Issues in emergency pharmacy

February 14, 2013

We can learn from New Zealand, Japan, and Pakistan

Over the past 12 years, the United States has dealt with the devastating effects of Tropical Storm Sandy, Hurricane Katrina, and the September 11 terrorist attacks, among other recent disasters.

These events tested in numerous ways the resolve of people in the affected areas. Individuals needed emergency treatment, medications, and often basic medical supplies. Pharmacies were damaged or destroyed, and supply lines for medication distribution to the appropriate facilities were compromised.

In these challenging scenarios, the logistics of providing proper care often required creative solutions, and in the end, the dedication of those who gave their time and efforts helped to provide a caring environment for those in need.

Since my visit to Port-au-Prince in Haiti after the January 2010 earthquake, this topic holds particular interest for me, so during my attendance at the International Pharmaceutical Federation (FIP) congress in November 2012, I sat in on a session discussing emergency pharmacy practice. During this session, speakers documented their experiences in disaster relief and emergency medicine in Christchurch, New Zealand; Japan; and Karachi, Pakistan.

New Zealand: New protocols

First to speak was Jane Dawson, from the New Zealand Defence Force, based in Wellington, New Zealand.

The 6.3 magnitude earthquake that struck Christchurch on February 22, 2011, was the area’s second major earthquake in six months. Structurally it caused far more damage than the first, being shallower and closer to the city center.

Destruction was widespread, and the city’s historic Christchurch Cathedral was damaged beyond repair. Even more than a year after the event, much of downtown Christchurch is still fenced off from the general public and considered part of the damaged “Red Zone” area.

The February quake also damaged portions of the city’s sewer system and power supply.

Damage to pharmacies

Twenty local pharmacies were damaged beyond the point where they could remain operational. Many prescription records and patient files were lost or destroyed. A nearby pharmacy wholesaler was destroyed. Large numbers of patients were displaced.

Without power, communication between healthcare providers ground to a halt. Unable to access patient profiles on their computers, and with original hard copies probably damaged, pharmacies faced the challenge of verifying medications needed by patients.

Obtaining new or replacement medication orders became difficult: Telephone lines were damaged and overloaded, mobile phone service was spotty, and facsimile prescriptions could not be received without power.

Some pharmacies damaged beyond the point of reopening were able to establish temporary facilities.

Emergency measures

The New Zealand Ministry of Health and Pharmaceutical Society of New Zealand (PSNZ) quickly instituted special criteria and protocols of practice, relaxing previously established standards if necessary. Additionally, PSNZ helped coordinate and deploy volunteers in the area, providing details on proper rationing of drug supplies and granting more leeway in distribution of emergency medications.

With a lack of proper documentation or actual prescriptions, it became imperative to establish a system that permitted pharmacists to dispense emergency supplies of medications.

Previously, pharmacists had been allowed to dispense a 72-hour emergency supply of a medication if they judged it vital for the patient to continue treatment and all other options for acquiring the necessary medication were exhausted.

Following the earthquake, the emergency supply period was extended to a full 7 days, with the option to grant refills after 7 days. This disaster displaced so many individuals that the updated rule was implemented across the entire country.

In order to provide these emergency supplies of medication, pharmacists needed to ascertain that patients were truly in need. Criteria included the following. Patients had to be:

• affected by the earthquake

• unable to get in touch with their doctors

• unable to obtain medication from their own pharmacies.

In addition, the medication and dosage had to be appropriate for the condition the patient was trying to treat.

To prevent drug-seeking behavior and diversion, controlled medications were not eligible for emergency dispensing.

Consequences

Supply issues occurred early on, with one wholesaler’s facilities rendered inoperable and large portions of roadway damaged. As Christchurch is the largest city on New Zealand’s South Island, these issues affected more than half the country. For months after the earthquake, medication rationing occurred.

A typical maintenance prescription in New Zealand is good for a 3-month supply of medication, but during this rationing period it was not uncommon for prescriptions to be dispensed for weekly supplies in some South Island pharmacies.

Despite the many difficulties, the situation was managed quite effectively.

Ms. Dawson emphasized the need to have in place a system to handle such scenarios, both nationally and internationally. Strategies key to making such a plan effective include alignment with national civil defense organizations, freedom to work hand-in-hand with volunteers, and the capability to manage emergency plans in smaller groups independent of the larger overall group.

Japan: Materiel management

Speaker Eiko Kobayashi from the Japanese Red Cross detailed some of the challenges faced in accessing and organizing relief medications after the earthquake and tsunami that struck the eastern coast of Japan in March 2011.

Following this disaster, donations of medications inundated the region. The sheer volume of these much-needed resources made sorting and quality assurance problematic and challenging.

With donations coming in from across the globe, the language of drug packaging became an issue, and so was determination of what specific active ingredients the medications actually contained.

Determining the original source of medication donations was another factor. When origins were unclear, it was often impossible to determine whether a drug was counterfeit. For volunteers, just to sort and organize the donated drugs was a massive undertaking, and it is possible that resources thus employed could have been used to greater benefit elsewhere.

When all was said and done, more than 4 tons of donated medications were deemed unusable and destroyed. The Japanese Red Cross plans to keep streamlining the donation process and to maintain emergency response stockpiles of the most frequently used medications.

Pakistan: Disaster preparedness

Feroza Perveen, PharmD, and Abdul Latif Sheikh reported on their experiences practicing emergency room pharmacy in Karachi, Pakistan. The country has experienced unrest in the form of terrorist attacks for much of the past decade, as well as an earthquake in 2005 that claimed the lives of more than 70,000 people in the Kashmir region.

Both speakers work at the Aga Khan University Hospital (AKUH). The hospital’s department of emergency medicine is the first in the developing world to be designated as a World Health Organization Collaborating Centre in Emergency Medicine and Trauma Care.

The pharmacy itself operates around the clock and has systems in place to handle large influxes of patients quickly and efficiently. In addition, the pharmacy serves as drug and poison information resource for local healthcare teams.

As part of their disaster preparation, emergency room physicians and pharmacy staff collaborated on a core list of necessary medications to have readily available. In response to changes in contemporary practice, the two groups continue to meet regularly to revise and update the list.

Inspection procedures are in place to guarantee availability of all life-saving medications and to ensure that none will be expired when an emergency occurs.

Regular training sessions and mock disasters are practiced to hone the team’s skills.

The takeaway

Continued development of emergency response systems, institutional research and training, and risk-management planning can maximize the effectiveness of our post-disaster efforts.

When disaster strikes, it is imperative that the appropriate organizations have the resources and tools to respond properly.

The development of emergency response plans and protocols must be flexible and allow for any number of variables.

Providing relief is never a one-size-fits-all type of operation. The qualities of quick thinking and adaptability, as well as the ability to solve unorthodox problems, are vital to working in disaster relief and emergency medicine.

Joel Claycombhas reported on his visits to Haiti and New Zealand in previous issues of Drug Topics. Contact him at jcclaycomb@gmail.com.