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External Disaster and Multiple Victim Trauma Response (MVTR)Plan (1.21)

External Disaster and Multiple Victim Trauma Response (MVTR)Plan (1.21) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.21

POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 1
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



I. PURPOSE: To establish a response mechanism by the Pharmacy Department in the event of
an external disaster, Multiple Victim Trauma Response (MVTR) or biological event in
coordination with the overall hospital External Disaster Plan (see hospital policy 12.17) and
Biological Event Plan (see hospital policy 12.20).

II. POLICY: The Pharmacy Department will implement the following procedure upon
notification of an external disaster, MVTR or biological event from the Hospital Incident
Command System (HICS).

III. PROCEDURE:
A. Plan Activation
1. The Hospital Incident Command System (HICS) is used to manage
implementation of this plan. In the HICS, the Pharmacy Unit Leader position
is assigned to the Pharmacy Manager On Call which will be covered 365 days
of the year for the purpose of handling emergency and disaster situations
(pager 8771). This individual will be paged in the event of a disaster, MVTR
or biological event. The Pharmacy Unit Leader will be notified of a disaster
by the Paging and Message Center Operator. The Pharmacy Administrator On
Call will work/communicate with the rest of the pharmacy management team
to respond to the situation.
2. In the HICS, the Hospital Administrator On Call assumes the role of Incident
Commander (IC) until the Chief Operating Officer (COO) or Chief Executive
Officer (CEO) arrives
3. The Pharmacy Unit Leader will call the informational message line (265-
7332) provided in the text page in response to the notification of the external
disaster or MVTR and determine whether the situation requires a change in
pharmacy personnel support or operations. It will not be necessary to report
to the Incident Command Center (ICC) unless notified directly by a member
of the HICS.
4. If the Pharmacy Unit Leader determines that a change in operations is needed
they may text page the Pharmacy Management Team (pager # 0535) for
assistance with operational management or to convey a message about the
department’s response to the event.
5. The Pharmacy Unit Leader will notify all inpatient pharmacists of the possible
pending emergency situation through a simultaneous text page (pager #7888)
if it impacts these areas. Additional notification of how subsequent
communications will be disseminated to those involved [e.g. email (Rx - All

POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 2
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



Inpatients Pharmacists), by sending a message through the pharmacy
information system, or by 1 on 1 communication] to communicate the
pharmacy department response effort and how to contact the Pharmacy Unit
Leader with questions, concerns or for clarifications.
6. The Pharmacy Conference Room (F6/133b) will be used as the central
meeting place for key pharmacy personnel, as determined by the Pharmacy
Unit Leader, to discuss the situation and formulate the departments response
to the disaster. Depending on the scope of the situation, individual
pharmacists may be notified via the communication channels outlined in A5
above to report to F6/133b to discuss the situation and help communicate the
department’s response plans to all pharmacy staff.
7. In the event that an emergency situation/disaster occurs after 5pm or on the
weekend or holidays, central pharmacy may become the hub for department
communications, in which case the Pharmacy Unit Leader will communicate
with the central pharmacist to serve as their liaison in triaging
communications to all other department staff to help communicate the
department’s response plan and to disseminate pertinent information to
pharmacy staff via the communication channels as outlined in A5 above.
8. The Pharmacy Unit Leader may request that existing staff stay late or others
come in early for their shift to assist in the department’s response to the
emergency situation. The communication will take place as outlined in A5
above.
9. In the event of a MVTR the following personnel will be text paged by the
Paging and Message Center Operator to report to the ED. This page
communication will occur prior to the Pharmacy Manager On Call being
alerted.
a. Team 1 RPh (7585) TLC South coverage
b. Team 2 RPh (7590) B4/5 coverage
c. Emergency Department RPh (9828)
B. Pharmacy Staffing Coverage
1. The Pharmacy Unit Leader will assess staffing requirements and assign
pharmacy staff to designated treatment areas as necessary (see below in
section B7 for assignment algorithm). In the event of a MVTR please refer to
A9 for initial staffing requirements. Additional staff will be called in to work
as necessary. Coverage for staff who are assigned to disaster treatment areas
will be arranged by the Pharmacy Unit Leader. Responding pharmacists will
keep their assigned pagers and notify unit staff of which pharmacist to contact

POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 3
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



for patient care issues. Each manager will be responsible for communications
in their assigned clinical areas.
2. The Pharmacy Unit Leader will assess the need for increased staffing support
by pharmacists and pharmacy technicians within Central Pharmacy in order to
address distribution of medications and associated supplies depending upon
the type of disaster and the volume of individuals affected.
3. The pharmacy management team will assess the types of medications and
quantities that may be required based upon the type of disaster (medications
commonly dispensed during emergency situations vary depending on the
situation). Arrangements will be made for obtaining additional drug supplies
as necessary.
4. Pharmacy staffing will be adjusted based on the extent of the disaster.
Pharmacists and pharmacy technicians that are not directed to the disaster site
may be asked to cover for other areas of the department/hospital until the
disaster is controlled or additional personnel arrive.
5. Disaster area coverage pharmacists, when notified by the Pharmacy Unit
Leader, should report to pharmacy office (F6/133b; 263-1290) to receive
specific instructions prior to responding to treatment areas. All personnel
working within the disaster area must wear a UWHC staff identification
badge. The pharmacy personnel will also obtain a Disaster Medication
Dispensing Documentation Form to facilitate the documentation of
medications administered during the disaster (refer to Appendix A).
6. Pharmacy staff that are not needed for immediate disaster response activation
should remain in their respective areas and be ready to assist with additional
disaster needs as directed by pharmacy management.
7. Pharmacists will be assigned as necessary by the Pharmacy Unit Leader to
designated treatment areas per the following hierarchy. Upon arrival to the
treatment area, the pharmacist will determine whether or not assistance is
needed from a pharmacy technician and will request this assistance via the
Pharmacy Unit Leader.
a. Critical area (South side of ED; 262-2398) – TLC pharmacist (7585)
b. Urgent area (North side of ED; 262-2398) – Cardiology pharmacist
(7590)
c. Ambulatory patients - (F4/2 Surgery Clinics) – Surgery pharmacist
(7586)

POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 4
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



d. Ambulatory over flow (VA hospital X-ray waiting area DG279; 256-
1907, ext.17603) or other areas as requested – Medicine pharmacist
(7950)
8. A staffing backup plan will be communicated to the appropriate pharmacists
at the time these disaster team assignments are made via the communication
channels outlined in A5.
C. Medication Allocation
1. Each designated treatment area has a supply of emergency medications
stocked in the area which may be used for treating patients. (Blue Cart/
Emergency tray)
2. If additional emergency medication supplies are needed, the pharmacist (or
pharmacy technician designee) may obtain additional emergency drug trays
from the Central Pharmacy.
3. If narcotic supplies are needed, the pharmacist (or pharmacy technician) may
request narcotic supplies and narcotic control documentation from the
NarcStation in the Central Pharmacy.
a. Issues from NarcStation will be done as a patient specific issue (see
Pharmacy Policy 7.1 for details).
4. Any additional medication supplies may be obtained by the pharmacist (or
pharmacy technician designee) from the Central Pharmacy as needed
5. Medications may also be dispensed via override transactions from the
AcuDose-Rx automated dispensing cabinet in the designated treatment area as
available.
6. Medications may be dispensed without a patient-specific order if requested by
medical personnel.
7. Pharmacists and pharmacy technicians will maintain a written list of
medications dispensed for inventory and charging purposes using the attached
Appendix A. This list will be forwarded to the Pharmacy Unit Leader upon
plan deactivation.

D. Command Center Phone Numbers for the Pharmacy Unit Leader
1. Primary Incoming Line: 890-9392
2. Secondary Incoming Line: 890-9088
3. Fax Line: 265-0718
4. Planning Chief – 263-9971
Mission: Collect and inventory available staff and volunteers at a central
point. Receive requests and assign available staff as needed. Maintain

POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 5
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



adequate numbers of both medical and non-medical personnel. Assist in the
maintenance of staff morale.
5. Logistics Chief – 262-6208
Mission: Organizes and directs those operations associated with maintenance
of the physical environment, and adequate levels of food, shelter, and supplies
to support the medical objectives.

6. Operations Chief – 262-4937
Mission: Organize and manage ancillary medical services including
Laboratory, Radiology, and Pharmacy and assist in providing for the optimal
functioning of these services. Monitor the use and conservation of these
resources.

E. Treatment Areas
1. Treatment areas will be established by the ED Physician On-Duty and ED
Care Team Leader as needed. For a major disaster, patients will be triaged to
any of the following areas:
a. Critical patients to the South side of the Emergency Department
b. Urgent patients to the North side of the Emergency Department
c. Ambulatory patients to the F4/2 Surgery Clinics
d. Ambulatory over flow is sent to the VA Hospital X-ray Waiting Area
DG279 (256-1901 ext.17603)
2. If it is determined, that a treatment area will not be needed, this must be
communicated with the ICC and staff assigned to those areas will be re-
assigned or dismissed.

F. Other Key Activity Sites
1. Incident Command Center (F2/210 ED Conference Room or announced
location). The HICS team will staff this area.
2. Family Waiting Area (F8/170-172)
All family/significant others should be directed to this area which will be
staffed by Coordinated Care/Case Management and Pastoral Care
Departments.
3. Press Room (H6/215)
All media should be directed to this area that will be staffed by the Public
Affairs Department.

POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 6
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



4. Physician labor pool will be at ED pharmacy desk (E1/269)
All physician personnel who are not needed in the Emergency Department
should report to this area to sign in and will be notified as needed.
5. Morgue
All expired patients will be transported to the Morgue. In the event of large
numbers of expired patients, the Incident Commander will determine an
expandable morgue area to be used.

G. Biological Event
1. In an event requiring surge capacity (e.g., a natural infectious disease event or
an event of bioterrorism), the Pharmacy Manager On Call will be notified by
the Hospital Incident Command System (HICS). The Pharmacy Manager On
Call will then contact the F6/5 pharmacist (pager 7950) to assist in the
biological event. Additional references include the overall hospital External
Disaster Plan (Hospital Policy 12.17) and the Biological Event Plan (Hospital
Policy 12.20).
2. Upon notification, the F6/5 pharmacy personnel will follow the necessary
procedures for isolation precautions as indicated. All pharmacy patient care
services will be provided during the surge capacity including medications
histories and discharge counseling.
3. The F6/5 pharmacy personnel will process medication orders per the standard
pharmacy process.
a. In the case that assistance is needed with specific order processing in
relation to pediatric patients, the surge capacity pharmacist will page
the AFCH PICU pharmacist for assistance.
b. If there is a high volume of pediatric patients within the surge capacity
unit, both the pediatric pharmacist and the corresponding manager will
be paged for additional assistance. If the manager feels it necessary to
call in extra pharmacy personnel to accommodate the situation, then
the pediatric pharmacist will be asked to physically move to the surge
capacity unit to assist the F6/5 pharmacist with pediatric medication
order processing and pediatric pharmacy services.
c. When possible, medications will be delivered to the surge capacity
unit per standard pharmacy procedures.
4. The AFCH PICU pharmacist (#7589) should be paged for assistance for all
pediatric resuscitations during the surge capacity event.


POLICY & PROCEDURE




Effective Date:

January 2004
⌧Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.21

Original
⌧Revision 5/2014
Page 7
of 7
Title: External Disaster and Multiple
Victim Trauma Response (MVTR)
Plan –
Department of Pharmacy



H. Plan Deactivation
1. The ED Physician On-Duty and ED Care Team Leader will advise the
ICC when the critical phase of the influx of casualties has subsided such
that normal operations can be resumed.
2. The Incident Commander will notify the paging and message center of an
all clear based on the situation status throughout the organization.
3. At any time, non-essential staff can be reassigned or dismissed.
4. After the all clear is communicated, the Department of Pharmacy will then
deactivate our disaster plan, communicate this to staff via a simultaneous
text page and replace any resources used during the incident.
5. Departments represented on the UWHC Emergency Management
Committee are expected to complete a written critique of the incident.
I. Useful resources for Pharmacy Department’s disaster response
1. The CDC website (http://emergency.cdc.gov/) contains a list of probable
infectious and biological agents to which patients may have been exposed
in the event of a disaster, including possible medication treatment plans
for exposed patients.
2. Appendix-B serves as a reference to the process for obtaining Wisconsin
Hospital Emergency Preparedness Program (WHEPP) emergency
medical/surgical supplies and Department of Public Health (DPH)
stockpiles which include; Interim Pharmaceuticals, Strategic National
Stockpile, CHEMPACK, Antiviral Medications, and Radiation Medical
Countermeasures (DTPA).
3. Appendix-C serves as a department management checklist for
implementing the Pharmacy Department disaster response plan.
4. Appendix-D is the Organizational Chart for the Hospital Incident
Command System
5. External Disaster Plan (Hospital Policy 12.17)
6. Biological Event Plan (Hospital Policy 12.20)
7. MVTR Plan (Hospital Policy 12.18)
8. Code Yellow/Active Shooter-CSA (Hospital Policy 12.61)


Approved By: ____________________________
Director of Pharmacy Services

Date: ____________