Organization of a Health-System Pharmacy Team
The role of a pharmacy emergency response team (PERT) trained to respond to episodes of terrorism involving chemical, biological, radiological, and nuclear (CBRN) agents is described.

Pharmacists must be prepared to support their health systems in responding to episodes of terrorism by detecting exposure to CBRN agents and mitigating, treating, and preventing casualties resulting from exposure to those agents. Maimonides Medical Center, whose pharmacists responded to the medical and pharmaceutical needs of victims of the World Trade Center attacks and anthrax exposures, has developed the PERT, modeled after the Health Emergency Incident Command System, to standardize the response of their pharmacists in the event of such an attack. Each team member has a specific role and can assume any other team member's role, if needed.

Key players in the PERT include the pharmacy administrator, drug information pharmacist, intensive care unit pharmacist, infectious diseases pharmacist, nuclear pharmacist, management-information-system pharmacist, hazardous materials pharmacist, and auxiliary-site pharmacist. The most important features of this disaster response model include activating the PERT to establish command and control in the pharmacy department, conducting a disaster-needs analysis, deploying PERT members in support of the medical center during a public health emergency involving CBRN agents while maintaining normal operations in the pharmacy, and maintaining, mobilizing, distributing, and receiving a pharmaceutical stockpile while ensuring that timely antidotes are available and used appropriately when distributed.

The PERT allows for a comprehensive pharmacy response within a health system to episodes of terrorism involving CBRN agents.

After the terrorist attacks on the World Trade Center (WTC) on September 11, 2001, and subsequent anthrax exposures in the United States, the role of the health-system pharmacist in responding to such disasters emerged at Maimonides Medical Center (MMC) in Brooklyn, New York. MMC is a progressive 705-bed teaching facility and a major affiliate of the State University of New York Health Science Center, located just 15 minutes from Manhattan. For example, the pharmacist in the department of emergency medicine, while in routine attendance in the emergency department (ED), coordinated pharmaceutical needs with the pharmacy directors, posted clinical treatment algorithms for expected injuries, assumed the role of chemical identifier, and educated staff of the decontamination procedures necessary to mitigate casualties. The pharmacist advised the department of pharmacy on mobilizing and distributing needed pharmaceuticals. During the anthrax exposures, the pharmacist was frequently consulted for clinical recognition, management, and education of patients potentially exposed to anthrax and provided information about the overall preparation of the medical facility. This involvement suggests that, in times of crisis, those with an inherent understanding of hazardous materials (HAZMAT) management, regardless of scope of practice, will be consulted and must be prepared to respond knowledgeably. Because few medical personnel were trained or had experience managing an incident involving HAZMAT intended to cause mass casualties, staff relied heavily on the emergency department clinical pharmacist to provide these technical skills. In these situations, pharmacists may serve in a more contemporary provider role. However, this role is not well defined by state boards of pharmacy and national pharmacy societies and requires standardization.

Evidence to support a formal definition of the scope of practice in disaster medicine has been published, including accounts of pharmacy directors faced with the immediate need to ensure that adequate supplies of pharmaceuticals, pharmacists, and pharmacy technicians are deployed to the ED to support nurses and physicians and of community pharmacies serving as triage centers for paramedics. When faced with a public health emergency the pharmacist has an important role, yet the description and standardization of this role are antiquated and ill-defined. For example, as early as 1963, the role of the pharmacist in national defense was recognized. Pharmacists were viewed as medication experts who could assist in emergency medical treatment of patients, train the public in medical self-help, and coordinate preparedness measures by establishing standby emergency operational plans. In 1966, the American Pharmaceutical Association (APhA) continued to support the pharmacist's role in national defense, encouraged the development of a national drug stockpile, and promoted a division of health mobilization to further develop pharmacy activities in all phases of preparation for natural, accidental, and nuclear disasters. In 1971, a model disaster plan for the guidance of pharmacy organizations in responding to the needs of pharmacists who experience losses from natural disasters was developed and disseminated to state pharmaceutical associations. After September 11, 2001, APhA released guidelines regarding the involvement of pharmacists in bioterrorism preparedness planning. These guidelines recommended that pharmacists create a disaster response team, develop a list of pharmacists to call on for assistance, identify a lead pharmacist to coordinate activities within the pharmacy, and stay informed of current emergency preparedness procedures. In 2002, the American Society of Health-System Pharmacists (ASHP) published a statement on the role of health-system pharmacists in counterterrorism, advising pharmacy directors to communicate preparedness planning with local authorities and ensure the collaboration and coordination of the pharmacy's efforts. The ASHP statement provided general guidance to health-system pharmacists that was similar to what is recommended by the APhA guide. ASHP also provides a counterterrorism resource center online that offers essential information for preparation and preevent planning. How should pharmacists maintain a rapid-response capability and ensure adequate staffing during such an event? Other than data on specific antidotes to stock and methods of purchasing them, there are no published reports on how pharmacists can ensure a continuous, organized, and systematic response during a terrorist attack involving chemical, biological, radiological, or nuclear (CBRN) agents. Also, there are no standard methods of response for pharmacists during an incident involving CBRN agents that intentionally target civilians, health care workers, and critical infrastructures.

We combined our experience gained during the WTC attacks and anthrax exposures with the Hospital Emergency Incident Command System (HEICS) model for response and created a pharmacy emergency response team (PERT) at MMC. The purpose of this article is to describe our PERT as an innovative pharmaceutical service to manage terrorism involving CBRN agents that standardizes the role of the pharmacist during such an emergency.