Incident Command Research Articles

Equity and Disasters: Reframing Incident Command Systems.

In the late 1980s, the hospital emergency incident command system (now HICS) was developed to align with the National Interagency Incident Management System, the federal plan for improving coordination among agencies in a broad range of large-scale emergencies 2 As HICS have been deployed over recent decades, we have deepened our understanding of the strengths and weaknesses of their structure for addressing the needs of diverse populations Recurrent experiences with large-scale disasters, including the COVID-19 pandemic and Hurricanes Katrina, Maria, Harvey, and Sandy, have underscored the ways in which health care responses, emergency preparedness, and broader social determinants of health lead to preventable morbidity and mortality in marginalized communities 3 Here we share the case for embedding an equity element in HICS, our institutional experiences in operationalizing equity, and our recommendation for a structural change in the national HICS guidelines: including a defined equity officer (EO) and subject matter experts in health care equity to ensure that actions are taken to improve outcomes for diverse groups during public health emergencies or disasters The absence of equity as an emergency management principle in responses to COVID-19 has resulted in a slow and incomplete hospital response to the disproportionate mortality and morbidity in several historically marginalized populations 4 For example, hospitals have access to detailed information on the demographic composition of their inpatient populations, the ability to screen patients for social needs, and the opportunity to conduct coordinated community outreach to address the needs of communities of color through HICS infrastructure An after-action review is a structured process developed by the US Army to identify strengths and weaknesses in event response 10 This concept has been adapted as a critical step after public health emergencies to gather information on quantitative and qualitative issues to improve preparedness, mitigation, response, and recovery for future incidents 11 Our institution has conducted several after-action reviews within the past decade after local events including the Boston Marathon bombings and an active shooter incident in our hospital 1214 We have also facilitated reviews in the wake of other large-scale events such as the urban terror attacks in Paris and Brussels 15 Since our initial patient surge in Boston, Massachusetts, in April 2020 (and given the concern for future surges), we have conducted several debriefings with more than 150 staff members across an academic medical center and community hospital within our larger multihospital health care system

Swift Water Oil Spill Response Techniques

ABSTRACT Swift water oil spill response (SWSR) has many different aspects that present more of a challenge than slow moving or static water oil spills. The American Petroleum Institute (API)/Association of Oil Pipelines (AOPL) Emergency Response Work Group's inland SWSR Guide will be a compilation of industry best practices describing initial spill response management and operational tactics in these uniquely challenging conditions. This paper will summarize the API Guide which focuses on the highest priorities of spill response including people, environment, and assets. The intended audience for this paper are responders that have baseline spill response knowledge. Operations managers will be able to use the API Guide to develop timely Incident Command System (ICS) 201 briefs, organizational structures, and Incident Action Plan (IAP) operational work assignments. Safety of responders will be emphasized, particularly site safety, and personal protective equipment (PPE). Site safety and job specific hazard identification best practices will inform responders, managers, and Incident Commanders of the important aspects of overall safety management. Site evaluation topics will cover the following areas: access, staging area, boat launches, shoreline composition, and wildlife considerations. Response strategies involving equipment for containment and recovery will be described for effective SWSR. Additional factors that must be considered include riverbed composition, current velocity, flow pattern, water depth, water course width, and obstructions. There is a limited amount of literature on the unique response techniques of SWSR developed by industry groups or governmental agencies.

Analysis of Psychosocial Hazards Encountered by Responders during an Event or Response that Applies the Incident Command System

Analysis of Psychosocial Hazards Encountered by Responders during an Event or Response that Applies the Incident Command System

Incident Command Futurism

ABSTRACT The availability of integrated remote sensing platforms and digital data collection and sharing tools is changing spill response. These tools facilitate a more effective and rapid decision-making process that can increase resource protection, improve responder safety, and reduce response costs. Early detection and response are a key to preventing smaller incidents from becoming larger. A variety of innovative tools now exist or are in development that could assist facilities and responders in the early stages and throughout an incident event to reduce human, environmental, and economic impacts. Real time field data collection for key parameters such as oil thickness and trajectory, SCAT data, oiled wildlife details, and resources at risk identification, allows for more robust data to be shared rapidly throughout the response operation. This information facilitates more effectively targeted deployment and re-deployment of human and mechanical response assets, and more immediate assessment of both environmental impacts and cleanup progress. Auto-population of incident command system forms as well as better document sharing and document retention through remote and cloud-based file saving platforms can improve the administrative and functional aspects of the response, contributing to enhanced efficiency. The ability to identify and effectively respond to rapidly changing circumstances provides the Unified Command with new tools to make better decisions and keep the public informed of progress. This paper considers new and emerging technologies as they may be applied to the work in a unified command setting, and how they may allow us to compress the operational period for decision-making and action, more accurately and more rapidly understand and share the spill response status, and how we may be able to enhance responder safety and recognize cost savings. We also consider some inherent risks associated with reliance on integrated technologies and digital information and will offer suggestions for drills and exercises to test and optimize these tools.

Current and Proposed Efforts to Resolve HSPD-5 and NCP Authorities (NIC and PFO)

ABSTRACT During the evening of 20 April, 2010 U.S. Coast Guard District Eight Command Center watch standers received a report of an explosion aboard the Deepwater Horizon (DWH), an oil rig working on the Macondo oil well approximately 42 miles Southeast of Venice, LA (OSC Report, 2011). The explosion on board the DWH and resulting fires eventually destroyed the oil rig and caused it to sink into the Gulf of Mexico. Eleven crewmembers lost their lives in the tragic events that unfolded that night, and one of the nation's largest environmental disasters would soon follow. Estimates of the oil discharged from the Macondo oil well were between 12,000 and 25,000 barrels per day, and the response involved approximately 47,000 oil spill response personnel, 6,870 vessels, approximately 4.12 million feet of boom, and 17,500 National Guard personnel, five states (OSC Report, 2011). The massive oil spill lasted 87 days and estimates suggest that more than 200 million gallons of oil was discharged into the Gulf of Mexico, which stands as the largest oil spill event in U.S. history. From these massive response operations came important lessons learned for SONS event planning, preparedness, and response, as it became apparent during DWH response operations that oil spill response governance and doctrine was not well understood across the whole-of-government. This issue was well documented in the National Incident Commander's report and several recommendations were identified to address this issue. This paper will explore the steps taken within the U.S. Coast Guard's (USCG) SONS Exercise and Training Program to promote a better understanding of oil spill response governance and doctrine among Cabinet-level senior leadership and the interagency representatives that will ultimately be involved when the next SONS event happens.

Communicating Internally and Externally during a Response: Life's Lessons Over 32+ years…

ABSTRACT The author has served over 32 years with the National Oceanic and Atmospheric Administration (NOAA) first in the role of Scientific Support Coordinator (SSC) for 28 years and then as a supervisor of SSCs for five years. During this period, he participation in hundreds of actual emergency response events and exercises. He had numerous opportunities to witness both effective and not-so-effective methods of communicating, within a command post situation with other responders and incident command staff, and externally with the general public and media. The effective delivery of a message is greatly affected by circumstances under which you are operating, with whom you are talking, the information or message you are conveying, and the situation surrounding the event. Over many years, the author has gained practical experience through a variety of learning opportunities including professional development programs and on-the-job. His insights on effective communications are provided in this paper to show how messages can be delivered effectively, heard clearly and understood. Practical “tips,” best practices, anecdotes, and concrete examples will be shared to help ensure your message is heard and understood. The author provides examples drawn from actual incidents including the Deepwater Horizon, MT Heibi Spirit, TS Athos I, as well as exercises including PREPs, EcoCanal, and SONS. In addition to these incidents, exercises and drills, the author has continued to expand his knowledge through classes presented by leading subject matter experts involved with the Alan Alda Center for Communicating Science, National Academy of Science, US Coast Guard, and NOAA.

Incorporating wildlife effectively into oil spill exercises – An Australian Story

Australia holds regular National oil spill exercises through the National Plan for Maritime Emergencies. Two National Plan exercise activities that have taken place include Exercise Northerly held in Darwin (Northern Territory) in 2014 and Exercise Torres focussed on the Torres Straits (Queensland) in 2018. The overall aim of the two exercises were to implement and review the effectiveness of a combined Commonwealth (Federal), Territory/State and industry marine pollution response to a Level 3 pollution incident. Both Exercise Northerly and Exercise Torres included oiled wildlife response actions to practice and test. Exercise Northerly for wildlife was principally a desk top activity that included a number of injects relating to wildlife threatened and impacted by an oil spill event. Wildlife considered in Northerly included cetaceans, dugong, marine reptiles and seabirds. The key wildlife objectives for Northerly were to establish and maintain a wildlife Incident Management Team under the broader Incident Command structure and develop wildlife incident action plans for hazing wildlife and responding to oil impacted wildlife. Exercise Torres incorporated both planning and field based operational activities and considered cetaceans, dugong, marine reptiles and seabirds both threatened and impacted by oil pollution. Wildlife planning during exercise Torres was principally held in Cairns at the established Incident Control Centre where incident action plans were developed to haze oil threatened wildlife, collect oiled impacted wildlife and then rehabilitate wildlife considering the strict quarantine restrictions imposed on wildlife movements through and out of the Torres Strait Protection Zone. The field deployment activities for Torres were then managed and undertaken through a forward operations base established on Waiben Island, some 800 kilometres or 500 miles north of Cairns that borders Papua New Guinea. The wildlife field teams were required to establish an oiled wildlife response centre making it fully operational with pre-deployed equipment, manage responder safety for actual dangerous wildlife in the area, respond to reports of impacted wildlife, transport impacted mock wildlife through the different contaminant hazard zones (i.e. hot, warm and cold zones) and then to the wildlife care centre, undertake wildlife assessment using narrative techniques, triage wildlife based on provided wildlife assessment data, decontaminate mock wildlife and then provide basic wildlife rehabilitation practices. Both of the National exercises provided effective opportunities to practice the skills necessary to support oiled wildlife response actions and to identify key learnings for better practices when responding to oiled wildlife threatened and impacted in remote areas.

Geographic Response Strategies on Canada's West Coast

Abstract In 2012, Western Canada Marine Response Corporation (WCMRC) began developing site specific shoreline protection strategies, known at Geographic Response Strategies (GRS) for the entire coast of British Columbia (B.C.). The project started in Vancouver Harbour and has since spread along the Salish Sea and Strait of Juan de Fuca, as well as into Prince Rupert and Kitimat on the northern B.C. coast. Recognizing that B.C. has approximately 27,000 km of coastline (~16,777 miles) and with 450 strategies already developed only within a few hundred kilometres, WCMRC saw a need to automate the GRS development process from data collection all the way to the final GRS output. In conjunction with a local environmental consulting company, WCMRC developed a new sensitivity model. This new model can help the Response Readiness Team quickly assess intertidal sensitivity to oiling based on shoreline type, oil residency index, biological, archaeological, and/or socio-economic features of the shoreline, as well as operational protection feasibility. Now, using ESRI GIS web tools, a GRS can be developed automatically as a geo-referenced PDF, easily exportable to mobile devices for operational use. Overall, the automated enhancements have provided WCMRC with the tools necessary to manage the GRS program for B.C.'s entire coast. This means that more coastline can be assessed far more quickly and GRS's can be developed using fewer human resources. Additionally, if a spill occurs in a more remote area that has not yet had GRS's developed, they can be created within minutes based on the information from the Environment Unit in the Incident Command Post, or initial assessments by responders.

The SONS Money Tale: From Exxon Valdez to Deepwater Horizon to ??

Synopsis SONS (Spill of National Significance) have been extensively studied from multiple perspectives. In the realm of the Incident Command Structure (ICS) there have been numerous Operations, Planning, and Logistics examinations, reviews, and recommendations. The fourth ICS node – Finance – has seen little such scrutiny or review. This paper, written by two individuals at the heart of each respective response, will address that gap and identify the problems that arose, were solved, or remain problematic for the next SONS that occurs in the United States. Each spill posed different problems, driven by statute, prior experience, fiscal systems, and the expectations of outside stakeholders. The paper will examine the following dimensions. 1) The available fund balance at the start of the response, and how the fund could be replenished under existing statute.2) The financial role taken by the spillers/responsible parties.3) The mechanisms to provide response funding to the FOSC during the incident.4) Funding National Contingency Plan participants (Federal, State, Local) supporting the FOSC response.5) Funding Trustee led natural resource damage assessments and damage restoration plans during and after the response concluded.6) Payment of claims to injured third parties.7) Billing the spillers/responsible parties for the incident costs and the disposition of the resulting payments. The paper will conclude with an examination of the financial issues that remain and will probably arise for the next SONS. It will summarize possible solutions, reflecting when appropriate a number of legislative changes that have been proposed by various parties.

Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic.

The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic. We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates. U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data. None. Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients. The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.

A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part I: System Planning and Care Teams

Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. Results: Over 2100 patients were successfully admitted to system hospitals; 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. Conclusions: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic.

All Hands on Deck: Local Public Health Agencies Leveraging the Incident Command System During Crises

The COVID-19 pandemic has stretched limited public health resources beyond measures, particularly at the local level. What started as an interesting report of pneumonia of unknown etiology in late December 2019 in Wuhan, China, bloomed into an international crisis by mid-January 2020. However, it was not until late January, when the first case was reported in the United States, that a new reality took shape for US public health agencies. After all, severe acute respiratory syndrome never made it to this country, and the only 2 cases of Middle East respiratory syndrome here were imported and never spread. Local public health agencies are notoriously short-staffed and underfunded. Therefore, when a crisis looms, personnel from a multitude of areas within the agencies are called upon to help out. Under its innovative and forward-thinking leadership, the St. Louis County Department of Health internally implemented the Incident Command System, a component of the National Incident Management System. While reassignment of individuals to new responsibilities under a new and temporary reporting structure did not always go perfectly, Incident Command System kept its promise to be adaptable to a fast-evolving situation, to clearly outline needed areas of responsibility, and to provide scaffolding that kept the Department of Health functional in chaotic times. It was able to be implemented quickly within hours of the first confirmed COVID-19 case in St. Louis County and enhanced the quality and timeliness of the public health response. This experience is being shared to provide a model of how organizations with limited personnel can use the Incident Command System to reorganize and meet unexpected challenges with increased success.

Knowledge of Nurses in Hospital Preparedness in Emergency Response in Saudi Arabia: Basis for Staff Program Development

Objective: The study assessed the level of knowledge of nurses in hospital emergency response based on WHO standard and determine what staff program development may propose to enhance the knowledge of nurses in hospital emergency response. Methods: The study utilized quantitative type of research and used the descriptive evaluative design. Results: Results of the study revealed that respondents are knowledgeable in 2 categories of hospital preparedness in emergency response, the safety and security (WM=2.5443, SD=.13295)) during MCI and the human resource during MCI (WM=2.9266, SD= .13901). Conclusion: With the findings of the study the respondents need to have more training related to hospital preparedness in emergency response. The training should focus on incident command system, communication, triage during MCI, surge capacity during MCI, continuity of essential service, logistics and supply and post disaster recovery. The training should situate the Health Emergency Response Recovery Plan (HERRP) and policy of hospital, covering all-hazard approach based on their risk assessment.

Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers.

BackgroundPublic Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.ObjectiveThis scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.MethodsA systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.ResultsThe initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.ConclusionPublic safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.

Rapid Scale-up of an Antiretroviral Therapy Program Before and During the COVID-19 Pandemic - Nine States, Nigeria, March 31, 2019-September 30, 2020.

In 2018, an estimated 1.8 million persons living in Nigeria had HIV infection (1.3% of the total population), including 1.1 million (64%) who were receiving antiretroviral therapy (ART) (1). Effective ART reduces morbidity and mortality rates among persons with HIV infection and prevents HIV transmission once viral load is suppressed to undetectable levels (2,3). In April 2019, through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR),* CDC launched an 18-month ART Surge program in nine Nigerian states to rapidly increase the number of persons with HIV infection receiving ART. CDC analyzed programmatic data gathered during March 31, 2019-September 30, 2020, to describe the ART Surge program's progress on case finding, ART initiation, patient retention, and ART Surge program growth. Overall, the weekly number of newly identified persons with HIV infection who initiated ART increased approximately eightfold, from 587 (week ending May 4, 2019) to 5,329 (week ending September 26, 2020). The ART Surge program resulted in 208,202 more HIV-infected persons receiving PEPFAR-supported ART despite the COVID-19 pandemic (97,387 more persons during March 31, 2019-March 31, 2020 and an additional 110,815 persons during April 2020-September 2020). Comprehensive, data-guided, locally adapted interventions and the use of incident command structures can help increase the number of persons with HIV infection who receive ART, reducing HIV-related morbidity and mortality as well as decreasing HIV transmission.

Integrating the Food and Drug Administration Office of the Coordinated Outbreak Response and Evaluation Network's foodborne illness outbreak surveillance and response activities with principles of the National Incident Management System.

The Food Safety Modernization Act mandates building a national Integrated Food Safety System, which represents a seamless partnership among federal, state, local, territorial, and tribal agencies. During multistate foodborne illness outbreak investigations, local and state partners, the Centers for Disease Control and Prevention, the United States Food and Drug Administration (FDA), or the United States Department of Agriculture Food Safety Inspection Service, depending on the regulated food product, become engaged and assist in coordinating the efforts between partners involved and determine the allocation of resources. The FDA Center for Food Safety and Applied Nutrition (CFSAN) Office of the Coordinated Outbreak Response and Evaluation (CORE) Network coordinates foodborne illness outbreak surveillance, response, and post-response activities related to incidents involving multiple illnesses linked to FDA-regulated human food, dietary supplements, and cosmetic products. FDA has implemented the National Incident Management System (NIMS) Incident Command System (ICS) principles across the agency to coordinate federal response efforts, and CORE has adapted NIMS ICS principles for the emergency management of multistate foodborne illness outbreaks. CORE's implementation of ICS principles has provided several benefits to the operational cycle of foodborne illness outbreak investigations, including establishing a consistent, standardized, and transparent step-by-step approach to outbreak investigations. ICS principles have been instrumental in the development of a national platform for rapid and systematic laboratory, traceback, and epidemiologic information sharing, data analysis, and decision-making. This allows for partners across jurisdictions to reach a consensus regarding outbreak goals and objectives, deploy resources, and take regulatory and public health actions.

Hospital Incident Command System: Preparedness and application for COVID-19 response in California’s Central Valley

This paper describes the types of emergency and disaster events that could potentially impact the healthcare system and the need for healthcare executives to be knowledgeable and able to respond to emergencies quickly and appropriately. It discusses the barriers to the engagement of hospital and healthcare senior executive teams in emergency preparedness activities and proposes a pragmatic approach for the engagement of healthcare executive teams. Drawing on the experience of hospitals in California’s Central Valley, the article hypothesises that a full implementation of this programme would have supported hospital executive teams to provide a more effective and efficient response to the management of COVID-19.

Building on lessons learned: A US Midwest healthcare system’s COVID-19 response

While noting that the COVID-19 pandemic remains ongoing, this paper reviews the incident response at one Midwestern healthcare system in order to identify lessons learned and key modifications to strengthen the response. The paper describes how a strong modified incident command structure provided the framework for the response. These modifications were based on successes during a system-wide electronic medical record implementation and included workgroups specific to a subject or discipline. These workgroups reported up through the traditional hospital incident command structure, allowing for situational awareness at all levels. A solid meeting cadence ensured proper visibility into the work being completed, while a data analyst group provided the much-needed data to make good decisions. Ensuring cross-pollination in the workgroups assisted with communication throughout, while establishing a regular cadence for all staff e-mails and executive updates supported frequent communication and information sharing to all 42,000 employees.

Osteoporosis care amidst the prolonged pandemic.

As SARS-CoV-2 stunned and overtook everyone’s lives, multiple daily briefings, protocols, policies and incident command committees were mobilized to provide frontline staff with the tools, supplies and infrastructure needed to address the COVID-19 pandemic. Medical resources were immediately shifted. In light of the necessity for self-isolation, telemedicine was expanded, although there has been concern than non-pandemic disorders were being ignored. Ambulatory care services such as bone densitometry and osteoporosis centered clinics came to a near halt. Progress with fracture prevention has been challenged. Despite the prolonged pandemic and the consequent sense of exhaustion, we must re-engage with chronic bone health concerns and fracture prevention. Creating triaging systems for bone mineral testing and in person visits, treating individuals designated as high risk of fracture using fracture risk assessment tools such as FRAX, maintaining telemedicine, leveraging other bone health care team members to monitor and care for osteoporotic patients, and re-engaging our primary care colleagues will remain paramount but challenging. The pandemic persists. Thus, we will summarize what we have learned about COVID-19 and bone health and provide a framework for osteoporosis diagnosis, treatment, and follow-up with the extended COVID-19 pandemic. The goal is to preserve bone health, with focused interventions to sustain osteoporosis screening and treatment initiation/maintenance rates.

Advancing ambulatory pharmacy practice through a crisis: Objectives and strategies used in an ambulatory care action team's response to the COVID-19 pandemic.

PurposeThe objectives and strategies used by an ambulatory care action team operating within a large health system’s pharmacy incident command structure during the initial response to the coronavirus disease 2019 (COVID-19) pandemic are discussed.SummaryIn a time of crisis, a pharmacy ambulatory action team was formed to provide ambulatory clinical pharmacy expertise and meet an immediate and ongoing need to limit nonemergent care during the COVID-19 pandemic. By building a strong communication infrastructure and partnership with ambulatory care providers, clinic medical and operational leaderships, clinical laboratory staff, and infusion centers, the team was able to swiftly execute solutions and respond to new issues and requests. Ambulatory care pharmacy practice continued to advance through provision of services to vulnerable patient populations with chronic conditions that were anticipated to experience gaps in care management during the COVID-19 pandemic. These efforts resulted in expansion of pharmacists’ involvement in collaborative drug therapy management, support of patients’ transition from in-clinic injection to home self-administration, provision of medication assistance support, and management of 1,300 patients via protocol-based warfarin management. Additionally, ambulatory pharmacy services in 15 primary care, anticoagulation, and specialty clinic sites were transitioned to telehealth. The ambulatory action team also implemented several strategies to manage medication therapy associated with COVID-19–related shortages and implemented electronic decision support to guide prescribing of hydroxychloroquine and azithromycin.ConclusionBuilding a strong communication infrastructure and a pharmacy ambulatory action team were essential to respond to a crisis and continue ambulatory clinical pharmacy services expansion.