UPPER CHESAPEAKE HEALTH HOSPITALS
PHARMACY POLICY MANUAL
TITLE: Emergency Management Plan / Code Orange Response
APPROVED BY:
Vice President Patient Services: ____________________________________
Director, Pharmacy Services: _______________________________________
Original Date: 9/02
Revised Date:
Next Scheduled Review Date: 9/03
PURPOSE: To ensure preparation of Pharmacy team members for response to an internal
or external disaster.
POLICY: There is a planned response to a code orange alert
JCAHO Functional Chapter: EC
PROCEDURE:
I. First Steps – Overview:
A. Locate “Departmental Emergency Response Plan” and the “Hospital Emergency Management Plan” located in the Meditech Library under “Hospital P&P – EOC Policies – EOC Policies – Emergency Management Plan/Code Orange.
1. A printed hardcopy is maintained in the Pharmacy Reference section and in
the Director of Pharmacy’s office.
B. Identify “Lead Person” / Notify HECC :
1. That team member present within the hospital and highest on the following list
shall be in charge of the Department's Orange Alert Plan upon notification and
is designated as the “Lead Person”. That team member in charge will refer to
the Department Plan for guidance and will so function until relieved by a team
member higher in command authority.
2. Lead Person / Chain of Command order
a. Weekdays: Operating Hours - Director, Chief, Opening Pharmacist,
Closing Pharmacist
b. Weekend, Holidays: Operating Hours - Opening Pharmacist; Closing
Pharmacist
c. During Closed Hours: On-Call Pharmacist, Chief, Director
After notification of the Department Manager by the Hospital, he/she
will contact the appropriate team member prior to leaving for the
hospital. All team members will report to the hospital immediately for
assignments.
i. Orange alert when department is closed: The first team member
to arrive at the hospital will open the Pharmacy and contact the
control center with a report of available team members.
3. Relief will be provided to the Lead Person, as determined by the
Director or Chief Pharmacist; or other senior authority.
C. Contact the Hospital Emergency Command Center (HECC) at the respective facility
for known information at hand.
UCMC- extension 1002, 003, 1004; 443-643-2930
(Located in the Maryland Room)
HMH- extensions 6602, 6603, 6604, 5343: 443-843-6602
(Located in the Administrative Conference Room)
Identify yourself as the “Pharmacy Contact / Person ____________”
1. Gather information about the Type of Emergency to include; time, date,
nature of event (i.e. chemical, trauma, bio, radiation, weather), number of
casualties, and any directives from the HECC. Document on the “Time /
Activity Log” (Appendix #1)
2. Provide the HECC with Staffing information about the number of immediately
available team members in-house.
D. Assess current staffing levels, call-in availability, and the Emergency at hand.
1. Assess the number of additional team members that are needed.
2. Contact and delegate to one individual (i.e. Administrative Assistant or
designee) to initiate calling team members on the Call list and maintaining the
“ Emergency Call Log” (Appendix 2) Follow Section IV.
3. Gather team members within your department and await further instruction
from the HECC.
a. Assess how the type of emergency will impact the essential functions and current workflow of the pharmacy; take alternative steps to ensure continuity of service during the emergency; assess inventory/supply needs. Make vendor information available to team members, as necessary.
b. (See also Section V-Assessment of Emergency at Hand)
E. Coordinate all needs, personnel and service activities through the Hospital
Emergency Command Center.
1. The HECC is established at the onset of every Code Orange and is
charged with the house-wide coordination of supplies services, and
personnel in response to the emergency situation. All department
communications relative to service need (e.g., the ED needs linen),
personnel (e.g., additional transporters or physicians) and the direction
of activities should be routed through the centralized HECC.
F. Personnel Identification:
All vehicles will display hospital stickers and team members will wear their ID badges for identification purpose.
G. Coordinate Critical Areas of Pharmacy’s Responsibilities (delineated in Section II)
H. Maintain Department Information Log (Time Activity Log – Appendix 1 )
A log will be maintained of all activities performed by the Pharmacy Services. Such
log will be made available for the purpose of identification of improvement
opportunities by administration. The team member present that is highest in
command shall be responsible to keep the log.
II. Critical Areas of Pharmacy’s Responsibility
A. Activities
1. Maintain existing medication inventory in the ED, OR, ICU, and priority
treatment stations or areas as designated by the HECC.
a. Coordinate ordering and receipt of additional medications
2. Prepare IV solutions, meds for patient use.
3. Evaluate internal needs of Pharmacy for additional meds and other
departmental needs based upon Emergency at hand with HECC (Command Center). Keep HECC informed of critical supply needs.
B. Resources used to facilitate treatment of exposed victims
1. Automated Dispensing System – provides initial medications to ED and in-
house patient care units
2. Meditech Pharmacy Module – supports patient record keeping and med
dispensing
3. Provide Staffing to support inpatient and Emergency demands
4. Pneumatic Tube System (UCMC Only)- facilitates efficient delivery of non-controlled substances to in-house treatment areas.
5. Access to Drug Reference Resources
C. Treatment Protocols / Antidotes Available
1. Treatment information about which meds are to be used, established par levels,
adult dosage, and the approximate number of patients that can be treated for a
72-hour period are delineated in detail within APPENDICES 3 through 6
a. The Pharmacy is responsible for maintaining sufficient inventory of
medications that may be used in the treatment of individuals during
Emergency.
b. Medication needs for extended emergency will be determined and
coordinated through the HECC and Pharmacy Lead Person
2. Physical Trauma Event à Analgesics / Anesthetic Medications
(see APPENDIX 3 – Automated Dispensing System list of Stocked Meds)
3. Antibiotics/Bioterrorism Exposure Event (see APPENDIX 4)
4. Chemical Exposure Event / (see APPENDIX 5 – “Antidote List”- from
Pharmacy P&P Manual, Drug Stocking and Distribution, Section 18)
5. Radiation Exposure Event (see APPENDIX 6)
6. Updated information from the Dept. Health and Mental Hygiene (DHMH)
Guidelines, FDA and/or Center for Disease Control (CDC) will be used for treatment decisions. (see APPENDIX 7- General Treatment)
a. Continually access these resources for up-to-date Information or
Guidelines.
i. Assistance may be provided by the Hospital Safety Officer or
the HECC
ii.Treatment Guidelines can be found at the following internet
addresses: www.cdc.gov; (see also Appendix 7)
D. Oversight Responsibilities
1. Provide an initial assessment of the emergency at hand to estimate support and
med supplies needed. Policies and Procedures for types of Internal and/or
External emergencies are located as follows:
a. Internal Event
i. Meditech Downtime (see Procedures located in Meditech
Library / and in the Policy and Procedure Notebook located
in the Pharmacy Department. A back-up copy is located in the
Director’s Office. APPENDIX 8 .
1) Planned downtime
2) Unplanned downtime
ii. Automated Dispensing System (see Procedures located in
Meditech library / and in the Policy and Procedure Notebook
located in the Pharmacy Department. A back-up copy is located
in the Director’s Office. APPENDIX 9 .
b. External Event
i. Weather Emergency
ii. Code Orange Emergency
III. Pharmacy Team’s Supportive Roles
A. Pre-defined roles / Primary Scope of Responsibilities
1. Pharmacist - Process med orders, verify dispensing accuracy, assure timely
delivery or access to meds, provide drug information.
2. Technicians - Assist with med selection, preparation, delivery, other duties
as assigned.
3. Assistant – Responsible to maintain “Call – Log”; and to keep Lead Person updated; Assist with med delivery; internal record keeping as may be needed
4. Buyer – Procure needed medications; coordinate receipt; maintain vendor or “borrow/loaner” invoices.
5. MIS Tech – Responsible to maintain and support ADS and Meditech Systems; provide assistance with med selection, preparation, delivery as may be needed.
6. Volunteer – Assist with med delivery to patient areas; Assist with pre-packing meds.
B. Assisting Other Departments - Pharmacy Team members may be assigned to other
areas as determined by the HECC.
1. Provide drug information, medication administration guidance, pain
management therapeutic guidance
2. Clinical decision support for patient specific care
C. Surplus Team Members
1. Will be on “Stand-by” to support Pharmacy services. An assessment will be
determined by the “Lead Person” in collaboration with the HECC as to the
need to provide support outside of Pharmacy’s primary area of responsibility.
a. Examples of potentially useful support roles include: Oral Med
Administration/Documentation; Medication History taking; ACLS.
b. Volunteer team members may be “pooled” by the HECC for further
direction.
2. Emergencies outside of UCH jurisdiction may request Pharmacist or technician support. Decreased Hospital staffing is anticipated during this time in order to provide extended-community support.
IV Call-in procedures, Call Process, and Staging
A. Initial contact to the On-Call Pharmacist is to be made by Hospital Operator.
This individual will be designated the “Lead Person” and is responsible to
assess “Emergency Pharmacy needs.” The Lead person will initiate/delegate
call-in procedures.
1. Delegate to single individual to contact the required number of team
members; and to “stage” individuals for potential call back.
(i.e. Administrative Assistant or Technician).
a. Record on the “Emergency Call Log” (See Appendix #2)
2. Access to Emergency On-Call List
a. Find by going to Meditech Library, open Cabinet named; “Pharmacy Employee Phone Numbers,” and scroll down to file named;
“Emergency Call List Pharm”; Choose UCMC or HMH.
b. Pharmacy Policy and Procedure Manual
i. Find by going to; “Structural Standards,”; “Safety, Security, and
Emergency Preparedness,” “Emergency On-Call List.”
c. A hard-copy list is distributed to Pharmacy team members during
orientation, when staffing changes occur, and at least annually during
competency assessment of “Emergency Management” response.
d. A hard-copy list is located in Appendix 2 of this policy.
V. Assessment of Emergency at Hand
A. Ensure Adequate Staffing Availability
1. Based upon estimated INITIAL patient care needs and estimated patient
volume
a. Current Staffing: Pharmacists # _______ Technicians # ________
b. Staffing Needed: Pharmacists # _______ Technicians # ________
2. Based upon estimated patient care needs and volume for extended outage
a. Based upon current inpatient volumes
b. Estimated Minimal Needs: 4 Pharmacists 4 Technicians
B. Assess Inventory and Anticipate Needs.
1. Determine if established inventory or Quarantined medications are sufficient to
treat the number of patients and event at hand. An assessment can be made by
comparing treatments listed in the appropriate Appendix with the number of
patients needed to treat as reported by the HECC.
2. The HECC may also specify that “X – doses of a drug” are needed. Determine
the number of doses immediately available in the Pharmacy Inventory; or
could be re-distributed from stocking areas within the hospital (i.e. check
Diebold, OR, or other areas).
a. On Diebold PC, go to “Examiner,” Find “Med Report,” type in the
generic name of the drug, and print.
3. Immediate Sources of Medications are located as follows:
a. Emergency Antidote Kits – located in ED
b. Emergency Antidote Treatment Supplies and Locations
(refer to Appendix 4).
c. Emergency Medication Quarantined Supplies for Bio-terrorism; or
Chemicals – located in Pharmacy in locked cabinet near drug info room.
d. Additional supplies will be provided within 24 hours by the Federal
Government.
i. Government supplied “Push Packs”
ii. Aberdeen Proving Ground
C. Alternate Vendors for Critical Supplies (See Appendix # 10 )
D. Mutual Support for Smaller Quantity and Emergency Needs (See Appendix # 11)
E. Drug Information
1. Determine if additional drug or treatment information is needed.
a. Contact the Maryland Poison Center
b. Contact the Kansas Drug Information Center
F. ADS Support (Automated Dispensing System; aka Diebold/MedSelect)
1. Determine if additional staffing is needed to physically unlock and man the
machines.
VI. Assessment of extended surge demand
A. Meds - evaluate needs, coordinate procurement and receipt
B. Staffing - scheduled; staged for later arrival
C. Central Pool Staffing
1. Pharmacy’s Contribution to Organization
a. Medication History taking
b. Assisting Nursing with med administration and documentation
2. Pharmacy Needs
a. Messenger to deliver supplies to ED, and designated Treatment Areas
b. Transportation into Work (i.e. Weather Emergency)
c. Procurement of off-site Supplies
i. Taxi, UPS, Fed-Ex, Security, Pharmacy Team Members
3. Individuals to physically man and distribute meds from the automated
dispensing system (ADS) in the event of emergency electrical power failure.
1 (one) individual per nursing area.
VII. Communication (Centralized information UPDATE during Emergency)
A. Information occurring during the emergency event will be maintained on the Time/Activity Log (See Appendix # 1 ). This information will serve as a central resource for Pharmacy Team members to become updated during the Emergency. The log will be maintained by a Lead Person or a designated individual (i.e. Administrative Tech or designee).
B. An Emergency Call Log (See Appendix # 2 ) will be maintained by the Administrative
Assistant or designee to determine actual and potentially staffing availability.
VIII. Outstanding Issues - Emergency Preparedness Organizational Issues to be assessed or
addressed.
A. Assumption - patients will be registered in Meditech
B. Emergency Lock Boxes for controlled substances are located on each unit in case of Automated Dispensing System (ADS; aka MedSelect / Diebold) downtime.
1. Upon activation of ADS downtime procedures (see also Nursing P&P,
Automated Medication Dispensing Policy; (See Appendix # 9) controlled
substances are transferred from the ADS unit by Pharmacy representative,
recorded on manual “Controlled Substance Disposition Forms”, and secured in
the locked cabinet.
a. There are 2 sets of keys to each ADS; one is kept in the Pharmacy
Vault; and the other is in the Director of Pharmacy’s office within the
lateral file cabinet.
2. Keys for the locked cabinet are maintained by the Nursing Unit; and are passed
between shifts assuring accountability and maintaining security.
C. Recommend that APG provide an supply of meds/antidotes for initial treatment to
be kept in Quarantined Pharmacy Area.
C:\DOCUME~1\jthomas\LOCALS~1\Temp\pharmacy code Yellow policy .doc Page 1 of 7