COLLABORATIVE DRUG THERAPY AGREEMENT

Step 7: An Emergency is Declared…..You’re Activated!

Every response effort will be different and it is important to have situation-specific planning which also includes some flexibility. Decisions will need to be made on whether to activate the area command center as well as considering the activation of standing agreements such as CDTAs and MOUs. These decisions should be made in consultation with the multi-agency coordination (MAC) group in your region. Let’s take a look at an example of the activation process within Public Health Seattle-King County (PHSKC).

The decision process to activate the Area Command Center within Public Health Seattle-King County begins with the call to the Duty Officer. It is the policy of PHSKC to establish and maintain a system to provide immediate access to a Public Health Duty Officer every day of the year on a 24 hour basis.

The purpose of the Public Health Duty Officer program is to provide a point of contact for coordinating the Public Health response to emergencies with external health, medical, and public safety agencies, and internal Public Health personnel and sites. The primary functions of the Public Health Duty Officer include:

Serving as a bridge between Public Health resources, the county’s medical community, Seattle, suburban cities, King County government, special purpose districts, and all other public health partners
Prioritizing and documenting incident information and linking callers with appropriate department personnel or external agencies
Keeping appropriate Public Health department personnel notified and briefed of significant incidents
Making recommendations to department leadership regarding activation of the Public Health EOC in response to incidents
Serving as an initial responder to the Public Health EOC to coordinate activation

Decision to Activate Area Command Center
The following types of events or requests indicate automatic Emergency Service Function ESF - 8 area command center activation:

Earthquake
Widespread critical infrastructure impact
Extensive flooding impacting healthcare system sectors
Other major natural disasters warranting activation of emergency plans
Terrorism event potentially generating significant number of patients
Mass casualty or mass fatality event projected to overwhelm resources
Influenza pandemic of any magnitude
Healthcare facility evacuation requiring external relocation

Factors to consider when evaluating ESF-8 AC center activation for other events include:

Assistance in locating medical resources
Request for assistance for a non-medical issue if local emergency operations center (EOC) cannot be contacted
Critical infrastructure damage affecting a healthcare facility
Major traffic events affecting a healthcare facility
Need for enhanced coordination of incident information among multiple healthcare and external partners
Damage to supporting infrastructure (power, roads, public works, communications) impacting health and medical operations of one or more healthcare sectors

Decision-making protocols and medical resource allocation strategies for each type of event can help dictate when to activate a CDTA and MOU.

When choosing to activate CDTAs and MOUs, consider the following factors:

What populations are being affected by this event? Is there a specific age group that is being targeted?
Do we have agreements with pharmacies who serve those populations? In what locations?

Once the decision is made to activate Area Command, an incident action plan will be utilized to dictate the operational objectives for the response effort.

The Area Command organizational structure will depend on the size and scale of your response. Regardless of the structure, it will most likely be the operations chief or more specifically, a designated pharmacy branch lead who will serve as the main point of contact for pharmacy partners. Again, let’s take a look at an example of the decision tree utilized by Public Health Seattle & King County when making the decision regarding ACC activation.

ESF-8 area Command Activation
The ESF-8 area command center may be activated to support ESF-8 agencies impacted by a localized event, or in response to a major incident, in conjunction with the EOC, to direct the region-wide health, medical and mortuary response during a major incident. The following individuals have the authority to activate the ESF-8 area command (AC) center:

Director of Public Health
Chief of Staff
Chief of Health Operations
Chief Administrative Officer
Preparedness Director

Upon activation of the ESF-8 area command center, the Preparedness Director will immediately designate an ESF-8 area commander. The area commander will perform these duties:

Activate and staff appropriate ICS functions for the incident
Determine the health department sections that must be represented in the ESF-8 area command center based on existing or anticipated consequences of the incident
Determine if the primary ESF-8 ESF-8 area command center is safe and operational, if not, identify a back-up facility listed in this manual
Establish and communicate the initial operational objectives for AC staff
Conduct an AC briefing with staff to assess progress and share information

Immediately following activation of the ESF-8 area command center, the public health duty officer contact telephone number is forwarded to become the main telephone number for the AC. This ensures that all calls of an emergency nature to the health department are coordinated through the AC. The duty officer number will be forwarded back to the public health duty officer when the ESF-8 AC center is deactivated.

Area Command Mission and Operational Objectives
The area commander, in conjunction with the planning section chief, develops the AC mission and objectives for each operational period (usually eight hours). The mission provides overall direction and purpose for AC participants while the objectives focus all staff toward clear priorities. The area commander restates the mission and objectives during each AC briefing to ensure all staff are aware of current department priorities. Upon activation of the ICS structure, the area commander will evaluate the following operational objectives and assign or revise these as events dictate:

Determine the status, health and safety of all public health staff and family members
Ensure the ESF-8 area command center is staffed and operational
Establish contact with the EOC, clinics, hospitals, other healthcare organizations and State DOH
Staff city and county EOCs with liaisons as necessary
Initiate risk communications; educate the public and responders on critical health issues
Assess impacts to critical healthcare sectors, resources, facilities and functions
Activate business continuity plans as needed to restore and maintain those functions immediately affecting public health and safety
Investigate potential threats to the public’s health; reduce or eliminate risks
Provide medical resource and information management support to healthcare partners across the county

ESF-8 Area Command Staffing
The area commander activates appropriate area command (AC) sections (Planning, Logistics, Finance and Administration) based on the circumstances of the event. The specific health department functions represented in the AC for each event will vary depending on the public health consequences and technical support needed to address the health threat. Once mobilized, these positions will remain active in the AC as long as there are resource and coordination issues that require their involvement.

Area Command Briefings
Area command briefings are conducted by the area commander or designee at the beginning and end of each operational period and at regular intervals throughout each period as needed. Briefings include identification of AC command and general staff, an overview of the situation, review of significant events, major coordination issues, anticipated actions and the AC mission and objectives. Briefings are limited to 30 minutes in length and may include updates by specific AC staff selected by the area commander.

Deactivation
The ESF-8 area command center is deactivated at the direction of the area commander when health and medical response and recovery activities can be effectively managed through normal operations. The planning section chief will develop a demobilization and deactivation plan for approval by the area commander. The planning section cief, with support from command staff, will ensure that appropriate public health staff and response partners are notified, responsibility for documentation of AC activities is assigned, and points of contact are established within public health for ongoing coordination issues.

Communicating with Pharmacies During a Response
Communication is key in every event. The ability to communicate effectively with pharmacy partners will be critical to response efforts. It is likely that pharmacies will receive information through multiple communication channels, so it is imperative that these messages be coordinated and timely.

It is possible that information will be acquired from several health department sources, such as a public health call center (such as a Flu Hotline), broadcast faxes, e-mails, and information from other governmental agencies such as the Centers for Disease Control and Prevention (CDC) or the United States Department of Health and Human Services (HHS). The pharmacy branch chief (or main communication liaison) should work with the call center branch chief as well as any other departments sending out communication to ensure everyone is disseminating the same information.

Conference calls should be held weekly, at minimum, with pharmacy partners, providing an opportunity for updates, sharing of best practices, and answering questions.

Communicating with the Public During a Response
Pharmacies can serve as information hubs during an emergency. It is likely that customers waiting in line will have pressing questions and will look to the pharmacist to answer them. Health departments need to ensure that pharmacists are not overwhelmed with having to answer repeated questions while also serving as a mass dispensing site. Several mechanisms can be used to ensure that the public is receiving critical, timely updates about the response:

Websites: notify the public about where to access vaccine and other resources by providing a web tool which lists all of the dispensing locations, the age groups they serve, hours of operation, and contact information.
DVDs: ensure that pharmacies with audio/visual capabilities have running DVDs which can include answers to frequently asked questions (FAQs).
Informational brochures: Ensure that pharmacies have public education materials in multiple languages.
TV/Radio Ads: produce scripted messages that give updates about the response.

Tracking and Reporting Considerations
In an effort to maintain situational awareness and track medical resources, local health departments should evaluate various methodologies for tracking and reporting.

Does a statewide online system exist? How can pharmacies plug-in?
What method of reporting is more convenient for the pharmacy: fax, e-mail, mail-in, online?
What is the desired frequency for report submission? Daily? Weekly? Monthly?

Here are some examples from the H1N1 response:

In Washington State
The existing CDTA for antiviral medications in Washington State was in the early process of development when the H1N1 influenza outbreak occurred. Team members working on the CDTA, which included members of the state pharmacy association and the University of Washington, were able to compile a list of contacts from pharmacies. Pharmacy representatives participated in weekly conference calls and those who had signed a provider agreement were considered to be included as part of the public health department’s medication dispensing strategy. Pharmacies were asked to provide information about the age groups they were able to vaccinate and to provide a list of stores within our jurisdiction that would be able to assist. Ultimately, pharmacies to assist in medication dispensing were chosen based on geographic distribution and the age groups they were capable of serving. This ensured we targeted medication dispensing to otherwise difficult to reach populations and age groups. Moving forward, the public health department aims to obtain a comprehensive list of pharmacies from the board of pharmacy that includes smaller, ethnic pharmacies and create a database of pharmacists who are also registered as vaccinators, including age-level restrictions for each pharmacy.