Preparing the pharmacy service for a hurricane

As System Director of Pharmacy at Lee Health Mr Armitstead is responsible for 400 pharmacy employees in 15 different sites in Lee County in south west Florida. These include five hospitals, a micro-hospital, a home infusion service, a mail order pharmacy and an infusion site pharmacy, all of which deliver care to the citizens of Lee County.

“Every year …. we establish a ‘hurricane pack’ or a wish list of pharmaceuticals that we might need prior to a hurricane from our wholesaler”, says Mr Armitstead. The pack is not ordered until a hurricane is expected. In addition, every employee at Lee Health is assigned to Team A or Team B. Team A staffs the hospitals for the first 48-72 hours and is then relieved by Team B.

First steps for pharmacy when the hurricane hits

Pharmacy managers need to plan for the provision of emergency pharmacy services after the hurricane has passed and must bear in mind that wholesalers may be out of action and transport disrupted. Typically, the medicines in a ‘hurricane pack’ will include tetanus vaccines, antibiotics, analgesics and products for surgical procedures such as intravenous propofol.

Hurricane damage arises from strong winds, heavy rain and, for coastal areas, storm surges. On this occasion the storm surge caused significant damage because south west Florida is not far above sea level. “Twelve of my 400 employees … lost their homes during hurricane Ian from total flooding of their home”, says Mr Armitstead. In addition, 32 employees lost their cars after they had been totally submerged in sea water.

How the pharmacy service responded to hurricane Ian

As a member of ‘Team A’ Mr Armitstead was present in the hospital during the hurricane and set up a command centre to monitor and guide pharmacy services in the other facilities. “Once the hurricane starts to hit, a variety of different events start to occur and you need to adapt your disaster plan with a dose of reality”, he says.

For a period of 48 hours after hurricane Ian, the five hospital outpatient pharmacies were the suppliers of prescriptions for outpatients throughout Lee County, a population of about one million people.

Lessons for pharmacy from hurricane Ian

Reflecting on his experiences during and after hurricane Ian, Mr Armitstead says how proud he is of the dedication and professionalism of his staff for the way in which they responded to the demands of the situation.

The workload in the outpatient pharmacies tripled in the post-hurricane period and at one hospital they converted the retail pharmacy into a drive-through pharmacy to reduce the volume of patients coming into the hospital to collect prescriptions. Mr Armitstead emphasises the importance of having a written emergency plan and of revising it in the light of experience “such that we’ve got a better plan next time”.

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After hurricane Ian, the pharmacy service at Lee Health was able to provide medication therapy for any patient, whether inpatient or outpatient, who presented. In doing this, the five hospital outpatient pharmacies saw their workload increase threefold.

Mr Armitstead pays tribute to the dedication and professionalism of his staff. He says: “I was proud of all my staff but particularly proud of the step up that was made in the outpatient and retail pharmacies as they had a surge of prescriptions that was probably three times their normal prescription volume. Imagine a pharmacy that is built to do two to three hundred prescriptions a day that is now doing anywhere between 700 to 900 prescriptions a day, and …. not only [having] the supplies to be able to provide those prescriptions but the personnel to be able to provide those prescriptions 24/7 in a time period where a lot of people did not even know the impact of the hurricane on their own home”.

Some members of his staff had themselves experienced devastating losses. “I did have some people that were totally flooded out with their home and lost their car and still came into work. So, I mean it’s quite admirable to be able to provide care as a caregiver but knowing that you lost your all your possessions”, he says.

He continues: “This [hurricane] was quite dramatic. We usually think that in regards to hurricanes we over-prepare because sometimes we get ready and we do some of these things and the hurricane does not hit. In this case, we prepared and we were ready and we provided care. We did not really [foresee] that the devastation that happened to the community would be as widespread as it was. In this case, like I mentioned, there was the wind and the rain and that did some damage but the storm surge provided the devastating damage in Lee County, Florida this year”.

Mr Armitstead acknowledges that there are always lessons to be learned from reflecting on how well the emergency plans worked. He cites one example of an adaptation that worked particularly well: “In one of our hospitals we turned our retail pharmacy into a drive-through retail pharmacy. We used the front drive-through of the hospital to provide care, so we actually were delivering prescriptions out to the kerb where patients were waiting in their cars, to alleviate the volume of traffic of patients coming into the hospital”, he says.

He also notes that they did not run out of any drug that was needed. “Overall, I think it really was something that the team really made as successful as it could be”, he adds.

In conclusion, Mr Armitstead says that he continues to build on his experience of previous hurricanes. It is important to have a written plan and he advises pharmacists to “think about not only your employees but the pharmaceuticals and the supply chain and the unique needs post-hurricane – and you really need to take those learnings and put them together to enhance your plans each and every time. So, we will make revisions to our disaster plan ….. such that we’ve got a better plan next time”.

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Mr Armitstead himself is a member of ‘Team A’, the team that staffs the hospital during the hurricane. “We have some advanced planning for the hurricane but then once the hurricane starts to hit, a variety of different events start to occur and you need to adapt your disaster plan with a dose of reality”, he says. As a leader, he finds it is better to be on site where he can establish a pharmacy command centre, check on his other sites and instigate adaptations to the emergency plans, if necessary.

After the hurricane, large numbers of patients came to the hospitals. Many required emergency treatments for puncture wounds. “Imagine that you have been in a house and let’s just say that the house has got three feet worth of water …… there’s either glass or nails or something like that, so now your skin is submerged in the water and you’ve got a puncture wound from either glass or some other foreign object ….. so the risk of an infection, of cellulitis, is quite high”, explains Mr Armitstead. Such patients require tetanus immunisation (if not up-to-date) and prophylactic antibiotics.

Another common scenario is disruption of treatment for patients with chronic conditions. “Let’s say that you’re a chronic obstructive pulmonary disease patient and you weren’t doing well before the hurricane and now you’ve got no electricity, no air conditioning, no lights in your home and now you’re struggling because also your nebuliser is not working because there’s no electricity”, he says.

Mr Armitstead emphasises, “It’s not like the hurricane passes and everything’s okay – you have to think of the loss of utilities ……. the first one that usually goes is electricity but don’t forget that we probably lost the internet too and then you’ve got [water] penetration”.  In addition, there may be no running water or sewerage.

In fact, after hurricane Ian, the only places with electricity were the hospitals, which each have emergency power plants. “The lights never went out at the hospitals. At each one of our five hospitals there was nothing more than a three-second delay in conversion to emergency power”, Mr Armitstead recalls.  The five hospital outpatient pharmacies were the only retail pharmacies open in Fort Myers for the first 48 hours post-hurricane. Had these not been available “people would have to leave the county to find a pharmacy that was open and had not only lights but their computer running [because] ….. with no computer you could almost not fill a prescription”, he says. The result was that these hospital pharmacies were the suppliers of prescriptions for outpatients throughout Lee County, a population of about one million people, he explains.

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Typically, the medicines in a hurricane pack will include tetanus vaccines, antibiotics, analgesics and products for surgical procedures such as intravenous propofol. Puncture wounds are very common in the wake of hurricanes as people are often waking round damaged building with exposed nails and splinters of wood, notes Mr Armitstead.

In addition to planning for services that the pharmacy will have to deliver in the aftermath of a hurricane, pharmacy managers also need to consider the possibility that the pharmaceutical wholesalers might also be hit by a hurricane. “Our wholesaler happens to be a little bit further north of us – about 150 miles away on the Interstate [Highway] 4 corridor – so we have to prepare for them not being able to service their sites post-hurricane. So, we have to think about not only the impact of the hurricane on us but we’ve got to look at the impact of the hurricane on our suppliers and make sure we have enough drug supply to be able to run through the period of time in which our supplier chain might be broken”, he says.

Hospital Pharmacy managers also track hurricanes that hit other areas of the country and consider what the impact on the supply chain might be. For example, hurricanes that hit mid-Florida or northern Florida could disrupt pharmaceutical supplies and hurricanes that hit Puerto Rico can be a problem because a number of pharmaceutical manufacturing plants are there.

Hurricane damage arises from strong winds, heavy rain and, for coastal areas, storm surges. The best way to describe a storm surge is “the waves …. that you’re used to seeing at the beach – they don’t know where the beach is anymore and they disregard the fact that they should stop at the beach and so, for example, during hurricane Ian we had anywhere from six to ten feet of storm surge”, says Mr Armitstead. This caused significant damage because south west Florida is not far above sea level. “Twelve of my 400 employees … lost their homes during hurricane Ian from total flooding of their home.  I had 32 employees who lost their vehicles – their cars – because they were totally submerged in water and once your car is totally submerged in water, and particularly sea water, it is no longer a viable vehicle”, explains Mr Armitstead.

The hurricane ruined the roof of Mr Armitstead’s home. “I view myself as fortunate as a Southwest Floridian that that was the only thing affected – but basically I need to replace my roof”, he says. There were more than 100 deaths in the region as a direct result of the hurricane and the impact on property, homes and livelihoods was severe. “There were many places that were totally wiped out [by] the storm surge”, he adds.

Some 30 million dollars’ worth of damage was inflicted on health care facilities belonging to Lee Health, mainly as a result of the storm surge.

Read and watch the full series on our website or on YouTube.

As System Director of Pharmacy at Lee Health Mr Armitstead is responsible for 400 pharmacy employees in 15 different sites. These include five hospitals, a micro-hospital, a home infusion service, a mail order pharmacy and an infusion site pharmacy all of which deliver care to the citizens of Lee County, Florida.

Fort Myers is situated on the south west portion of the Florida Peninsula; to the south lie the Straits of Florida and the country of Cuba and to the west lies the Gulf of Mexico. “An interesting fact is that we are closer to the capital of Cuba – Havana – than we are our own state capital in Tallahassee, Florida so we are pretty far south in Florida”, says Mr Armitstead.

On September the 28th 2022 hurricane Ian made landfall at Fort Myers Beach and – over the next few hours – brought devastation to a wide area of south west Florida. Preparations for hurricanes are made well in advance. The hurricane season in Florida runs from June 1^st to November 1^st, so hurricane Ian fell right in the middle of the season.

“Every year …. we establish a hurricane pack or a wish list of pharmaceuticals that we might need prior to a hurricane from our wholesaler”, says Mr Armitstead. The pack is not ordered immediately but in response to the anticipated arrival of a hurricane. “We watch the tropics and most of the hurricanes in this area of the country ….. begin by spinning off the Western portion of Africa. …. we watch for the possibility of hurricanes all season during that time period and then if one is starting to approach and looks like it will make landfall in Florida, we would order the hurricane pack prior to the hurricane arriving”, he explains.

The hurricane packs are delivered on pallets and contain sufficient drug supplies to last for 72-96 hours post-hurricane.

Another important aspect of hurricane preparation is assigning employees to teams with specific responsibilities. “Every employee at Lee Health is either in team A or in Team B. Team A employees are physically present in the hospital during the hurricane and so that means Team A people …. would come in and usually spend anywhere from 24 to 48, maybe 72 hours in the hospital –  even sleeping in the hospital during that time frame. Employees in Team B come in after the roads are cleared or after the hurricane has passed and it is safe to come to the hospital.  Team B comes in and replaces Team A after the hurricane”, explains Mr Armitstead.

Provided that the hospital buildings are not affected by winds, rain or flooding the time when the hurricane passes over is relatively quiet but there is a surge of activity after the hurricane has passed.

Read and watch the full series on our website or on YouTube.