City-County Health Department Emergency …...2 Cascade City-County Health Department Emergency Response Plan Annex M: Procedures for EMC Caches Last Updated: June 2011, March 2012,

City-County Health Department Emergency Response Plan

Annex M: Procedures for EMC Caches

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Cascade City-County Health Department Emergency Response Plan Annex M: Procedures for EMC Caches Last Updated: June 2011, March 2012, August 2012, December 2012, January 2013, March 2013

This plan is hereby improved for implementation and supersedes all previous editions. ___________________________________ ___________________________________ Alicia M. Thompson, MSW, Health Officer Jane Weber, Chair Cascade City-County Health Department Cascade City-County Board of Health ____________________ ____________________ Date Date

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Table of Contents

Primary and Support Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Concept of Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Additional Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Plan Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Attachment A: CHEMPACK Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Attachment B: HPP PPE Cache Policies . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Attachment C: PHEP PPE and Equipment Cache Policies . . . . . . . . . . . . 11

Attachment D: HPP Antibiotic Cache Policies . . . . . . . . . . . . . . . . . . . . . . 12

Attachment E: Radiological Cache Policies . . . . . . . . . . . . . . . . . . . . . . . . 13

Attachment F: Pandemic Antiviral Cache Policies . . . . . . . . . . . . . . . . . . . 14

Appendix A: Cascade Region-CHEMPACK/Antibiotic Cache Hosts . . . . . 15

Appendix B: Chain of Custody Transfer Form . . . . . . . . . . . . . . . . . . . . . . 18

Appendix C: Patient Tracking Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Appendix D: Local Memorandum of Agreement . . . . . . . . . . . . . . . . . . . . . 20

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PRIMARY AGENCY Cascade City-County Health Department SUPPORT AGENCIES Benefis Health System Cascade County Disaster and Emergency Services (DES) Cascade County Local Emergency Planning Committee (LEPC) Montana Department of Public Health and Human Services (DPHHS) INTRODUCTION Overview In collaboration with selected medical facilities, the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA) and DPHHS maintain Emergency Medical Countermeasure (EMC) caches throughout the state of Montana. These caches include nerve agent antidotes with the CHEMPACK program, antibiotics and PPE caches with the Hospital Preparedness Program, antivirals, and DTPA (radiological countermeasure) agents with the Public Health Emergency Preparedness Program. These caches are for use by health agencies, hospitals, and Emergency Medical Services (EMS) during a medical and/or public health emergency. These assets must comply with the procedures and requirements of the DPHHS & CDC outlined in this plan. These assets are placed for the protection of Montana’s citizens and healthcare personnel. All emergency countermeasure cache assets are to be administered to no cost to the recipient. The materials are to be accessed only during recognized emergencies and only as a last resort in the absence of local resources. Purpose The protocols in this plan provide a background on the type and usage of selected medical assets pre-positioned throughout Montana. This guidance details a plan of action for the request, mobilization and distribution of the specific asset. EMC Caches are pre-positioned strategically around the State for the protection of Montana’s citizens and healthcare personnel. Due to Cascade County’s location within the State and role as a population center, Benefis Health System serves as a host hospital that houses these assets for the region. Other counties and jurisdictions in this region include: Meagher, Teton, Chouteau, Pondera, Glacier, Toole, Liberty, Hill, Blaine, the Blackfeet Reservation, Rocky Boy’s Reservation and Ft. Belknap Reservation (see Appendix A). SCOPE This Standard Operating Procedure addresses health emergency management issues for Cascade County related to the deployment of EMC Cache assets including:

1. Multi-agency coordination and planning 2. Resource management 3. Communications 4. Mission essential tasks

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Situation Public health events requiring EMC Caches may be limited in scope and exposure (e.g., small workplace accident) or might affect a larger population. All local resources are to be utilized prior to use of any cache. These procedures are inclusive, based on established relationships and partnerships with the public, stakeholders and partners, and contributing agencies, including local and state entities, hospitals and EMS. Use or transport of EMC Cache assets to the scene for staging should be initiated when a nerve agent release involving multiple victims is suspected. The transportation or use of EMC Cache assets to the scene should not be delayed while waiting for confirmation of an exposure. Inventory for each Cache can be found in Attachments A, B and C. Assumptions When any EMC Cache is activated and mobilized it is assumed that

A potential or actual exposure to a biological, chemical or radiological agent has occurred

All local medical resources are (or anticipated to be) exhausted and resupply is not anticipated within an appropriate timeframe

Request for use of EMC Cache assets is received from a competent authority (defined below).

Prescribing of cache medications will be done by an appropriate medical clinician and administered by qualified healthcare personnel.

All MOUs are maintained and are on file at DPHHS. CONCEPT OF OPERATIONS Authority EMC Cache containers are to be requested only by a competent authority. Competent authority for each Cache can be found in Attachments A, B and C. Requesting Assets Requests for mobilization of the appropriate EMC Cache assets should be made following the directions listed in Attachments A, B and C.

Public Health Notification Once the EMC Cache container has been opened and materials are distributed, the official authorizing the release (Benefis) will notify CCHD and DPHHS officials. For events or incidents outside of Cascade County that request the CHEMPACK assets, it is the responsibility of the requesting entity to notify DPHHS. Information given to DPHHS will include a description of the event, who requested the assets and the amount of assets released. Montana DPHHS or the State Emergency Coordination Center (SECC) will monitor operations and may coordinate transportation, mass care and security efforts to non-victims at the incident site.

24/7 DPHHS Duty Officer 406-444-3075

See ERP Attachment 1: Contact Information – Annex M for more contact information.

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Monitor Event DPHHS and DES (as appropriate) will monitor the public health event and available emergency medical countermeasures. Patient Tracking All patients receiving medications from EMC Caches should be tracked. Local healthcare providers are responsible for tracking and reporting to DPHHS the patients receiving stockpiled medications. Local health jurisdictions may asked by DPHHS to assist in collecting that information. A sample patient tracking form can be found in Appendix C. Return Unused Assets Once the event is ended, all remaining product will be returned as soon as practical to the host facility. Opening a CHEMPACK container will result in the loss of that CHEMPACK asset for future use once the drug content expiration dates have been achieved. Once the container has been opened, there is no way to verify that the contents have been maintained at proper climate and temperature parameters. Therefore, the contents will revert to the expiration dates marked on each product. ADDITIONAL RESPONSIBILITIES Primary Agency

Plan Maintenance and Review This plan will be reviewed, updated and maintained by City-County Health Department. CCHD will notify support agencies if any changes to this plan are made.

Support Agencies Benefis Health System On an annual basis, have an opportunity to review

plan.

Cascade County LEPC On an annual basis, have an opportunity to review plan.

DPHHS Supply materials and support necessary to maintain CHEMPACK and antibiotic caches at host hospitals

Collaborate with host hospitals, health/response agencies and requesting agencies to ensure formal processes and procedures are in place to ensure rapid deployment of CHEMPACK and antibiotic cache assets by qualified healthcare providers/responders

Replenish/replace items used or outdated items

Provide/support training to hospitals and agencies regarding requesting, mobilizing, distributing and use of CHEMPACK and antibiotic cache

PLAN DISTRIBUTION The following agencies and individuals have received the most up-to-date version of this plan:

Benefis Health System

Cascade County DES

Great Falls Fire Rescue

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REFERENCES -Montana Department of Public Health and Human Services; Standard Operating Procedures for: CHEMPACK, Pharmaceutical Cache and Antiviral Caches; Draft 4/08 -Montana Department of Public Health and Human Services; Standard Operating Procedures for Emergency Medical Countermeasure and PPE Caches; Draft 11/12

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ATTACHMENT A: CHEMPACK POLICIES Accessing CHEMPACK assets should be initiated when a nerve agent release involving multiple victims is suspected. The transportation or use of CHEMPACK assets to the scene should not be delayed while waiting for a confirmation of an exposure. DPHHS and The Centers for Disease Control and Prevention (CDC) authorize breaking the EMC cache container seal and using the packaged products only when the competent authority, as defined below, in coordination with an incident commander at the scene determines that an accidental or intentional nerve agent release has:

1. Threatened the medical security of the community; 2. Put multiple lives at risk; 3. Is beyond local emergency response capabilities; and 4. The material is medically necessary to save lives.

Requesting CHEMPACK Assets CHEMPACK assets may only be requested by a competent authority. A competent requesting authority is defined as a public health, DES, hospital or other medical professional or any organization identified and trained by the local public health jurisdiction. It is not the responsibility of the host facility to verify the validity of the request when the use is outside of the host hospital. Requests for the CHEMPACK assets should be made directly to the host hospital.

a. Benefis Health System Pharmacy Department will be notified by calling 455-5000 (switchboard)-or directly at 455-5430.

b. Pharmacy staff will contact the authority necessary to process the request and release the assets.

c. Staff receiving request may ask for any of the following information: 1. Estimated number of confirmed or potential adult patients and pediatric patients 2. Signs and symptoms exhibited by patients 3. Name/information of the nerve agent if known and form of release 4. Routes of exposure, if known 5. Any additional information or needs

Accessing the CHEMPACK Container

a. Authorized Benefis staff members have access to the room where the EMC Cache is being stored (see Appendix E for contact information).

b. Designated pharmacy staff are authorized to access and extract the requested amount of material needed.

c. Authorized pharmacy staff will complete the Chain of Custody Transfer Form (Appendix F) that is located with the EMC Cache. They will ensure the courier responsible for transport signs for the material and that the host hospital retains the signed “white copy” of the custody form.

Coordinate Transportation within Cascade County

a. The requesting entity and Benefis Health System will coordinate and determine the most rapid method of deploying assets to the treatment site. Unless otherwise arranged prior to the event, the transport of the assets will be the responsibility of the requesting entity.

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b. On-Scene Incident Commander should identify and communicate a specific location for delivery and an individual authorized to receive assets.

c. Benefis Health System, in coordination with the requesting entity will make every attempt to utilize the quickest and most efficient mode of transportation to deliver EMC Caches supplies. Potential sources for transportation include but is not limited to:

Organization Phone After-Hours

Benefis Mercy Flight 1-800-972-4000

Regional HAZMAT Team 727-8070 911

Montana Highway Patrol 1-800-525-5555 1-800-525-5555

Cascade Co. Sheriff’s Office 454-6820 454-6848

Great Falls EMS, Inc. 453-5300 911

Great Falls Fire/Rescue 727-8070 911

Great Falls Police 452-5425 911

d. The courier will sign for custody of the EMC Cache material at the host hospital.

CHEMPACK Inventory EMS Configuration for up to 454 Casualties

Medication NDC # Unit Pack Cases Qty.

Mark 1 auto-injector 6505-01-174-9919 240 5 1200

Atropine Sulfate 0.4mg/ml 20ml 63323-234-20 100 1 100

Pralidoxime 1gm inj 20 ml 60977-141-01 276 1 276

Atropen 0.5 mg 11704-104-01 144 1 144

Atropen 1.0 mg 11704-105-01 144 1 144

Diazepam 5 mg/ml auto-injector 6505-01-274-0951 150 2 300

Diazepam 5 mg/ml vial, 10ml 0409-3213-12 25 1 50

Sterile water for injection (SWFI) 20cc 0409-4887-20 100 2 200

Opening a CHEMPACK container will result in the loss of that CHEMPACK asset for future use. There is no funding for restocking. The CHEMPACK is sustained through the CDC’s CHEMPACK sustainment program.

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ATTACHEMENT B: HPP PPE CACHE POLICIES The Hospital Preparedness Program’s Personal Protective Equipment Caches is used to provide rapid access to PPE during a public health emergency and hospital surge situations when normal supply channels are inadequate. Use of the Cache is intended for healthcare workers and first responders. Requesting HPP PPE Assets Hospital authorized individuals may request the HPP PPE Cache. Requests for the HPP PPE Cache should be made by the hospital directly to Kriesers Inc. by calling 406-252-4650. When the HPP PPE Cache has been mobilized, the DPHHS DOC will be contacted. All requests or notifications received at DPHHS will be forwarded to the appropriate SME and the Incident Command Advisory Group (ICAG). Shipment of HPP PPE assets will be made by Kreisers, Inc.

HPP PPE Cache Inventory

Respiratory Particulate Glove Exam Nitrile XLarge

Mask N95 Magic Arch 35/BX Gown Imperv Univ 30-54

Mask Isol. Yellow Gown Thumb Cape Reg Blue

Face Mask W/Ear loops Gown Thumb Cape Blue XL

Gloves Nitrile SM 10/200 Gown Imperv XL White

Gloves Nitrile MD 10/200 Gown Cover XL Extraction

Glove Nitrile LG 10/200 Hand Saniti 2OZ Pump Btl

Glove Nitrile XLG 10/200 Hand Sanit Pump 12OZ

Glove Exam Nitrile Small Sani Cloth Wipes 8x14in

Glove Exam Nitrile Medium Dispatch Trigg Spray 32OZ

Glove Exam Nitrile Large

Patients or recipients should not be charged for Cache assets.

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ATTACHMENT C: PHEP PPE AND EQUIPMENT CACHE POLICIES The Public Health Emergency Preparedness Personal Protective Equipment Cache is for the provision of PPE due to shortages during a public health emergency. Cache assets are intended for use by public health and clinical personnel. Requesting PHEP PPE and Equipment Caches Local/tribal public health departments, hospitals and first responder agencies are authorized to request PHEP PPE and Equipment assets. Requests for the PHEP PPE and Equipment Cache should be made to the DPHHS Department Operations Center (DOC) by calling 406-444-3075.The request will be forwarded to the appropriate SME and the Incident Command Advisory Group (ICAG). Transportation of Cache assets will be arranged through DPHHS.

PHEP PPE & Equipment Cache Inventory

Face Shields (full and partial length)

Gloves (misc. sizes)

Surgical Gowns

Procedure Face Mask (yellow masks)

Sharps Container (misc. sizes)

Coolers (various sizes)

Patients or recipients should not be charged for Cache assets.

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ATTACHMENT D: HOSPITAL PREPAREDNESS PROGRAM ANTIBIOTIC CACHE POLICIES

Currently under revision by DPHHS The purpose of the HPP Antibiotic Cache is to provide prophylaxis to healthcare workers, first responders, and their immediate families in response to the public health emergency from potential exposure to a biological infectious agent. Requesting HPP Antibiotic Cache Assets HPP Antibiotic Cache assets are owned by DPPHS, and the Hospital Preparedness Program. Assets should be requested by calling the DPHHS Department Operations Center by calling 406-444-3075. Transportation of assets will be coordinated by the requesting agency. Chain of custody will be maintained and tracked; forms are with the cache. HPP Antibiotic Cache Inventory TBD All individuals receiving cache assets should be documented and tracked. Medication use, quantity remaining, and anticipated needs will be reported to the DPHHS DOC. Patients or recipients should not be charged for Cache assets.

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ATTACHMENT E: RADIOLOCAL CACHE POLICIES The purpose of the Radiological Cache is to provide rapid access to medications for the treatment of specific forms of internal radiological contamination. Radiological Caches are located at DPHHS and the Benefis Hospital CHEMPACK location in Great Falls. Requesting Radiological Cache Assets The treating medical authority is authorized to request Radiological Cache assets. Requests will be made through the DPHHS Department Operations Center by calling 406-444-3075. Medications will be transported to the treating facility; DPHHS DOC will coordinate transportation. Chain of custody will be documented.

Radiological Cache Inventory

Item Pentatate Calcium Trisodium injection (ca-DTPA) 5mL

Pentatate Zinc Trisodium injection (Zn-DTPA) 5mL

Lot # R543062 R446060

NDC # 52919-001-03 52919-002-03

Expiration Date October 2015 November 2014

Doses per Box 10 Doses 10 Doses

Location/Doses Helena: 2 Boxes=20 Doses Helena: 1 Box=10 Doses

Great Falls: 8 Boxes=80 Doses

Total Boxes/Doses 10 Boxes=100 Doses 1 Box=10 Doses

All individuals receiving cache assets should be documented and tracked. Medication use, quantity remaining, and anticipated needs will be reported to DPHHS. Patients or recipients should not be charged for Cache assets.

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ATTACHMENT F: PANDEMIC ANTIVIRAL CACHE POLICIES The purpose of the Pandemic Antiviral Cache is to provide rapid access to antivirals for influenza patients during a declared pandemic or as otherwise recommended by CDC and DPHHS. By CDC directive, the Antiviral Cache is only to be used during a declared pandemic. Requesting Pandemic Antiviral Cache Assets The Antiviral Cache can be requested by authorized by hospital or public health authorities. In Cascade County, the local public health jurisdiction has authorized the Health Officer or designee to make this request. Requests will be made through the DPHHS Department Operations Center by calling 406-444-3075. The requesting organization will coordinate transportation with DPHHS. Chain of Custody will be documented.

Pandemic Antiviral Cache Inventory

Item Relenza

Description 5 MG RotaDisk (5x4) Relenza, 16 Units Per Case

Manufacture GlaxoSmithKline

Quantity 590 Cases

Labeled Expiration* September 2011

Extended FDA Expiration*

September 30, 2013

NDC # 0173-0681-01

*Tamiflu Capsules and Relenza Inhalation Powder FDA Approved supplemental New Drug Applications for Relenza Inhalation Powder and Tamiflu Capsules that provided an expiration dating period of seven years. Approvals of new drug applications are generally prospective. FDA is aware that the following lots of Relenza Inhalation Powder and Tamiflu Capsules are currently packaged with an expiration date less than seven years. Provided that the products have been stored under the labeled storage conditions, FDA believes it would be scientifically supportable for the expiry extension (for a maximum of seven years) to apply to these lots that have already been manufactured. Thus, FDA does not intend to take an enforcement action with regard to the following lots of Relenza Inhalation Powder and Tamiflu Capsules that are retained for potential use in future emergencies, provided that the products have been stored under the labeled storage conditions. This information is provided by the FDA at http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm216249.htm

Lot Number Manufacturer’s Original Expiry Date 7 Year Expiry Date

274 September 30, 2011 September 30, 2013

http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm216249.htm

http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm216249.htm

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APPENDIX A: CASCADE REGION – CHEMPACK/ANTIBIOTIC CACHE HOSTS

Geographical Area

Host Hospital

Population Hospitals Name of Facility Contact Number

Blackfeet Reservation

Great Falls 10,100 1 Blackfeet Service Unit 338-2959

Blaine County Great Falls 7,009 1 PHS Indian Hospital 353-3100

Cascade County Great Falls 80,357 1 Benefis Healthcare 455-5000

Chouteau County Great Falls 5,970 2 Missouri River Medical Center Big Sandy Medical Center

622-3331 378-2188

Fort Belknap Great Falls 2,959 1 PHS Indian Hospital 353-3100

Glacier County Great Falls 13,247 1 No. Rockies Medical Center 873-2251

Hill County Great Falls 16,673 1 Northern Montana Hospital 265-2211

Liberty County Great Falls 2,158 1 Liberty County Hospital 759-5181

Pondera County Great Falls 6,424 1 Pondera Medical Center 278-3211

Rocky Boy’s Reservation

Great Falls 2,676 1 Rocky Boy’s Clinic 395-4486

Teton County Great Falls 6,445 1 Teton Medical Center 466-5763

Toole County Great Falls 5,267 1 Marias Medical Center 434-3200

Blackfeet

Ft. Belknap Ft. Peck

Flathead

Crow

N. Cheyenne

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APPENDIX B: CHAIN OF CUSTODY TRANSFER FORM

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APPENDIX C: SAMPLE PATIENT TRACKING FORM

Documents

City-County Health Department Emergency …...2 Cascade City-County Health Department Emergency Response Plan Annex M: Procedures for EMC Caches Last Updated: June 2011, March 2012,