ASHP InterSections ASHP InterSections

December 1, 2008

How to Handle a Hospital-Wide Power Outage

Editor’s Note: Craig Steinberg, Pharm.D., pharmacy manager of Sharp Coronado Hospital in Coronado, Calif., is a Disaster Medical Assistance Team member and serves as chairman of the San Diego Pharmacy Emergency Response Team (RxERT). Although the recent wildfires that ravaged Southern California did not reach Coronado, Steinberg noted that the essential elements of emergency preparedness tend to be similar across most situations.

Imagine if your hospital suffered a pre-dawn electrical fire that started in your hospital’s main switchboard. Breakers fail to trip and the emergency switchboard is wiped out, melting components of all power. A minute later, your hospital is totally dark. The emergency generators are running, but they’re unable to feed the emergency switchboard, which is now a smoking ruin.

In other words, there is no electricity.

What would you do? The pharmacy refrigerator contains thousands of dollars worth of medications. How would you provide medications now that your automated dispensing systems are down? With no available computers, how would you know which medications are on the medication administration record (MAR)? And most importantly, are your patients in need of pain or other medications? Think! The clock is ticking!%%sidebar%%

Well, it happened at my hospital on July 18, 2007. Apparently, an electrician had been upgrading an electrical panel when an arc flash occurred, sparking a fire. Although it was extinguished within a minute, all power sources were out for a much longer time.

I was at the scene in a short time. En route to the hospital, I noticed a major problem as I crossed the Coronado Bridge. The big blue sign that flashes ‘Sharp Coronado Hospital’ was out and as I came closer, I saw that no lights were on in the entire hospital.

Hospital staff mobilized and set up an incident command center outside the facility and switched monitors and ventilators for some patients to battery power before moving these patients to a nearby skilled nursing facility that had electricity.

Because we are a small hospital, our pharmacy is closed at night. So the first thing I did was open it. After fumbling with the pharmacy door lock, I entered and found the flashlight. I then checked with the nursing staff to see whether there were any urgent patient needs.

Next, I opened the drawers of the Pyxis machines, but it was too dark to access medications. The medication refrigerators also couldn’t be accessed. Thankfully, the phones were working, so I told the nurses to call for any medication doses they needed.

But I soon realized that there were more difficulties ahead. I learned that the nurses didn’t know the doses needed because the MAR was down. That meant we would need to create new MAR s from scratch, reviewing each patient’s chart.

Thankfully, I had an epiphany. I could call other Sharp hospitals for help. Since we use a shared information system, they could print hard copies of the MAR s. I called a delivery company, and the records landed at our hospital an hour later. We had to update these by hand and distribute medications using the MAR s as a guide.

We also had to make sure items in the refrigerators could be kept cold. I brought items from the pharmacy refrigerator to a working refrigerator in an adjacent building. Normal power slowly returned one circuit at a time. To access restored power, we summoned the maintenance department to provide extension cords. More cords were purchased from a store to use throughout the hospital.

By 9:30 p.m. that night, normal utility services were restored and full patient care services were available. The hospital counted this crisis as one of the emergency drills that are required, although it was not a drill in this instance.

As Fires Raged, ASHP Members Stepped in to Help

ASHP members were instrumental in helping evacuees from the vast southern California wildfires in late October to manage their medications, highlighting the crucial role pharmacists can play in emergency situations.

More than 150 pharmacists and pharmacy students worked around-the-clock shifts at the Qualcomm Stadium and other shelters in San Diego over the course of four days to provide medications for hundreds of weary nursing facility patients and other evacuees.

Reconstructing Medical Records

“There was a big need for pharmacists. All of those nursing home patients really needed their medications” said S. John Johnson, Pharm.D., a pharmacy manager at Sharp Memorial Hospital in San Diego and ASHP member who helped fill some of the more than 500 prescriptions dispensed during the evacuation.

As thick, noxious smoke hovered over the San Diego region, volunteers buckled down at the makeshift pharmacies to provide needed medications, sometimes helping patients avoid admittance to hospitals. Some patients were evacuated so quickly that medical records were left behind, and elderly patients struggled to comprehend or communicate as pharmacists tried to glean the information.

 Despite the challenges, healthcare professionals of all types were able to successfully maintain continuity of care for patients affected by the fires.

Treating Patients at the “Bar-macy”

For pharmacists and pharmacy students at the stadium, that work occurred at the affectionately labeled “bar-macy,” a temporary pharmacy set up at a bar inside the facility. There, first-year pharmacy students rubbed elbows with seasoned pharmacists who dispensed drugs from behind beer taps. What made the experience all the more harrowing for the pharmacists who volunteered was the fact that many of them also had to evacuate their own homes in the face of fire.

On Oct. 22, the day after the fires erupted, Craig Steinberg, Pharm.D., pharmacy manager at Sharp Coronado Hospital, Coronado, Cal., and chairman of the San Diego Pharmacy Emergency Response Team (RXERT ), was helping to set up the pharmacy at the Del Mar Fairgrounds shelter when the call to evacuate his Del Mar neighborhood came in.

He raced home to his family and collected music, photos, and other memorabilia, and shot a video of the entire home to help with insurance claims in case the house was consumed in the fire. The family then headed to a friend’s home away from the fire.

“We had a couple of hours, and we packed up four cars and drove away,” Steinberg said. After a brief respite, Steinberg headed back to the Del Mar shelter pharmacy.

Steinberg and Johnson helped start RXERT . When the evacuations started, Johnson sent out 1,500 e-mails to pharmacists on the team’s contact list seeking volunteers to serve at the shelters. Day after day, dozens of pharmacists, pharmacy students, and technicians answered Johnson’s call.

Pharmacists as Primary Caregivers

 “In situations like this, you become a primary caregiver. It’s up to the pharmacy community to put together a response to disasters,” Johnson said, highlighting how important it is for pharmacists to become trained in emergency response.

It is a belief that ASHP ardently shares and fully supports. That’s why the Society has established a professional policy on emergency preparedness, developed a comprehensive emergency preparedness resource center on its Web site, and helped establish national pharmacist response teams after 9/11.

Space & Service: The Impact of Architecture on Patient Care

DeeAnn Wedemeyer-Oleson, Pharm.D., director of pharmacy for Guthrie County Hospital, Guthrie Center, Iowa, couldn’t be more thrilled with her new, spacious pharmacy.

With ample drug storage and a patient education room, the space is a complete departure from the hospital’s first makeshift pharmacy, a dark, windowless drug closet too small for a desk. Wedemeyer-Oleson, whose former office actually occupied a tiny hospital chapel after she was hired as the institution’s first staff pharmacist, jokes that she competed for office space with God, and won.

“This is the first time that there has even been space built intentionally for a pharmacy” in the 56-year-old, 25-bed facility, she said. “Before, we felt that we were busting at the seams. We were all on top of each other. Now, we each have our own workspaces, and we enjoy coming to work everyday.”

Guthrie County’s ground-level pharmacy is just one example of a growing trend in pharmacy architecture toward larger space, better light, more visibility, and room for patient education. Hospitals and health systems across the country are moving their pharmacies out of closets or up from basements to increase space for medication therapy management and patient counseling.

“Pharmacists will only be utilized to their potential if they are available to consult with medical and nursing staff,” Wedemeyer-Oleson said, adding that pharmacists should also be close to their patients. “For us, this is extremely important because our pharmacists constantly work with Guthrie’s admission medication history and discharge medication education services. Our pharmacists and pharmacy students frequently talk with patients in their rooms throughout the day, so it is most convenient for us to have the pharmacy on the nursing floor.”

There are other factors driving what three ASHP members described as one of the largest building booms in U.S. history in the Handbook of Institutional Pharmacy Practice.[1]

The need to replace aging 1970s hospitals, the growing number of elderly, and the introduction of new technologies will fuel hospital construction spending of up to $20 billion a year by the end of 2010, according to authors Kenneth N. Barker, FASHP ; Elizabeth A. Flynn, Ph.D.; and David A. Kvancz.

Better pharmacy design can help increase effectiveness in care delivery, improve patient safety, and lower staff stress, according to the authors.

Room to Work More Effectively

While Wedemeyer-Oleson struggled with a pharmacy in a closet, Bonnie Pitt, M.A.S., director of pharmacy at Frederick Memorial Hospital, Frederick, Md., had to work in the dark confines of a basement-level pharmacy.

That is, until this year.

“We have windows!” Pitt said about the hospital’s new third-floor pharmacy.

Prior to the renovation, Pitt’s staff of 42 pharmacists and technicians (15 of whom work on any given shift) endured cramped quarters in the small basement pharmacy that hadn’t seen significant renovations in two decades.

“We just kept smashing into things,” she said. “There were noises and distractions. You couldn’t hear yourself think.”

 For Pitt and her staff, the move to a 3,300-square-foot pharmacy on the third floor means that pharmacy staff members are now more accessible to patients, nurses, and other healthcare providers.

“The new pharmacy keeps us more connected to patients and prescribers,” she said. “You can just run over and talk to someone or look at a chart at a nursing unit.”

When Wedemeyer-Oleson worked on the redesign of her hospital’s pharmacy, she ensured adequate space for staff to carry out drug distribution and clinical and administrative duties.

“I listed every single function staff carries out under those categories and thought, ‘When my pharmacy technicians arrive in the morning, what is the first thing they do?’ ”

Wedemeyer-Oleson also considered efficiency in the staff ’s workflow; planned space for future processes, such as barcode medication administration; and allotted adequate drug storage space.

 At Frederick Memorial Hospital, the differences in the old and new spaces highlight the importance of pharmacy size and location.

 “When you work in a well-lit space, you can spread out your work and not have people on top of you while phones are ringing off the hook. We are now serving patients better,” Pitt said.

The hospital pharmacy at the National Institutes of Health (NIH) Clinical Center, the nation’s largest hospital solely focused primarily on clinical research, relocated to new digs in 2005, according to Robert DeChristoforo, FASHP , interim chief of the pharmacy department.

NIH hadn’t relocated its pharmacy from an isolating closet or basement, but the first-floor pharmacy was far from perfect. Gone is cramped space and outdated utilities, as staff members enjoy bigger, brighter space, improved ventilation, upgraded technology and space set aside for exciting, new additions, such as a robot.

“Although the staff was thrilled with the new space, ironically their new concern was the additional walking needed to accomplish the same tasks as in the past,” DeChristoforo said, laughing.

[1] Handbook of Institutional Pharmacy Practice, “Facility Planning and Design,” 2006, 4th ed., pp 519-541.

Cutting-Edge Care at the VA

Having worked for the U.S. Department of Veterans Affairs (VA) for a quarter century, Jan Carmichael, Pharm.D., FCCP, BCPS, has witnessed its evolution into a technologically savvy institution.

Key among those innovations is the VA’s centralized patient information system, which pharmacists use to access patients’ entire medical histories.

“There is power in that because you can identify problems in larger groups,” said Carmichael.

 A pharmacy executive with one of the VA’s 21 Veterans Integrated Service Networks and past president of ASHP, Carmichael believes there are many benefits of working with the nation’s largest healthcare system. For instance, VA pharmacists can evaluate and prescribe medications on collaborative healthcare teams. This ability makes the institution a magnet for pharmacy students and residents who want to dive into clinical pharmacy, she said.

Cutting-Edge Patient Care

The VA is just one of several distinct organizations operated by the federal government, including the Indian Health Service, National Institutes of Health, U.S. military, federal prisons, and the U.S. Department of Homeland Security’s Division of Immigration Health Services, where you’ll find ASHP members taking part in forward-thinking practices that emphasize clinical patient care, education, and counseling.

Over the years, ASHP has supported federal pharmacists with special continuing education forums at its Midyear Clinical Meeting and programs like free membership for pharmacists serving in Iraq. The Society also recently launched a staff committee to explore ways in which federal pharmacists could be prominently recognized for their professional promotions.

Carmichael points to the advocacy of Kenneth W. Kizer, M.D., MPH, who served as the VA under Secretary for Health in the 1990s, as a powerful catalyst for change at the VA.

“People attribute his tenure to changing the philosophy from a chaotic large organization to an organization that focuses on primary patient care and delivering high-quality care through performance measures,” Carmichael said. ASHP recognized Kizer’s achievements with a Board of Directors Award of Honor in 2002.

The VA’s reach in the U.S. is staggering. The organization estimates that about one-quarter of the nation’s population—74.5 million people—are potentially eligible for VA benefits because they are veterans or are either a family member or survivor of veterans. Comprised of 155 medical centers, the health system employs nearly 250,000 people who work with a growing patient population.

The VA has been the only organization where Kristina De Los Santos, Pharm.D., BCPS, has worked since receiving her doctor of pharmacy degree in 1999.

Improving Outcomes and Safety

De Los Santos is a pharmacy program manager for clinical services and the first-year pharmacy residency program director at the Southern Arizona VA Healthcare System in Tucson. When she worked in clinical practice, De Los Santos gave medical guidance to nurse practitioners and physicians and reviewed medication orders.

“I sometimes caught potential mistranslations of doses,” she said. “Pharmacists at the VA are in a position to really improve patient outcomes and safety.”

Robert Pittman, MPH, has dual roles as a federal pharmacist. He’s chief pharmacy officer for the U.S. Public Health Service, a position in which he advises the U.S. Surgeon General, and director of health professions for the Indian Health Service.

Pittman emphasizes the importance of having electronic access to his patients’ entire medical records.

“We have diagnoses, results of lab tests, notes from physicians. That’s all available for us to decide appropriate therapy” for the estimated 1.5 million American Indians and Alaska Native people treated at more than 300 clinics and 48 hospitals, Pittman said. “We think it’s the model for pharmacy in the future.”

ASHP, Member Efforts Secure Delay in Tamper-Resistant Requirement

What happens when a well-intentioned policy has an effective date that could result in patients going without needed medications? You get a groundswell of advocacy that causes Congress and the White House to take notice.

When the Centers for Medicare & Medicaid Services (CMS) announced a new tamper-resistant requirement for prescriptions for Medicaid beneficiaries, ASHP quickly realized that the timeframe for implementation was too short.

“As a fraud-prevention measure, this is a good rule,” said Joseph Hill, director of ASHP’s federal legislative activities. “But we immediately began to hear from members that there was no way that they could be ready to follow through by the rule’s deadline.”

The Society quickly swung into action, working with several other pharmacy organizations to urge CMS to delay the requirement’s implementation, seeking legislative relief by working with key legislators, and enlisting ASHP members to contact their Congressional representatives.

In the span of just one month, Congress passed legislation postponing the rule for six months. President Bush then signed it into law in late September.

“This issue really hit home for a number of our members, and I am thrilled that we were able to give them some breathing room to properly prepare for the new requirements,” said ASHP President Janet A. Silvester, MBA, FASHP .

Check out to see how the Society’s work on this issue evolved.

First Educate…Then Advocate

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            You’ll notice on the next page a series of pictures of ASHP ’s recent Legislative Day, Sept. 27. In all, members held more than 100 meetings with Congress members and their legislative staff to educate them on pharmacists’ critical patient-care role.

            Members started early, with a breakfast meeting featuring Leigh Ann Ross, a pharmacist and healthcare legislative assistant in the office of Sen. Thad Cochran (R-Miss.). And they finished late—tired but excited to have connected with key decision makers.

            It’s an exhausting day—not just because of the long hours, but because we ask members to step far outside of their comfort zones. We ask them to be ready to talk about the Society’s legislative priorities and to transform themselves into lobbyists for a day. And it works! Because of what our members do each year, and the continual work of our government affairs staff, Congress is more aware of the ways in which pharmacists improve patient care.

            Whether you’re walking the halls of Congress or inviting a local representative into your hospital to observe how your pharmacy works, I believe it’s vital to educate, then advocate. I also believe that effective advocacy starts with certain assumptions, including that:

  • One person with an idea can initiate change,
  • Most legislators want to positively affect the lives of their constituents (aka your patients), and
  • Legislators are not well-versed in medication use, patient safety, pharmacists’ changing roles, or health-system pharmacy professional issues.

It’s up to all of us to educate decisionmakers, including our elected officials, about the best care for patients.

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