12/2/2020 Conflicts of Interest • Dr. Ehret has no actual or potential conflicts of interest and no relevant financial interests When a Disaster Strikes: Access associated with this presentation. to Medications? Megan J. Ehret, PharmD, MS, BCPP Associate Professor University of Maryland, School of Pharmacy 1 2 What type of practice setting are you Pharmacist and Technician Objectives currently working in? • A. Community Pharmacy • Describe pre ‐ disaster planning for healthcare professionals, in particular for pharmacies • B. Hospital Pharmacy • C. Advance Practice/Clinical Setting • Review medication supply chains and consider weak points in the chain • D. Academia • E. Industry • Describe a needs assessment for a patient prior to a disaster • F. Government • G. Veterans Affairs • Outline a disaster planning guide for a pharmacy setting • H. Other 3 4 Types of Events ”Drug Refugee” Minor Disaster • Complex Natural – Power Outage Humanitarian Disaster Emergency – No pharmacist today – Evacuation – Riots/Protests Man ‐ Major Disaster • War made – Flooding Occupation Disaster – Hurricanes – Earthquake – Tsunami Terrorist CBRNE Events Event 5 6 1
12/2/2020 Minor Disaster Question Minor Disaster Question • Thunderstorm with major wind damage in a local • A. Turn the patient away ‐ you can’t call for a town. Power is out at one of the major hubs and transfer due to the independent being closed the independent pharmacy that everyone in town • B. Provide the patient with 3 days worth free uses is closed. A major retail chain in the next of charge town over has power. • C. Provide the patient with an entire refill ‐ • Patient presents to the major retail chain with a worry about the transfer when the bottle for warfarin from the independent and independent reopens states, “I am out of medication and my pharmacy • D. Call the provider to obtain a new script for is closed.” the medication to fill • What do you do? 7 8 Major Disasters Minor Disasters No medications available • – Pharmacies are closed Pharmacies might not be open • – Specialty medications ‐ mail is slowed or stopped – Can I fill my prescription at any pharmacy – Medications are expired ‐ no fridge services available that is open in town? – No medications coming into area – I don’t have my insurance card – Disruption in supply chains – I lost my prescription in the process Back order of medications • – My pharmacy filled it, I didn’t pick it up yet, now they are – Medication is unable to be made ‐ example IV fluids/sterile water not open Hurricane Maria – My medications were left out of the fridge, can I get new – Concerns over raw ingredients and drug supply manufacturing locations ones? No providers to prescribe medications • – I am due for an injection, but my provider is not open or – Provider may not know medication history only doing telehealth – Provider may be uncomfortable with certain medications (e.g. could a psychiatrist prescribe oncology medications?) 9 10 Supply Chains Supply Chains • Social and technical system by which demand is identified, targeted, and fulfilled • Process of deciding what, when, and how much is to be moved where Ritchie EC et al. Current Psychiatry 2019 11 12 2
12/2/2020 Commercial Supply Chain Disaster Occurs Transportation Electrical Fuel Power Financial Food/Water Telecoms Medical Ritchie EC et al. Current Psychiatry 2019 13 14 Questions to Consider Questions to Consider • Do I have a clear understanding of what • Should I be considering maintaining a supply medications would be available through relief of certain medications? How do decision? efforts? What is expected timetable would be • If I opt to maintain a small supply of certain for their restoration? medications, do I know what I need to know • What basic formulary should I anticipate? to execute that plan? (e.g., securing of pharmaceuticals, expiration, temperature) • In case of an interruption in medication supply, which of my patients are likely to have • For long ‐ term stability ‐ maintenance patients, the most severe discontinuation syndromes? what is a reasonable degree of disaster planning education/discussion? • What are my ethical and professional duties? Ritchie EC et al. Current Psychiatry 2019 Ritchie EC et al. Current Psychiatry 2019 15 16 Questions to Consider • What could be the short ‐ term and mid ‐ term Assessment of Where You Stand impacts of not having access to the electronic medical record be in may particular practice? Preparation Disaster • How have other providers dealt with these questions in previous disasters? Mitigation Response Ritchie EC et al. Current Psychiatry 2019 Recovery 17 18 3
12/2/2020 Reasons to do an Assessment Needs Assessment • Develop a strategic plan • Individual • Group • Reports to command, families, media • Population – Consider vulnerable populations • Chronically mentally ill • Apportion resources • Physically ill • Disabled • Target interventions 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 19 20 Basic First Assessment of Physical Assessment of Health Needs Needs • Number affected • Vulnerable populations – Mentally ill • Shelter – Children • Food – Prisoners • Wounds/Illnesses – Wounded • Infectious Disease – Bereaved • Medications available • Medications • Hospital Beds • Fuel – General – Heating – ICU – Cooking – Medical surge • Continued violence – Psychiatry • Mass fatalities 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 21 22 Assessment of Health Needs Assessment Needs to be On ‐ Going • Try to gain as much information as possible • “Honeymoon” period common following before departure to affected site disasters • On the ground assessment usually necessary • Attention and media leave: • Persons to talk to – Physical and psychological needs surface – Schools – Feeling of bitterness, abandonment, anger – Hospitals • Clean ‐ up period – Clergy – Tedious, may still be dangerous – Community leaders – Shelters 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 23 24 4
12/2/2020 Assessment Question • In your current place of employment, have you ever had training in disaster planning? Completing the Assessment • A. Yes • B. No • C. I might have, but I can’t recall 25 26 Disaster Assessment Disaster Assessment • Develop Preparedness Plan • Identify your team – Healthcare and medical response coordination • Identify risks and needs (SWOT) – Emergency operations plan – Access to regional healthcare resources – Communications Medical Surge – Essential functions – Prioritize resource gaps and mitigation strategies Alternative Care Systems ‐ • Different for each setting Telemedicine/Virtual – Consider vulnerable populations • Supply chains • Finance functions – Regulatory compliance • Sheltering in place • Protecting healthcare information systems and networks • Protecting responders’ safety and health – Healthcare evacuation and relocation 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 27 28 Disaster Assessment • Recovery Plan Examples/Thoughts for • Train and prepare the healthcare medical Discussion workforce • Ensure preparedness is sustainable 2017 ‐ 2022 HealthCare Preparedness and Response Capabilities; Dept. of HHS 29 30 5
12/2/2020 Psychiatric Issues ‐ Acute “Drug Refugees” • Stress as a reaction • Additional fear of unknown with CBRNE • Limited to no medications • Changes in mental status secondary to any • Withdrawal symptoms agents • Symptoms return • Medical triage • Self inflicted harm • Quarantine, reverse isolation • Psychosis • Loss, grief • Cravings • Under ‐ reactions Ritchie EC et al. Current Psychiatry 2019 Ritchie EC et al. Current Psychiatry 2019 31 32 Katrina Behavioral Health Needs Opioid Withdrawal • Chronically mentally ill off medications – Note: psychiatric medications not in stockpile Early Later Cramping • Displaced psychiatrists and populations • Watery eyes • Diarrhea • – Volunteers needed • Runny nose Vomiting • Increased heart rate and – Issues of housing, transportation • • Sweating blood pressure • Louisiana National Guard Restlessness • • Anxiety/Irritability Shakiness – All flooded to the “crash site” • Chills • • Importance of pets • Poor sleep Sweating • • Long term issues of “diaspora” Goose bumps • Muscle pain • Dilated pupils • Ritchie EC et al. Current Psychiatry 2019 Ritchie EC et al. Current Psychiatry 2019 33 34 Resources Solutions Patient Provider Refills prior to disaster • Develop emergency • (personal stockpile) plans for injections, Emergency kit prepared to • blood draws, and other grab if you need to go quickly time sensitive Stock medications in multiple • places ‐ office, home, family monitoring members house • Provide patients with Carry medication list with • current and past medication lists medications, allergies, and • Discussions with provider contact information patients to be prepared Ritchie EC et al. Current Psychiatry 2019 35 36 6
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