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Illinois Hospital Pharmacies Check Their Emergency Preparedness

Cheryl A. Thompson

TOPOFF 2 (short for Top Officials 2), described by the federal government as the most comprehensive terrorism-response exercise undertaken to date in the United States, gave health-system pharmacies in Illinois a chance to test their emergency preparedness.

The simulated attack in Chicago played out as follows: A fictitious terrorist organization on May 10 released an infectious biological agent at the United Center where the local National Hockey League franchise would have played the team from Vancouver, Canada. When configured for a professional hockey game, the sports arena seats up to 20,500 visitors.

Three days after release of the infectious agent, "paper" and "live" mock patients started arriving at Chicago-area hospitals complaining of flu-like symptoms, including cough and fever. Patients continued arriving throughout the day, their number increasing greatly as time passed.

At some point that day, according to TOPOFF 2 organizers, hospital authorities diagnosed the problem as pneumonic plague and, for confirmation, sent patient samples to the Centers for Disease Control and Prevention. Also, Health Canada began receiving reports of mock patients with flu-like symptoms in Vancouver and elsewhere in the country.

Hospital admissions in Illinois continued to escalate on May 14, and the federal government deployed the Strategic National Stockpile (formerly the National Pharmaceutical Stockpile) to the Chicago area for distribution at public facilities.

As part of the Chicago-based preparedness drill, the Illinois Council of Health-System Pharmacists (ICHP) activated its emergency-response network for gathering information from hospital pharmacies in the state.

ICHP Executive Director Scott A. Meyers said his staff and the organization’s volunteer leadership created the network a year ago "as a response to the activities of September 11."

With some work, he said, ICHP identified the person at the Illinois Department of Public Health who, during a large-scale emergency, would want to know the inventory levels of certain pharmaceuticals in hospitals across the state and the names of pharmacy personnel who would volunteer to travel to help distribute the contents of the Strategic National Stockpile or provide backup to hospital pharmacy staffs under stress.

Meyers said he knew in advance that pneumonic plague bacteria would be used for TOPOFF 2 in Illinois. Within a few minutes of the May 13 call from the state’s public health department, he said, the Illinois Health-System Pharmacy Network—Emergency Response sent an e-mail, with a questionnaire attached, to the 180 hospital pharmacies in the network, covering about 70% of the inpatient pharmacies located on hospital grounds in the state.

ICHP’s Web-site designer had installed a bulk e-mail function that allowed the office staff to e-mail the hospitals simultaneously rather than in groups of 50, as Meyers said he had been doing when using his regular e-mail software to contact members interested in information on emergency preparedness.

The network received responses from 44% of the pharmacies within the first three hours, Meyers said. Within seven hours, the response rate was 72%. By Friday afternoon, three days after activation of the network, 97% of the pharmacies had responded with their inventory levels and the names and telephone numbers of 214 registered pharmacists and 117 registered technicians who volunteered to assist elsewhere, he said.

Karen Nordstrom, pharmacy director at Chicago’s Northwestern Memorial Hospital, which has about 650 beds, said responding to the ICHP e-mail consumed very little of her time "because we were in the throes of the TOPOFF drill with the Chicago Board of Health." Chicago is a city with a home rule unit of government, she explained, so the city’s response to a massive emergency involves the Chicago Board of Health and the Illinois Department of Public Health. Northwestern had been working with the city’s health board in advance of TOPOFF 2, she said.

Had the e-mail been a "cold call" about an outbreak of pneumonic plague, Nordstrom said her response to ICHP would probably have taken longer than during the drill.

Northwestern, about three miles from the United Center, had opted to handle a total of 50 paper and live mock patients and test the hospital’s bioterrorism and emergency-response plans, Nordstrom said. Patients arrived alone or in pairs, she said, not in a large group, which would be the case after a chemical disaster.

"The greatest strain was on the emergency department," she said. "For the pharmacy, [TOPOFF 2] didn’t push us as much as it did other departments."

One thing Northwestern’s pharmacy did learn from the drill, Nordstrom said, was that the lack of a pediatric unit did not preclude the need to stock medications in dosage forms and strengths designed for children. After an act of bioterrorism, the pharmacy would have to manage the prophylaxis of employees and any young children in the hospital’s daycare center, she said. Northwestern employs about 5000 workers.

Curt Lesher, pharmacy director at Advocate Good Shepherd Hospital, a 162-bed facility in Barrington, said he worked 16 hours a day for two days during the drill. The Barrington hospital, about 40 miles from the United Center, began receiving paper and live mock patients on May 14, he said. 

Good Shepherd is part of eight-hospital Advocate Health Care, self-described as the "largest fully integrated not-for-profit health care delivery system in metropolitan Chicago."

Advocate had a bioterrorism-response plan before TOPOFF 2, Lesher said. The pharmacies, through a plan developed by the health system’s centralized pharmacy director and the individual hospitals’ pharmacy directors, have maintained special inventories since the terrorist attacks elsewhere in 2001.

"We had a nice stockpile" for the test case of a pneumonic plague outbreak, Lesher said. Good Shepherd had 1000 doses of ciprofloxacin and 2000 doses of doxycycline, he said, but "they’re almost out of date."

According to the Working Group on Civilian Biodefense, i.m. or i.v. therapy with streptomycin or gentamicin is the preferred treatment for pneumonic plague, with i.v. ciprofloxacin, doxycycline, or chloramphenicol as an alternative. For prevention of pneumonic plague infection after exposure, the working group recommends oral ciprofloxacin or doxycycline as the drug of choice and oral chloramphenicol as an alternative.

"If I didn’t have a drug and I really needed it, I could find it as long as the computer wasn’t down," Lesher said, referring to the information on hospital pharmacy inventories amassed by ICHP’s emergency-response network.

Lesher said that most of the changes to be made to Good Shepherd’s emergency plan as a consequence of TOPOFF 2 would pertain to the communication processes. "There was confusion as it was," he said, even though hospital personnel knew about the event in advance.

ICHP’s Meyers said his office staff of five made phone calls and collected data as it arrived by e-mail and fax.

"We had one incoming fax line and one outgoing fax line because some of the facilities could not open the e-mail file," he said. "They didn’t have the right [Microsoft] Word package" to handle the attachment to the e-mail message. "There were a lot of complaints about busy fax lines because we only had one incoming fax line the first day."

As for the inventory form itself, Meyers said the next one would list all of the available dosage forms and strengths for the preferred agents so that respondents need only report the numbers on hand.