Island Health Authority disaster preparedness strategy for medication supplies

Creating a priority medication list for disaster preparedness

To determine a list of medications that Island Health Authority could need in a major disaster, normal medication usage patterns were first identified before clinicians selected the high priority medications for a disaster response.

While imperfect, this health authority’s best approximation of drug usage was based on purchasing data. A 3-year report was generated for the years 2017, 2018, and 2019 to identify drug names, the base unit of measure (BUOM), amounts purchased in each year, and the gross total for the 3 years. A preliminary list of medications was then selected by the emergency pharmacist based on the likelihood of increased usage in a disaster and the potential for clinical harm should these medications run out. Lessons from previous literature, and resources such as the World Health Organization’s Model List of Essential Medicines and the Interagency Emergency Health Kit, were used to assist in determining the key medications that should be in the disaster plan. ^26,27 Additional subjective recommendations were provided by the emergency pharmacist to include medications that should also be considered by the broader stakeholder group.

Once the preliminary list was created, 3 medication stocking strategies were drafted. Category A consists of medications that should be overstocked and have an immediate purchase order at the time of initiating the disaster plan. Depletion of category A medications is subjectively considered to be associated with a higher likelihood of patient harm and/or a significant impact on patient flow in the healthcare system within the first 72 hours post-disaster. Category B requires an immediate order of these medications if a disaster occurs, but no perpetual overstocking. Selection of these medications was subjectively based on the potential for patient harm or a significant impact on patient flow within a week. Category C consists of all other medications considered low risk for patient harm or bottlenecking of healthcare services should they become depleted. These medications are ordered per normal procedures (i.e., as supplies reach minimum quantities without a pre-emptive purchase order or overstocking). Additional factors in determining the strategy for each medication included the likelihood of the medication to be easily available to patients within the community and possible altered usage during a disaster.

Following the preliminary categorization of medications, stakeholders including physicians and clinical pharmacy specialists from emergency, critical care, cardiology, ophthalmology, anaesthesiology, psychiatry, pediatrics, neonatology, internal medicine, nephrology, and infectious disease were asked to review all 143 drugs in category A, all 238 drugs in category B, and 220 of 2816 drugs in category C. The subset of category C medications was selected by the emergency pharmacist for broader review to determine if these medications should continue to be excluded from categories A and B. Stakeholder feedback including potential additions to the list, was then used to finalize the disaster strategy for each item. In situations with conflicting recommendations, a panel of 4 clinical pharmacy specialists reached a consensus on the final disaster medication list. Order sheets were then created for use at the time of a disaster (Tables 2, 3, and 4). The final numbers were 159 drugs in category A, 254 drugs in category B and the remaining drugs in category C.

Table 2. Medications listed in the controlled drug order form for Island Health Authority during a disaster

* Category A medications requiring a 6–12-week overstock target for pre-disaster stock on hand (may vary per site). All other medications listed are deemed Category B medications. Medications not listed are considered Category C medications.

Table 3. Medications listed in the non-controlled part 1 drug order form for Island Health Authority during a disaster

* Category A medications requiring a 6-12 week overstock target for pre-disaster stock on hand (may vary per site). All other medications listed are deemed Category B medications. Medications not listed are considered Category C medications.

† Medications ordered through alternate vendors

Table 4. Medications listed in the non-controlled part 2 drug order form for Island Health Authority during a disaster

* Category A medications requiring a 6-12 week overstock target for pre-disaster stock on hand (may vary per site). All other medications listed are deemed Category B medications. Medications not listed are considered Category C medications.

† Medications ordered through alternate vendors

^§ SWFI = sterile water for injection

^¶ D5W = dextrose 5% in water

Disaster binder and workflow

Disaster binders were created so procedures can be operationalized under duress, possibly by people who are unfamiliar with the pharmacy purchasing procedures. The first binder provides an overview of the ordering process, followed by vendor and staff contact lists, drug order forms, and a drug catalogue. The second binder contains reference resources including contact numbers and locations for the EOC, phonetic alphabet guide, Island Health Authority’s Pharmacy Disaster Policy and Procedure, Pharmaceutical Vendor Business Continuity plans, and an inter-authority agreement.

An outline of the workflow is shown in Figure 1. When a state of disaster is declared, the EOC determines the need to order an emergency supply of medications for each Island Health hospital location. The most senior South Island Pharmacy Leader in the EOC communicates this decision and coordinates pharmacy operations for Island Health as a whole. The Pharmacy Leader works with the EOC Logistics Leader to gather information including: the number of anticipated disaster patients for all 9 acute care hospitals (including rural sites supported by these acute care hospitals), the operational status of these sites (e.g., accessibility of current medication supplies), requirement for alternate delivery locations, and operational status of transportation and communications from areas that are shipping medication supplies. The EOC determines secure locations to store ordered drug supplies. The senior Pharmacy Leader in the EOC delegates either the Pharmacy Purchasing Coordinator, a Pharmacy Purchasing staff member, or an alternate pharmacy staff member to initiate the medication purchase orders, using additional staff as needed, for each site using the information provided by the EOC.

Figure 1. Emergency/Disaster pharmacy drug ordering flowchart. * Communications of this process may be initiated by anyone; however the medication purchase order must be approved as shown.

If all communications are functioning appropriately, the purchasing office will use standard purchasing procedures to initiate the purchase order using near normal processes. The vendor is then notified that the order placed requires immediate prioritization as part of the emergency disaster response.

Once the disaster purchase orders are submitted to the vendor (or activated by alternative means as described below), an update to the EOC Pharmacy Leader, geography EOCs, and each site pharmacy leader is provided to confirm that the medication purchase orders are initiated. Additional feedback provided to the EOC includes an estimated time of delivery, the expected means of delivery, and instructions for proper handling and storage of medications such as narcotics, anesthetic gases, and medications requiring refrigeration.

If the disaster impacts the capacity for normal purchasing procedures, copies of the pre-planned order sheets are available with both the vendor and a geographically distanced health authority (Interior Health) in the event further assistance is required. Should the disaster prevent Island Health from initiating the purchase orders via normal procedures, the vendor will activate and process the immediate purchase orders (already on file) based on the estimated number of disaster patients expected at each site. This information may be relayed to the vendor through the EOC or via Interior Health. This disaster preparedness plan has been confirmed with the vendor.

At Island Health, there is an inter-authority partnership with Interior Health to initiate the medication purchase orders if Island Health is unable to complete the task. Interior Health is a publicly funded health authority which provides healthcare services across the Okanagan, Kootenay, Thompson, Cariboo, and Shuswap regions of British Columbia. This partnership was formed based on the use of similar purchasing processes in each region and the low likelihood that a major local disaster event will significantly affect both health authority populations at a given time. This partnership involves no cash exchange and requires sharing disaster binders and contact information in the event of a disaster.

Basic communication may become inoperable in the event of a disaster; therefore, satellite phone capabilities are required, and information must be updated when vendor or administrative contact names change.

Limitations

Different geographies may have different medication needs based on different disaster risks. A large earthquake and tsunami currently pose 1 of the greatest risks to Vancouver Island, but this is not the case for many other geographies. Some disasters may not require many medications in the response, so this described strategy may not be appropriate for all types of disasters.

This disaster plan is for medications only and must be coordinated with strategies for other supplies (e.g., syringes, needles, intravenous tubing). Medications not available through normal vendor procedures are ordered from specialty vendors or general stores. It is expected that most hospital pharmacy departments have an additional disaster plan for staffing. Initiating the procedures outlined in this document should be considered when creating a staffing plan.

It is unclear if having 1 person complete the purchase orders for all sites in a health authority is more advantageous than having staff from each site follow the disaster binder procedures. This may be disaster-dependent, and the outlined strategy provides the structure for either option at the EOC’s discretion. The challenges with transportation and delivery of supplies during a disaster is typically handled by the EOC and outside the scope of this review.

Large scale disasters can impact medication supply chains, and there is no guarantee that an immediate drug order will be fulfilled and delivered efficiently during a disaster event. Therefore, inventory mitigation strategies were included as a surplus for target medications. However, physical space and avoiding drug wastage and budgetary losses are significant considerations.

While selecting the medications for use in a disaster, multiple drug strengths are ordered to avoid issues with backorders if a specific strength was not available at the time. However, choosing a single strength of a specific drug would allow for a shorter order list and quicker completion of the purchase order. Furthermore, the threshold of requiring 200 disaster patients to initiate a medication purchase order was arbitrarily chosen and there is no data to support this. It simply reflects a reasonable estimate of current surge capacity within Island Health. Previous disasters provided insight on the possible surge demand (including possible ED presentation and admission rates), but this data may not be generalizable to other geographies and disaster types. ^{Reference Klitzman and Freudenberg7,Reference Pang, Lim, Chua and Seet8,Reference Equipment23,Reference Higgins, Wainright, Lu and Carrico28–Reference Yen, Chiu and Schwartz31}

This strategy is based on numerous subjective assumptions. The EOC must provide an early estimate of the number of disaster patients expected to present to health care sites, which may be inaccurate at the onset of the disaster. Clinical judgment was used to create the list of medications for category A and B (i.e., overstocking and the immediate medication purchase orders). While a reasonable process for stakeholder input was included, broader input may further strengthen the final list of medications identified in this disaster plan. Analytics used to capture the number of patients seen in Island Health over the 3-year medication purchase order history (i.e., to create an estimate of normal drug usage patterns per patient) may not accurately represent medication usage for patients seen during a disaster event. Additionally, estimating the deviations from these calculated medication usage patterns during a disaster event is not evidence-based. Lastly, this strategy does not account for previous reports that medications could be hoarded out of panic by individuals in the healthcare industry. ^{Reference Tsai, Lurie and Sehgal32,Reference Sterman and Dogan33}

The authors acknowledge that such compromises lead to an imperfect disaster plan, but this may hopefully serve as a foundation for further iterations and discussions in disaster preparedness literature.