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Deborah Hubbell, R Ph, University of Connecticut
Lois F. Parker R Ph, Massachusetts General Hospital
Amy Sauls, Pharm D, University of North Carolina at Chapel Hill
Tabby Ragland, Pharm D, Middle Tennessee State University
Disclosure
� We have NO actual or potential conflict of interest in relation to this educational activity or presentation
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Objectives� Describe a pharmacist’s contribution on a medical
relief trip to assist in rebuilding the medical infrastructure of Haiti.
� Describe the use of Clinical Pharmacist Practitioner protocols.
� Explain the collaboration involved and discuss the lessons learned in managing a bacterial meningitis event.
Why are we here?� To gain a better understanding of who we are as college
health pharmacists and explore what we can offer to our health centers
� Presenters will share their experiences on the topic areas
� Audience is invited to share their experiences also to expand the knowledge base of everyone in attendance
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Service to Others
Compassion for All
� If you want others to be happy, practice compassion. If you want to be happy, practice compassion.
� The Dalai Lama
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Volunteering in Haiti Volunteering in Haiti
with Project with Project MedishareMedishare
Lois F. Parker, BS Lois F. Parker, BS RPhRPh
Project MedishareProject Medishare
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Project MedishareProject Medishare
�� A group of physicians and health care A group of physicians and health care professionals committed to rebuilding the professionals committed to rebuilding the medical infrastructure of Haiti medical infrastructure of Haiti
�� CoCo--founded in 1994 by Drs. Barth Green and founded in 1994 by Drs. Barth Green and Arthur Fournier of University of MiamiArthur Fournier of University of Miami
�� The Global Institute for Community Health & The Global Institute for Community Health & Development aims to mobilize global Development aims to mobilize global collaborations in the pursuit of health and collaborations in the pursuit of health and prosperity for all human beings prosperity for all human beings
Haiti Earthquake and MedishareHaiti Earthquake and Medishare
�� January 12, 2010January 12, 2010
�� 7.0 magnitude, killed 300,000, 1.3 million left homeless7.0 magnitude, killed 300,000, 1.3 million left homeless
�� First team of foreign MDs to arrive in HaitiFirst team of foreign MDs to arrive in Haiti
�� Less than 24 hours after earthquake, set up field Less than 24 hours after earthquake, set up field hospital at request of President and Ministry of Healthhospital at request of President and Ministry of Health
�� Days later, began operating 300 bed hospital with 3 OR Days later, began operating 300 bed hospital with 3 OR and ICUand ICU
�� Transitioned in February to be 1Transitioned in February to be 1stst trauma and rehab trauma and rehab facility in Haitifacility in Haiti
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Hospital Bernard Mevs/Project Hospital Bernard Mevs/Project
MedishareMedishare
�� Moved out of tents in June and began Moved out of tents in June and began
partnership with Bitar brothers at Bernard Mevspartnership with Bitar brothers at Bernard Mevs
�� Project Medishare volunteers work side by side Project Medishare volunteers work side by side
with Haitian staffwith Haitian staff
�� Only trauma facility in Port au PrinceOnly trauma facility in Port au Prince
�� Only NICU/PICU in HaitiOnly NICU/PICU in Haiti
�� Volunteer PT team training Haitian PT techsVolunteer PT team training Haitian PT techs
Others with Presence in HaitiOthers with Presence in Haiti
�� Partners in HealthPartners in Health
�� MedicinsMedicins Sans Sans FrontieresFrontieres (Doctors without (Doctors without
Borders)Borders)
�� J/P HRO (Sean Penn)J/P HRO (Sean Penn)
�� Challenges associated with large numbers of Challenges associated with large numbers of
NGOs and lack of coordinationNGOs and lack of coordination
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Ongoing ProblemsOngoing Problems
�� HIV/TBHIV/TB
�� MalnutritionMalnutrition
�� Inadequate prenatal careInadequate prenatal care
�� High infant mortalityHigh infant mortality
�� Community health issuesCommunity health issues
Haiti from the planeHaiti from the plane
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Welcome from the Western Union Welcome from the Western Union
BandBand
Bernard Mevs Project Medishare Bernard Mevs Project Medishare
HospitalHospital
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The PharmacyThe Pharmacy
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Inside the PharmacyInside the Pharmacy
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Donated drugs from all over the Donated drugs from all over the
worldworld
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Outside the EROutside the ER
Security at the hospital entranceSecurity at the hospital entrance
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All kinds of emergency vehiclesAll kinds of emergency vehicles
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Thanks to the City of MiamiThanks to the City of Miami
Triage bay outside the ERTriage bay outside the ER
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PediatricsPediatrics
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Puppy Therapy in the ICUPuppy Therapy in the ICU
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The Chicken in the ERThe Chicken in the ER
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Working with the Haitian StaffWorking with the Haitian Staff
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PACU/PREOPPACU/PREOP
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ChallengesChallenges
�� Limited resourcesLimited resources�� BloodBlood
�� XX--raysrays
�� PeoplePeople
�� MedicationsMedications
�� Clean waterClean water
�� MoneyMoney
�� Language barrierLanguage barrier
�� Cultural issuesCultural issues
�� Discharge planningDischarge planning
�� ReRe--emergence of “old” diseases (typhoid, polio, emergence of “old” diseases (typhoid, polio, diphtheria, choleradiphtheria, cholera
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The FutureThe Future
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Living in HaitiLiving in Haiti
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A Tap TapA Tap Tap
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The U.N.The U.N.
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For More InformationFor More Information
�� Facebook: Facebook:
�� Project Project MedishareMedishare
�� Lois Lois FinsteinFinstein ParkerParker
�� Partners in HealthPartners in Health
�� Choose HaitiChoose Haiti
�� J/P HROJ/P HRO
�� TiKayTiKay HaitiHaiti
�� Email:Email:
�� [email protected]@comcast.net
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MAY 30 , 2013
AMY SAULS, PHARM.D, CPP
C A M P U S H E A L T H S E R V I C E S
S T U D E N T A F F A I R S
T H E U N I V E R S I T Y O F N O R T H C A R O L I N A A T C H A P E L H I L L
Role of theClinical Pharmacist Practitioner
in a College Health Pharmacy
Disclosure Statement
� I have NO actual or potential conflict of interest in relation to this educational activity or presentation.
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What is a Clinical Pharmacist Practitioner?
A Clinical Pharmacist Practitioner (CPP) is a licensed pharmacist approved to provide drug therapy management, including controlled substances, under the direction of, or under the supervision of a licensed physician. Only a pharmacist approved by the Pharmacy Board and the Medical Board may legally identify himself/herself as a CPP.
-North Carolina Board of Pharmacy
Requirements for Application
One of 3 ways to qualify:
1. Board of Pharmaceutical Specialty Certification or complete an ASHP-accredited residency + 2 years clinical experience
2. PharmD degree + 3 years clinical experience and a certificate program
3. BS degree + 5 years clinical experience and 2 certificate programs
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Protocols
� Collaborative practice agreement signed by supervising physician and CPP
� Outlines predetermined drug therapy, dosage forms, dosage schedules, tests that may be ordered, any modifications permitted
� Predetermined plan for emergency services
� Plan for weekly quality control, including review and countersignature of all orders through weekly face-to-face conference
� No more than 3 CPPs per supervising physician
Maintenance of License
� 35 hours of continuing education each year
� Renewal by birthday year
� May be audited
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CPPs at Campus Health Pharmacy
� Asthma inhalers – extend Rx
� Diabetic supplies – extend Rx
� Hormonal contraceptives – extend Rx
� Emergency contraception – write prescriptions for ella®
� Travel Medications – adjust quantities, change anti-malarial, change antibiotics for traveler’s diarrhea as needed, write for sterile syringe kits, reissue oral typhoid vaccine
� Smoking cessation aids – OTC aids on Rx
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Travel Clinic
� $50 for students
� Group sessions available
� Students fill out Travel Questionnaire
� Students are given a packet of information including summary of each country on the itinerary
� Providers make recommendations for vaccines and write prescriptions
� Pharmacist on Travel Clinic team, presents session on medications, gathers prescriptions for filling
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Travel Medications
� RPh with Certificate of Knowledge Certificate in Travel Health
� International Society of Travel Medicine
� www.istm.org
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Marketing of Service
� Group rates and sessions
� Set up at information fairs
� Meet with advisory board
� Website
� Activity TV
� Bulletin Board
� Travel section in Healthy Heels Shoppe
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Benefits of Travel Clinic
� Students� Detailed information
� Efficient use of time
� Help in negotiating insurance issues
� Pharmacy � Manages workflow
� Revenue – 2 to 4 prescriptions per traveler
� Professionally rewarding
� Organization� Manages workflow in immunization clinic
� Spares provider visits
� Public relations tool
� Revenue
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Using a CPP in a College Health Practice
� Easy access to emergency contraception
� Prescriptions for medications covered under the Patient Protection and Affordable Care Act
� Travel clinic
� Disease state management� Asthma
� Diabetes
� Smoking Cessation
� Hypertension
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Impacts of Social Media on the Management of a Meningitis Event
Tabby Ragland, Pharm.D.
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Background
• Middle TN State University
Murfreesboro, TN– 26,500 students– Largest undergraduate university in the state
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Meningitis Basics
• Meningococcal Meningitis: Neisseria Meningitidis• Leading Cause of Bacterial Meningitis age 2-18• 10-15% infected die, another 11-19% have serious
sequelae (ex. stroke, limb loss)• Vaccination effectiveness – Data on polysaccharide
vaccine (MPSV4) has shown 85% to 100% effectiveness in preventing infection (up to 3 years out).– Compared to MPSV4, Conjugated MCV4 induces higher
production of antibodies- protection is expected to last longer.
http://www.immunizationinfo.org/vaccines/meningococcal
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Medical History of MTSU Student Meningococcal Case
• Seen @ local ER Sunday Sept. 9th w/ N/V & sore throat.
• Worsened over next day & Re-presented 9/10 5am in distress –Deceased 8am– With critical condition no tap performed.
(Eventually initial blood gram stain would solidify diagnosis)
– Student not vaccinated
• Well liked socially active student w/ multiple fraternity events week of illness. – Many contacts - ? How many close contacts
– 2000 concerned eventually screened
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Timeline- Day of Incident
• Initial notification to Student Health Monday Sept. 10th @ 8:15 am– we notify PHD (w/o confirmation)
– Campus media relations, administration, legal, student affairs
• Twitter & texting spreads awareness nearly instantaneously to student body– press informed via social media as well
• Fraternity arrives en masse in office just after 9 am. – Cipro (from our pharmacy) for prophylaxis of close contacts (ID at local hospital insists on
Roc+Rifampin – adds some confusion – contact Vandy and PHD and proceed with recommended Cipro)
• Dedicated area set up for Meningitis Prophylaxis• Official Campus Response – 4:39 p.m.
– difference in opinion between state health department and campus on how much info
should/could be released. • Ongoing: Multiple Interactions w/PHD & Vandy• Clinic hours extended to 6:00pm
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Evolution of a Press ReleaseVERSION 1- from State
Sent: Monday, September 10, 2012 1:46 PMSubject: RE: Draft of MTSU release
Hello everyone…. I have reviewed this message with State PIO and we both feel it does not violate any privacy laws and the message will be received by the appropriate contacts. If they don't know who the case is they are unlikely to be a contact. Thanks all.
A Middle TN State University Student died early Monday morning at Vanderbilt University Medical Center. The cause of death at this time is unknown. Close personal contacts to this individual from September 2 to September 10 2012, should contact MTSU Student Health, or the local Health Department for further assessment.
CONCERNS EXPRESSED BY UNIVERSITYThis release would cause wide-spread panic, since it basically says anyone who has contact with any of our 25,000-plus students between Sept. 2 and Sept. 10 may have been exposed to some unnamed problem. We will not send this out and we strongly urge you not to send this as well.
We need to have a clear message that can be released when parents, students and media contact us. While I understand your concerns, the message must be specific enough to be useful.
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Final MTSU Press Release
Officials say that anyone who had direct, close contact with a Middle Tennessee State University student who died early Monday should contact Student Health Services or another health care provider for an evaluation.
Jacob Nunley, 18, a freshman from Dyersburg, Tenn., died early Monday at Vanderbilt University Medical Center. Nunley was a member of the Sigma Alpha Epsilon fraternity and lived in the fraternity's house on Greek Row on the MTSU campus.
The state health department is investigating the cause of death.
However, Vanderbilt officials said they were treating this as a possible case of meningitis and instructed anyone who may have had direct, close contact with Nunley from Sept. 2 to Sept. 10 to contact a health professional for evaluation. Direct, close contact means coming in touch with nose or throat discharges, which includes kissing, coughing, sneezing and sharing drinking glasses, eating utensils or cigarettes.
For more information, contact MTSU Student Health Services at 615-898-2988 or the Rutherford County Health Department at 615-898-7880.
Additional details regarding time and place of death
Additional details regarding suspected cause of death
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Info Sheet
• Provided to media contacts
• Posted online• Posted on clinic door
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Newspaper Coverage
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Television Coverage
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Student Coverage
“…unintentionally
endangered more than
twenty seven thousand
Middle Tennessee State
University students.”
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Social Media
• Text messages• Twitter• Instagram• Facebook
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Triage and Dispensing Processes
• Set up in break room• Fraternity members came first• Learned timeline of social contacts• Screening form developed
– Many close contacts
• Lobby signs• Antibiotic procurement
– Local pharmacies, PHD
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Event Management Complications
• Student/Faculty/Staff Concerns– Calming Fears– Cancelling Classes– Disinfection of classrooms/fraternity house– Concurrent Fungal Meningitis Scare @
St. Thomas Hospital (Nashville)– News begins Reporting Many Possible
Meningitis – next 6 weeks• MTSU student teacher w/ possible meningitis
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Event Management Complications
• Managing Misinformation– Bus Driver Scare
• 67 y/o bus driver, admitted to ICU w/SOB and gave c/o stiff neck
• Cancelled bus service (posted at stops) which fueled campus fears
• Campus email
– Email From Lab Professor • (late on a Friday)
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Event Management Complications
• Clinic Operation Issues– Increased Visits– Minimize elective visits to schedule– Transports to ER– Triage– Hyper-vigilance on Meningococcal symptoms– Increased calls to after hours nurse advice
line– Calls from surrounding schools/clinics
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Policy Questions
Tennessee one of many states using Meningitis Waiver
Students at public or private IHEs must return a completed waiver indicating that the institution has provided necessary information on meningococcal disease and vaccination.
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Is this Policy Adequate?
• EDITORIAL: Meningitis review is right policy after student death– DNJ editorial asks for review Current state legislative bills
• State Senator sends letter to TN Higher Education Commission asking for review
• MTSU President and VP’s ask for recommendation– Student Health Recommendation:
Mandatory for freshman under 22 living in dorms and Greek housing to have meningitis vaccination or have physician sign waiver to exempt (medical or religious reasons)
Also would favor extending this mandate to all freshman under 22 since we have so much off campus apartments that are really congregate housing.
• State Senate and House pass bill requiring proof of meningitis vaccination– Legislation tabbed as Jacob Nunley Act– Bill requires new, incoming students of public higher education living on campus
to prove that they have adequate immunization against meningococcal disease.
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QUESTIONS?
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Event Management Complications
• Defining Close Contacts– Sept 2-10th time frame – Concerned Groups:
• Shared classes• Host at local restaurant • Large Interfraternity party• Fellow bus riders
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Lessons Learned
• Ready list of campus, PHD, regional medical director, state lab phone numbers
• Plan for antibiotic acquisition• Benefit of pharmacy and HS student workers• Know your campus media relations staff• Get message out ASAP• Limit media interviews
• We limited after Day 4
