Introduction

Natural disasters such as hurricanes, tornadoes and flooding are usually unpredictable. These events typically occur suddenly and with little or no warning and can cause widespread chaos. In recent years, a variety of types of natural disasters have occurred in the United States and around the world. Natural disasters have both short-term and long-term consequences and may result in severe infrastructural damage, personal injury, and public health threats. This can lead to an increased need for pre-emergency planning and post-disaster patient care. Pharmacists are recognized – with increasing responsibility – as important members of disaster preparedness planning and response teams.^1-3

Following natural disasters, healthcare providers play a key role in recovery by providing patient care and helping to ensure access. However, during these times, pharmacists and other health providers also may be called upon for more nontraditional roles. In 2003, the American Society of Health-System Pharmacists (ASHP) released a statement outlining roles for pharmacists in emergency preparedness and provided advice tailored to specific groups (e.g., pharmacy directors, pharmacists, administrators).⁴ The statement included commitments made by ASHP to assist in communication and dissemination of information related to emergency preparedness through their member network.

Potential roles identified for pharmacists in emergency preparedness and disaster management in other literature include medication provision and prevention of communicable diseases.⁵ For example, pharmacists may be asked to provide medications and/or disease state education for rare infections or complications from exposure to contaminated flood water. Additionally, other literature identified that mass immunization campaigns might need to be initiated and patient needs can quickly overwhelm facilities that are working with limited resources. Pharmacists trained in the provision of immunizations may help to address these challenges.^1-6 Finally, management of chronic disease states also was cited as becoming more challenging, with interrupted supplies of common medications and potentially dangerous or difficult living situations that can exacerbate chronic diseases such as diabetes or hypertension.⁷ Pharmacist awareness of alternative supply chains may help to alleviate these challenges and ensure continuity of management of chronic diseases.

While the roles of pharmacists are expanded during a disaster, it is important to remain aware of and act within the laws, rules, and regulations. Following a severely damaging natural disaster, a state of emergency may be declared, which can lead to changes in rules and regulations that impact pharmacists and pharmacy operations. Specific changes vary among states, so it is important that pharmacists investigate their practice location.^8,9 Since natural disasters usually occur with little or no warning, development of comprehensive disaster preparedness plans tailored to individual pharmacies is important.¹⁰ Pharmacists at all levels can and should be involved in developing and updating these plans on a regular basis.¹ Many resources are available for pharmacies and pharmacists to develop and refine an emergency response and disaster preparedness plan to allow for a more efficient and timely response when needed.

Case

CC: “I lost all of my medications when I had to evacuate.”

HPI: DS is a 42-year-old male (71 in, 90.9 kg). His house was flooded in the storm and badly damaged. He is currently staying at a nearby emergency shelter until arrangements for longer term housing can be made with his insurer. He has a minor cut on his leg from an injury sustained while helping a neighbor with cleanup of his flooded home. He states that the cut hurts. Upon examination, you notice the wound is warm to the touch and is red and swollen. He also has experienced some shortness of breath and difficulty breathing during cleanup.

PMH: T2DM (controlled by diet); hypertension; asthma

FH:

• Father: heart attack at age 70
• Mother: history of DM

SH: Limited information about the patient’s social history has been provided. However, the patient states that he currently has limited access to shelter and basic medical resources as a result of his displacement following the hurricane.

Surgical history: Non-remarkable

Vitals:

• BP 149/85 mmHg
• HR 88 bpm
• RR 21/min
• Temperature 99.1 ºF
• Pulse oximetry 92% on RA

Labs: Unable to access. The pharmacy and the local health system computers were impacted and are not accessible. Patient is also unable to recall specific values and states he had a paper with some of his valuables, but this was lost in the storm.

Medications:

• Albuterol – Inhale 2 puffs every 6 hours as needed for SOB/wheezing for asthma
• Lisinopril/HCTZ 20/12.5 mg – Take 1 tablet by mouth daily for hypertension
• Advair HFA 115-21 mcg – Inhale 2 puffs 2 times daily for asthma
• Ibuprofen 200 mg – Take 1 tablet by mouth every 4 hours as needed for pain from leg injury/muscle soreness from clean up following natural disaster

Allergies: NKDA

Vaccinations: Patient is unable to recall

SDH: Patient states that he has medical and prescription insurance but cannot locate or provide his insurance card or identification. He is unable to recall a specific company that provides his health insurance but can tell you that he uses a local smaller chain pharmacy typically for accessing pharmacy services.

Additional context: A temporary clinic has been set up by employees of a local ambulatory care clinic to attempt to care for patients affected by the storm. The clinic location where the employees typically are employed was badly damaged in the storm and is not able to be used for normal operations for quite some time. The attached clinic pharmacy was also affected and is currently inaccessible; however, some supplies have been salvaged for urgent use. The clinic’s medical and pharmacy records are currently inaccessible. Pharmacies located out of state but nearby have offered assistance with obtaining medication stock but need clarification of what supplies are most needed and a plan for transport of the supplies to the affected areas.

Case Questions

1. What documentation needs to be done prior to dispensing medications to patients or providing medications to other healthcare providers involved in disaster management care? How and when should this documentation be completed to provide the patient with medications?

Documentation in a disaster management scenario still is important for legal and safety purposes associated with the provision of patient care. However, traditional documentation systems that are computer-based or require use of internet connectivity may or may not be available. Means of providing documentation, even paper-based recording, should be identified before medication dispensing begins and should include typical documentation parameters associated with legal prescription dispensing as well as an inventory management process. A team leader should be identified to ensure that this process is adequately and appropriately followed.

2. How can you determine or verify if a patient has a legitimate prescription when records are not accessible?

Verification of patient’s legitimate prescription is often a difficult task in a natural disaster or emergency management scenario. However, it is sometimes possible to gather enough detail from the patient to clarify recent medication use. Current pill bottles may be used or descriptions may be obtained from the patient. For example, in this patient with asthma, the patient might be able to describe physical details about his inhaler (color, shape, etc.) even if he does not remember the medication name.

Interprofessional education with a provider at the emergency medical shelter can provide short term prescriptions. Emergency prescription refill protocols may be enacted that provide legal guidance to pharmacy professionals to provide a 30-day emergency supply of medications. Collaborative practice protocols may allow pharmacists to provide certain medications and services for patients meeting specific criteria. State laws vary, so pharmacists should be aware of emergency processes that may require specific documentation.

In the instance where other physical locations or network pharmacies exist, although the records cannot be accessed at your physical location, a phone call (if networks are supporting calls) may help to obtain this information. A tool at https://www.healthcareready.org/rxopen can be used in U.S. disaster relief situations to locate the nearest open pharmacy to call. Data for this tool is based on recent pharmacy system transactions so may underreport pharmacies that are open if, for example, the pharmacy does not have power and is processing prescriptions manually. Action preparedness steps of pharmacies should include identifying locations potentially available out of the direct path of the natural disaster.

In future disaster preparedness, it is appropriate to counsel patients that, if able, it is advantageous to take a two-week supply of medications and to have a list of current medications accessible in a wallet or in non-physical location (e.g. email or cloud-based storage).^a

3. What pharmacy preparations could be undertaken in advance to ensure your ability to safely and appropriately respond in an extreme weather event?

If not already in place, one of the most important actions is for a pharmacy to create and frequently update a comprehensive disaster/emergency preparedness plan that is specific for the pharmacy. Preparedness plan templates can be found online and state and national organizations, such as Boards of Pharmacy and the National Association of Boards of Pharmacy, have resources.^a,b

Following development of the pharmacy specific disaster/emergency preparedness plan, ensure that employees have been regularly trained on the plan and are prepared to follow the steps described in the event of an emergency scenario or natural disaster. For the plan to be effective, it is crucial that contact information is updated regularly and easily accessible in case of emergency. It is also helpful to have contact information for the local emergency operations center that would be coordinating response efforts. Information for contacting pharmaceutical suppliers and the board of pharmacy should also be included. Electronic and paper copies of the plan should be available and accessible by multiple pharmacy emergency response team leaders, with copies in multiple locations to increase access in a disaster situation affecting all or part of the pharmacy. Consider providing or encouraging pharmacy staff to participate in educational activities on disaster response and emergency preparedness. Identify relevant laws/rules that may be enacted in the event that a state of emergency is declared to ensure that you can provide appropriate care according to your state laws and regulations. Practical considerations include maintaining appropriate storage conditions for medications and addressing potential security needs.^c If loss of power is expected, a backup generator should be considered. A disaster response kit with critical supplies may also be maintained.

Although many natural disasters are unpredictable, some advance warning may be given. If so, consider potential needs for your pharmacy and patient population that you could “stockpile” and store in a safe place to enable a more rapid response following the acute event. If possible, consider creating backups of electronic medical records that are stored at a secure off-site location outside the disaster risk area that could be accessed following the event.

4. What acute health risks does this patient have?

• Acute Risk 1:

Although the case states that the cut on the patient’s leg is minor, he has an increased risk of infection from exposure to potentially contaminated flood water or building materials as he is helping with clean up following the disaster. The patient has a slightly elevated temperature indicating a potential response to an infection. The physical exam findings (wound is sensitive to touch, red and swollen) also suggest possible infection. Additionally, the patient is diabetic; uncontrolled diabetes could result in delayed wound healing and increased susceptibility to infection.

• Acute Risk 2:

The patient had previously managed his diabetes through diet control; however, since he is currently living in an emergency shelter and has limited resources, he has less ability to control what he eats and may encounter challenges in maintaining a healthy diet. It is especially important for patients with diabetes in disasters to have previously prepared an emergency response kit for the purposes of management of the condition. For example: https://www.thediabetescouncil.com/diabetes-and-disasters-how-to-manage-your-diabetes-during-disasters/ (Accessed March 2019), or resources from professional organizations – https://www.hopkinsguides.com (Accessed March 2019). Practitioners may reference the American Diabetes Association (ADA) Statement on Emergency and Disaster Preparedness available at: http://care.diabetesjournals.org/content/30/9/2395 (Accessed March 2019)

• Acute Risk 3:

The patient has indicated that he has a past medical history of asthma that appears to have been controlled by use of his inhalers. However, the patient’s current vitals indicate that he is currently experiencing shortness of breath. This may be due to exposure to irritants exacerbating his condition or from lack of access to his rescue and controller inhalers.

5. How can you help educate and prepare the community and the patient for response and recovery?

To help educate and prepare patients, pharmacists may provide education for patients on the importance of having an updated medication list, listing of provider and insurer information, and ensuring at least a two-week supply of medications are stored in an emergency bag that can be easily taken prior to the occurrence of the natural disaster if there is a need to evacuate. If applicable, pharmacists can recommend and provide immunizations, direct patients to disaster and emergency preparedness resources, and provide public health education on proper sanitation and procedures for safe clean up following disaster (e.g., wearing appropriate respirator mask when removing flood-damaged building materials to reduce exposure to mold/particulates), and avoiding standing water due to hidden or unexposed risks. Pharmacists may participate in local emergency management organizations to ensure pharmacists are included as preparedness and response plans specific to their community are developed. As part of preparedness activities, pharmacists and pharmacies can identify community resources, partners, and opinion leaders who can help direct resources and effectively communicate details of resources and services that are being provided during the recovery process.

References:

a. Coppock K. Preparing for Medication Safety in a Natural Disaster. Pharmacy Times. September 12, 2018. Available at: https://www.pharmacytimes.com/news/preparing-for-medication-safety-accessibility-during-a-natural-disaster. Accessed February 14, 2019.

b. National Association of Boards of Pharmacy. Emergency Preparedness Guide: https://nabp.pharmacy/wp-content/uploads/2016/07/06Emergency_Preparedness_Guide.pdf. Accessed February 14, 2019.

c. D’Arrigo T. Disaster strikes! Are you ready to help your community? Pharmacy Today. 2017;23(8):34-37.

Author Commentary

Although this case focuses on a specific situation of severe flooding, many of the issues and concepts discussed can be applied in emergency situations arising from other natural disasters. As discussed above, the period following a severe natural disaster may be chaotic and contribute to worsening of a patient’s chronic disease states as well as introducing new disease concerns. Pharmacists can offer practical and creative solutions for health-related problems, especially in situations where the usual healthcare resources are limited or unavailable.

Many educational resources are available for pharmacists with an interest in disaster preparedness and management and are included in the references listed below. Participation in education and preparedness activities is key to effectiveness if faced with the challenge of providing care following a natural disaster. It is strongly encouraged that pharmacists seek out their local emergency management organizations to ensure that pharmacy interests are represented when plans are developed. Pharmacists also are reminded to contact state pharmacy boards for specific guidance and considerations pertaining to each state.

Patient Approaches and Opportunities:

When counseling patients, it is important to consider the effect of changes in living conditions (emergency shelter, traveling to stay with friends/family, etc.) on the management of chronic disease states. Aside from the added stress of the disaster situation, patients may be unable to adhere to complicated medication schedules; may be unable to eat regularly scheduled, nutritious or well-balanced meals; may have more limited mobility or other functional losses due to loss of medical equipment such as walkers and important personal items like eye glasses, hearing aids, or false teeth; or decreased accessible shower/restrooms. Plans for patients may have to include managing the acute needs (e.g., 72 hours following natural disaster) and guidance on longer planning/response.

Connecting patients with mental health resources following a natural disaster may be important. Education provided to the public and providers can assist with recognition and awareness of mental health needs in times of crisis/recovery. Depending on the type of disaster, patients may experience anxiety and/or depression and feel overwhelmed as they begin the recovery process. Responders and volunteers can also be affected, especially in the acute phase of recovery when the need is greatest and volunteers may be working long hours in high stress situations and austere conditions. It is critical to watch for signs and symptoms related to depression, stress, and post-traumatic stress disorder. Depending on the culture and understanding of mental health, patients may not directly recognize what they are experiencing as stress, depression, or trauma.

Natural disasters happen all over the world. Preparedness is critical wherever you might be.