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May 23, 2013

Moore Pharmacist Put Preparedness Into Action

Barbara Poe attempts to retrieve possessions from her GMC Yukon about two hours after an EF5 tornado tore through Moore, OK, on May 20. The tornado destroyed Moore Medical Center, where Poe is lead pharmacist. Photo courtesy of Darin Smith.

THE PHARMACY AT 45-BED MOORE MEDICAL CENTER in Oklahoma may be intact. On Wednesday, May 22, no one knew for sure. Moore’s former lead pharmacist, Barbara Poe, had not been able to return since she and pharmacy technician Kim Wedel left the pharmacy on May 20 in search of refuge from the oncoming tornado.

They eventually took cover under a desk in the postanesthesia care unit, using pillows and mattresses from gurneys for additional protection.

When they emerged, Poe said, “I looked to my left. Part of the building was gone.”

So, too, were the chairs that she had earlier kicked away from the desk.

And the auxiliary automated dispensing cabinet “was gone,” perhaps around the corner, Poe said.

No Place to Shelter

The maximum-strength tornado that tore through 17 miles of the Oklahoma City metropolitan area touched down at 2:45 p.m. CDT and ended at 3:35 p.m. CDT, according to the National Weather Service’s May 22 statement.

Poe, a lifelong Oklahoman, said she had been monitoring the weather since at least noon. At 1 p.m., when a local news channel’s noon broadcast ended, she had her computer display the weather radar. About half an hour later, the radar showed thunderstorms. Around 2 p.m., the meteorologists in Oklahoma City used the terms “the hook” and “well defined,” she said.

“This tornado blew up faster than any tornado I have ever seen in my life,” Poe said.

She didn’t hear the city’s tornado sirens or the hospital’s announcement of code black. Poe explained that was not unusual because of the pharmacy’s location on the first floor.

When the meteorologists instructed people to “get out of the way or get underground,” Poe said, she and Wedel left the pharmacy, which had no protective place for them.

Poe said they looked across the hall at the cafeteria and realized it was full, partly with hospital employees and partly with people from the community. Patients from the second floor had been moved to the first floor.

She said the next stop was the surgery area. The hospital did not have a basement.

After she and Wedel barricaded themselves under the desk in the postanesthesia care unit, Poe said perhaps 10 minutes passed. Then the electricity went out, something hit the building, there was a pause, and then she heard the sound of a train.

“And then,” she said, “it was as if there was a giant outside with a sledgehammer hitting the building.”

Meanwhile, Poe’s supervisor, Darin Smith, was in the incident command center at the 324-bed flagship of three-hospital Norman Regional Health System, less than 10 miles from Moore.

Smith, the health system’s assistant director for pharmacy services and performance improvement, said the group in the command center had been monitoring the path of the tornado.

Early information suggested that the tornado had not hit Moore Medical Center, Smith said. So he, his superior, who is the chief nursing officer, and the vice president responsible for the Moore campus drove together to the hospital with the goal to help the staff resume operations.

On the way, Smith said, they realized “the hospital had taken a direct strike.”

Setting Up Triage

The drive to the small hospital probably took more than an hour because traffic had backed up, he recalled. All the while, the group tried texting and calling Moore’s staff members.

“By the time we had arrived, all the patients and most of the employees, if not all of them, were already out of the building and they had set up a triage area at an adjacent building next door,” Smith said.

Vehicles lay near the southeast side of Moore Medical Center. The postanesthesia care unit, where Barbara Poe and Kim Wedel took refuge, was on this side of the facility. Photo courtesy of Darin Smith.

That building, the Moore Warren Theater, is what television viewers probably saw, he said, when they watched news footage of triage near the hospital.

No patients or staff members at Moore had injuries from the storm, the health system said.

Smith said his first sighting at the theater was of Wedel. She said Poe was OK and pointed in her general direction.

“I was quite in shock, a little bit,” he said. “I wasn’t expecting to walk up and see the building totally devastated. . . . I was expecting to be able to walk in and help Barbara and kind of get things going.”

The smell of gasoline from the destroyed vehicles and natural gas from broken pipes “was pretty overpowering,” he said. There was concern about the potential for an explosion.

In addition to the gasoline and natural gas leaks, the oxygen storage tank sitting outside the pharmacy on the hospital’s exterior was leaking. Poe said she learned of that leak when she tried to return to the pharmacy after leaving the postanesthesia care unit.

Smith said Moore’s pharmacy staff, which included a pharmacist who worked the seven-days on, seven-days off schedule opposite Poe, now reports for work at Norman Regional.

“Right now, Barbara has a lot of work to do,” he said.

Where to Begin to Pick Up the Pieces?

There are controlled substances at Moore to count and remove, Smith said. The whereabouts of the automated dispensing cabinets on the hospital’s second floor, where the nursing units had been, must be determined. Steps must be taken to close the pharmacy. Whether that closure is permanent or just temporary has not been decided, he said.

Poe, whose vehicle was damaged by the tornado, is not the only member of Smith’s staff who lost property.

The tornadoes that hit the area on Sunday destroyed a pharmacy technician’s house, Smith said. His department assistant lucked out in that her house is still standing despite the tornadoes tearing up her treed yard and damaging neighbors’ houses.

“We’ve had a tremendous outpouring” of concern from pharmacists across the country, he said. “It does give you a very good feeling of how close-knit and really how caring I think our profession is.”

On Wednesday, Poe and Smith said they were working on helping to meet the future needs of residents in Moore. Earlier in the day they had delivered albuterol inhalers, ceftriaxone injection, and a few other items that had been requested by Heart to Heart International for its mobile medical unit in Moore, Poe said.

Before choosing to work at Moore, Poe had been the pharmacy director at Norman Regional. She was a member of the ASHP Council on Administrative Affairs when it proposed the initial policy position on emergency preparedness in 1999.

Poe, who still remembers the sight of the Alfred P. Murrah Federal Building in Oklahoma City immediately after the bombing in 1995, said she was the council member who proposed the policy topic.

–By Cheryl Thompson; reprinted with permission from ASHP News

May 9, 2013

Pharmacist Involvement Integral to Medical Home at Advocate Health

From left, a patient reviews his test results with Golbarg Moaddab, M.D., and Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE.

AS HEALTH CARE REFORM EVOLVES and providers are held to higher standards of quality and improved patient outcomes, more physicians and health systems are turning to the patient-centered medical home (PCMH) to offer comprehensive, cost-effective care.

At Advocate Medical Group, a subsidiary of the Advocate Health System in Chicago, administrators recognized the value pharmacists can bring to the medical home. When they needed a pharmacist who had experience working with heart failure patients, they contacted the Midwestern University College of Pharmacy for a candidate.

Enter Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE, assistant professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, whose work with Advocate meets ASHP’s Pharmacy Practice Model Initiative recommendations for pharmacist involvement in the medical home. She is part of a PCMH that includes six primary care physicians, a cardiologist, a nurse practitioner, a physician assistant, a nurse educator, and a dietician.

Schumacher has a broad and well-integrated role in the PCMH. Through collaborative practice agreements, she initiates, discontinues, and titrates medications and provides medication reconciliation and education to improve patient adherence. She also orders and interprets laboratory values, arranges medical referrals, and provides disease-state and lifestyle education. Schumacher is also available for medication recommendations and physician consults.

A Key Member of the Health Care Team

Schumacher works closely with the team’s nurse practitioner, Monique Colbert, APN. The primary care physicians and cardiologist refer heart failure patients to Schumacher and Colbert through a “task” message in the patients’ electronic medical records.

Although physicians can select the team member whom they would like a patient to see, Schumacher and Colbert often review the medical history and make the determination themselves.

Patients who need more help with their medications see Schumacher, whereas those who need lifestyle management counseling see Colbert. Yet the two share the goals of improving patient outcomes and lessening the physicians’ load.

“We are extra help for the doctors. When patients need follow-up, the cardiologist and primary care physicians just can’t see them every two weeks. That’s where we step in and provide that in-depth care,” said Schumacher. Initial visits last about an hour, and follow-up visits last about 30 minutes.

Although Schumacher was initially tapped for her experience in treating heart failure, it soon became clear that patients needed assistance in managing coexisting conditions.

Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE

“We were seeing high A1Cs in people with diabetes, up around 10 or 11 percent, so we started making recommendations to the physicians about how to treat them. Then we did the same for patients with hypertension and dislipidemia,” said Schumacher. “The physicians asked us if we could handle treating this condition, and we went from there.”

Schumacher now uses pharmacist-created protocols and current guidelines to help her manage patients with diabetes, hypertension, dislipidemia, chronic obstructive pulmonary disease, and asthma. Plans are in the works to add chronic kidney disease to the mix.

Colbert said she has learned from Schumacher. “My background is heart failure, and Christie helped me come on board with diabetes. At first, I would see the patients with A1Cs of eight or lower, and Christie would see patients with more complex cases, but as I became more educated and more skilled, I began to take on complex patients as well.”

Proving the Case

The PCMH took six months to implement and, initially, there weren’t many patients to see: The primary care physicians and nurses were a bit wary of Schumacher conducting physical assessments. But support from the cardiologist, with whom she had worked before, helped, as did Schumacher’s own drive to show the value of pharmacist-provided care.

“I took the time to learn physical assessments. Many pharmacists aren’t comfortable with that, but it makes a difference. You need to show the physicians that you know what you are talking about,” she said. “At first, the physicians wanted us to run everything by them, but after two weeks of seeing what we could do, they told us to just go ahead [with our care].”

Although physicians still sign off on the care notes, both Schumacher and Colbert can now write prescriptions.

Golbarg Moaddab, M.D.

Goldbarg Moaddab, M.D., an internist on the team, finds the collaboration indispensible. “I can’t imagine practicing without the medical home anymore. The other professionals can be so much more thorough regarding patient history and medications, and they have more time to spend with patients than physicians do,” she said.

Advocate Medical Group is currently looking at outcome measures such as hospitalizations, readmissions, emergency room visits, blood pressure, LDL cholesterol, and A1Cs.

Regardless of how those measures come out, Moaddab said she has noticed a change among her patients.

“Before Christie was part of the medical home, it took much longer to get patients to their goals for A1Cs, blood pressure, and lipid control. Now that they are seen more frequently by other health care professionals on the team, they get there faster,” she said.

The patients appreciate the care, as well, said Schumacher, noting that for many patients, the in-depth follow-up is a new phenomenon.

“We have patients in their 60s who tell us that no one has ever sat down with them and discussed their medications,” she said. “We have a high turnout, and they like to come to their appointments. That’s going to go a long way toward increasing adherence and helping them to get better.”

–By Terri D’Arrigo

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