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4/8/2004

Omaha Pharmacist Helps City Prepare for Disasters

Donna Young

Pharmacists play an essential role in a community's emergency preparedness and disaster response, said Fred Massoomi, pharmacy operations coordinator at Nebraska Methodist Hospital in Omaha. Massoomi serves as pharmacy subcommittee cochair of Omaha's Metropolitan Medical Response System (MMRS).

MMRS was established by the Department of Health and Human Services (HHS) in 1996 to help communities develop or enhance their emergency-preparedness systems to respond to a public health crisisespecially an attack involving weapons of mass destruction.

MMRS was moved to the Department of Homeland Security (DHS) in March 2003.

There are 122 jurisdictions that receive federal funding from MMRS, according to DHS. Omaha was named an MMRS city in 2000, Massoomi said.

Why Omaha? The Midwest city, which has a population of about 300,000 people, could be a target for terrorists, he said, because it is home to several large companies, including Berkshire Hathaway Inc., a property and casualty insurance business owned by billionaire Warren E. Buffett, and ConAgra Foods Inc., an international food conglomerate that owns brands such as Healthy Choice, Banquet, and Hunts.

Union Pacific Railroad, Massoomi noted, is also headquartered in Omaha, and the city is the site of several large financial institutions' major computer network servers.

Also located in Omaha, he said, is the U.S. Strategic Air Command at Offutt Air Force Base, which controls military space operations, computer network functions, information processes, strategic warning and intelligence assessments, and global strategic planning for the U.S. military.

When terrorists attacked the United States on September 11, 2001, President George W. Bush stayed at the command center's bunker for several hours.

Another potential target for terrorists, Massoomi said, are two nuclear power plants positioned near Omaha.

Large public events can also be possible marks for terrorist attacks, he noted. Each summer, Massoomi said, Omaha hosts the College World Seriesthe NCAA Men's Baseball Championshipat Rosenblatt Stadium. More than 261,000 people attended the games last summer.

Nebraska has also had its share of natural disasters, he said, including tornadoes, floods, and severe snow and ice storms.

A hospital-based plan. Most communities' MMRS programs, Massoomi said, were initiated by first-responder agencies, such as emergency management services (EMS) or the fire department, with hospitals joining but not playing a major leadership role in establishing the program.

But Omaha, he explained, founded its program as a hospital-based plan after two nursesPat Lenaghan, emergency department service executive at Nebraska Methodist Hospital, and Phyllis Dutton, risk manager at Alegent Healthpursued the idea after attending a lecture about MMRS in 1998. Lenaghan and Dutton now cochair Omaha's MMRS program.

Even though the health systems compete with each other from a business perspective, Massoomi proclaimed, the organizations decided to "put down our competitive edge" and work together "from the hospital standpoint and then pull in the fire department, the ambulance folks, and the police department" for Omaha's program.

Pharmacists' skills needed. Massoomi joined Omaha's MMRS planning committee in 1999 and immediately suggested that there was a need to create a pharmacy subcommittee.

Pharmacists, he said, have expertise in drug distribution and control that is needed in establishing and coordinating an MMRS community's pharmaceutical cache.

MMRS program principles require a participating community to have a pharmaceutical cache sufficient to treat 1,000 victims of a chemical agent attack and up to 10,000 victims of a biological weapons attack, said Federal Emergency Management Agency MMRS Program Manager Dennis Atwood, in an e-mail response.

"The Omaha Nebraska MMRS is doing a very good job in managing their MMRS pharmaceutical cache," he said. "The management of this cache is left up to the MMRS jurisdiction, including matters relating to storage, distribution, and administration of the pharmaceuticals. The role of the hospital pharmacist is key to this capability because of their professional expertise regarding the types, formulations, and quantities of pharmaceuticals which best meet the jurisdiction's assessed risks and needs. The hospital pharmacist's daily work also makes them a vital surveillance point for significant changes in disease occurrence patterns."

The state's poison control center has, for several years, surveyed Nebraska hospitals about supplies of antidotes, such as snake antivenin, and stocks of antimicrobials, including ciprofloxacin, doxycycline, and amoxicillin, Massoomi said.

"We felt like we had an adequate amount of antibiotics in our community to appropriately meet the needs of the [MMRS] contract," he noted.

For its cache, Omaha's MMRS program purchased 3,000 nerve-agent antidote kits, known as MARK I kits, that include autoinjectors containing atropine sulfate and pralidoxime chloride, Massoomi said.

Most of the MARK I kits have been placed with first responders in fire department, police, and EMS vehicles, he noted. Hospitals also store some of the kits.

Omaha has an agreement, which Massoomi refers to as a "ghost order," with two local pharmaceutical wholesalers to supply the community with additional medications "in a timely manner" if a disaster occurs.

The city had an identical ghost-order plan in place when it prepared for Y2K compliance, Massoomi added.

Pharmacists' experience and knowledge, he said, are also critical to an MMRS community's plan for receiving a shipment from the Strategic National Stockpile (SNS)a federal repository of antiinfectives, chemical antidotes, antitoxins, life-support medications, i.v. administration and airway maintenance supplies, surgical items, and other medical supplies designed to supplement and resupply state and local public health agencies in the event of a national emergency anywhere and at anytime within the United States or its territories.

The stockpile is managed jointly by DHS and the Centers for Disease Control and Prevention (CDC). The SNS is deployed when an affected state's governor requests it from CDC or DHS. DHS, HHS, CDC, and other federal officials jointly evaluate the situation and determine a prompt course of action, according to CDC.

Testing preparedness. Omaha tested deployment of the SNS last July during a three-day disaster-preparedness drill, Massoomi said.

Pharmacists, pharmacy technicians, and other hospital staff from Nebraska Methodist Hospital, Creighton Medical Center, the University of Nebraska Medical Center, Bergan Mercy Medical Center, Immanuel Hospital, and the Veterans Affairs Medical Center Omaha participated in the mass dispensing exercise.

The two local pharmacy schools, Creighton University School of Pharmacy and the University of Nebraska College of Pharmacy, also took part in the drill.

Other agencies that participated included the community's poison control center, EMS, police and fire departments, and the Douglas County Health Department.

About 250 health care workers, pharmacy students and interns, and government officials participated in the drill.

Omaha's MMRS team recruited about 100 volunteers from local community groups, including the Boy Scouts and the Kiwanis Club, to act as victims for the exercise, Massoomi said.

The drill's scenario involved a simulated release of Bacillus anthracis at a Tuesday night concert in Omaha in which about 20,000 people were potentially exposed after coming in contact with a white powdery substance that had been sprayed on cars throughout the venue's parking lot.

Once it was determined that the white powder contained anthrax spores, Massoomi said, the city's mayor contacted the governor to request aid and the SNS.

For training exercises, the federal government sends a training, education, and demonstration (TED) package that simulates the contents of a 12-hour push package, a 50-ton container of drugs and supplies designed to provide rapid delivery of a broad spectrum of assets from an ill-defined threat in the early hours of an event.

The SNS program has 12 push packages that are kept in environmentally controlled secured warehouses in strategically located, secret locations around the country and are ready for deployment to reach any affected area within 12 hours of a federal decision to release the supplies, according to CDC.

If an incident requires additional drug products and medical supplies, vendor-managed inventory (VMI) supplies will be shipped to arrive within 24-36 hours.

VMI supplies can be tailored to provide medications and other supplies to respond to an attack in situations in which a specific biological or chemical agent has been identified, according to CDC.

Omaha received the TED package at the community's designated receiving, staging, and storing site (RSS)a predetermined location that is kept secret.

Once the TED was received, Massoomi said, drug products and other supplies were distributed to two patient clinics, known as Dispensing and Vaccination Education Sites, or DAVES.

The city has identified 21 potential locations for DAVES, such as high schools and other large buildings, Massoomi said, but only two were used for the drill.

Helpful tools. One important tool used during the drill was a nuclear, biological, and chemical (NBC) agents overview carda color-coded table of agents most likely to be used by terrorists and the antidotes used to counter those agents.

Massoomi and a University of Nebraska pharmacy intern, Tim Candy, who is now completing a Master of Science program in health-system pharmacy administration at The Ohio State University combined with an ASHP-accredited pharmacy practice residency program at Grant Medical Center in Columbus, developed the card for the MMRS program.

The card was reviewed by 10 physicians, including 5 physicians who specialize in infectious diseases, Massoomi said.

Omaha's MMRS program, he said, has published about 25,000 of its NBC agents reference cards and has distributed them to hospitals, EMS, fire departments, poison control centers, physician offices, and other organizations in several states, including Missouri, Iowa, and Kansas.

CDC also requested copies of the cards, he noted.

The card is also available in an electronic version for hand-held computers, Massoomi added.

Another tool developed by Omaha's MMRS is an "Office Go Kit," which contains administrative items, such as pens, paper, clipboards, and calculators, which are needed at the RSS, he said.

One hospital in the community also donated a laptop computer for the Office Go Kit, Massoomi said.

The city's MMRS committee also created similar "Medical Go Kits," which contain gloves, biohazard disposal bags, sharps containers, and some drug products, such as epinephrine, for DAVES, he added.

Dispensing drill. Pharmacists, pharmacy technicians, and other health care workers evaluated volunteer victims at the DAVES and counseled the patients about antimicrobials before dispensing simulated drug products to the victims.

Omaha's goal was to evaluate, counsel, and dispense the simulated drug products to at least 300 victims per hour, Massoomi said.

Volunteer victims were provided with scripts that described hypothetical symptoms.

Just as efforts to treat victims at the DAVES were getting underway, a simulated bomb was detonated, theoretically releasing a nerve agent at an annual air show at Offutt Air Force Base, in which several hundred people were in attendancea second part of the drill's terrorism attack scenario.

About 60 volunteer victims at the air show were transported to area hospitals, Massoomi said.

The exercise provided an opportunity for health care workers at the hospitals to test their decontamination equipment and processes, he said.

Goals met. The July drill helped Omaha identify how it can improve its emergency preparedness plan, Massoomi said. After analyzing the drill, Omaha's MMRS deemed the exercise a success, he declared.

"We met all the goals that we wanted," Massoomi maintained. "We were 15 minutes off of getting the medications to one of the DAVES to start the dispensing. So we didn't think that 15 minutes was too bad."

But, Massoomi counseled, communities need to constantly prepare and not stop at conducting one or two drills, adding that it is important to keep in mind that there are many forms of terrorism and that terrorists can strike at any time.