasters. Am J Health-Syst Pharm. 2009;66:1578-1581.
3. Bell C, Daniel S. Pharmacy leader’s role in hospital emergency preparedness. Hosp Pharm. 2014;49(4):398-404.
4. American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health-Syst Pharm. 2003;60:1993-1995.
5. National Association of Boards of Pharmacy. Emergency and disaster preparedness and response planning: a guide for boards of pharmacy. November 2006. From https://nabp.pharmacy/wp-content/uploads/2016/07/06Emergency_Preparedness_Guide.pdf. Accessed May 22, 2018.
6. Hannings AN, von Waldner T, McEwen DW, White CA. Assessment of emergency preparedness modules in introductory pharmacy practice experiences. Am J Pharm Educ. 2016;80(2):23.
7. Pincock LL, Montello MJ, Tarosky MJ, Pierce WF, Edwards CW. Pharmacist readiness roles for emergency preparedness. Am J Health-Syst Pharm. 2011;68:620-623.
8. Lavery AM, Patel A, Boehmer TK, Lee L, Bhavsar T, Thomas J, et al. Pharmacy needs after a natural disaster–Puerto Rico, September–October 2017. MMWR Morb Mortal Wkly Rep. 2018;67(13):402-403.