Maintaining comprehensive pharmacy services during a pandemic: Recommendations from a designated COVID-19 facility

In the event of a disaster, pharmacists are capable of undertaking crucial roles in hospitals and health systems, including various actions within the 4 phases of disaster management: prevention/mitigation, preparedness, response, and recovery.1 Previous events have highlighted pharmacists’ endeavors to fulfill needs of their patients, institutions, and communities as part of the disaster medicine response.2-7 The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) is no exception, and it was declared a pandemic by the World Health Organization in March 2020. In addition to infectious risks and a lack of definitive treatment(s) or an approved vaccine, challenges include surges of COVID-19 cases resulting in overwhelmed hospitals, healthcare staffing issues, and critical supply shortages including drugs. Medication management remains an important aspect of care for patients with COVID-19, including management of novel and experimental pharmacologic agents, pharmacotherapy to support life-sustaining and critical care treatments, and drugs needed to treat underlying comorbidities and for chronic disease management. The University Hospital of Brooklyn at SUNY Downstate Health Sciences University, a tertiary care urban academic medical center in Brooklyn, NY, was declared a designated “COVID-19 only” treatment facility by the governor of New York State, the epicenter of the US outbreak. The hospital leadership, department administrators, and frontline staff worked collaboratively in order to prepare for the influx of patients with COVID-19. The department of pharmacy was tasked with devising and implementing a sustainable action plan for continuity of pharmacy services. Herein, we provide recommendations on maintaining comprehensive pharmacy and medication management services during the COVID-19 pandemic. The department of pharmacy should be routinely involved in emergency preparedness and disaster management on the institutional level.8-10 This involvement may include conference calls with the hospital leadership, providers, and administrators of other departments to discuss the evolving COVID-19 situation and/or direct involvement with the hospital incident command system. It is crucial for the department of pharmacy to remain knowledgeable of hospital plans as they are being deliberated, including plans for bed management, opening of treatment areas, conversion of critical care units, and the disposition/transfer processs. This knowledge will provide advance notice to deploy resources timely and efficiently. Examples include modifying medication inventory in preexisting automated dispensing cabinets (ADCs) to match the needs of the patient population, redistributing or adding emergency supplies such as crash carts and intubation trays to more acute care units, and reallocating clinical services to accommodate areas of highest need. During these communications, the department of pharmacy should have a venue to regularly report on specific changes or trends in medication usage during the COVID-19 pandemic, clinical guidelines, staffing plans, and updates on critical drug shortages and inventory management. As the circumstances unfold and develop, the department of pharmacy should concomitantly be creating plans for eventual recovery and plans to be implemented in the event of a potential resurgence, with delineation of action items and responsible personnel. The specifics of these plans may be modified as a result of additional hospital plans, new clinical information, changes in resource allocation, and lessons learned. A surge of patients with COVID-19 is expected to correlate with increased needs for operational pharmacy services. As such, medication dispensing functions must be maintained, and available automation resources should be a focus of optimization. For institutions with ADCs, more rapid turnover of supply and higher incidences of stock-outs can be expected; thus, it is prudent to monitor drug utilization and make real-time adjustments, such as modifying par levels and adding delivery/restocking runs when resources allow. Similarly, the high clinical acuity of some patients with COVID-19 may result in more rapid turnover of emergency supplies, including crash carts, airway/intubation trays, and other institution-specific boxes and kits. Turnover and usage can be tracked manually or with automated kit tracking solutions, if available. The department of pharmacy may need to assess the number of carts and kits that are deployed to patient care areas in conjunction with providers and adjust quantities accordingly. Additional pharmacist, pharmacy intern, and pharmacy technician resources may be required to ensure adequate restocking of depleted emergency equipment items, followed by accurate verification. For institutions that involve multiple departments in restocking crash carts (eg, pharmacy, materials management, and central sterile departments), it may be worth initiating a conversation to agree on the most efficient workflow during the COVID-19 pandemic. Another operational area expected to be impacted is sterile compounding. For institutions that are increasing bed capacity for critically ill and step-down patients with COVID-19, the need for compounded sterile preparations (CSPs) such as continuous-infusion and piggyback medications will likely grow. Inpatients with documented or suspected COVID-19 pneumonia may potentially be instructed to take nothing by mouth for a variety of clinical reasons, further increasing the demand for CSPs. Depending on the sterile compounding workflow and available resources and technology, increasing the batching frequency for non–patient-specific doses of CSPs may be an option to minimize wastage and improve operational efficiency.11,12 Candidates to consider include commonly used critical care medications (eg, vasopressors, sedatives, neuromuscular blocking agents) and antiinfective drugs. Beyond-use dating (BUD) and personal protective equipment (PPE) conservation strategies are also vital considerations during the pandemic. Compliance with the standards set forth in United States Pharmacopeia general chapter 797 (“Pharmaceutical Compounding—Sterile Preparations”)13 should be followed, but pharmacy personnel involved in sterile compounding should remain vigilant of new communications regarding BUD or PPE conservation strategies from USP, their respective state boards of pharmacy, and other regulatory bodies issuing recommendations or waivers during the COVID-19 pandemic. Before implementing changes to sterile compounding procedures, it is important to consult with appropriate bodies and review applicable laws and requirements. Under normal conditions, operational pharmacy personnel are often present on patient care units and nursing stations to deliver, restock, and retrieve medications and medication-related equipment. In order to minimize potential exposures and movement throughout patient care areas, institutions with pneumatic tube delivery systems can utilize them to decrease the number of physical deliveries by sending supply either directly to nursing stations or to the nearest inpatient satellite pharmacy, if applicable; acquisition of additional empty carriers may be considered, depending on the system’s maximum capacity. Staff required to visit patient care or isolation areas should be provided with adequate PPE according to the expected level of exposure and institution-specific guidelines. For medications and medication trays returned from COVID-19 isolation areas, a separate secure location for quarantining of those items for an appropriate period of time before recirculation back into active inventory can be identified. Crash carts returned to the department of pharmacy should be cleaned with approved disinfectants. It may be prudent to agree upon an accepted disinfecting process with individuals who handle and transport crash carts (eg, nursing, security, transport team personnel) and to determine where carts should be located to minimize contamination of carts and their contents, including detailed discussion of cart storage in patient care areas and specific cart placement during an active resuscitation. Clinical pharmacists promote safe and effective medication management in patients with COVID-19, who often have comorbidities in addition to their presenting illness. The pharmacy leadership should collaboratively assess patient care needs with providers and the hospital leadership to develop a plan for continued delivery, allocation, and/or modification of clinical services.14 For example, select specialty services (eg, ambulatory care, hematology/oncology, solid organ transplantation services) may temporarily decrease their census or not be accepting new patients. If eligible, clinical pharmacists specializing in those areas may be reassigned to inpatient teams caring for patients with COVID-19 but should still maintain involvement and open communication with providers from their specialty-specific service lines. Expansion of critical care and emergency medicine treatment areas may warrant additional clinical pharmacy services to assist in managing increased patient volume and/or acuity to positively impact clinical outcomes.15,16 Clinical pharmacists in other specialties who may have prior critical care or emergency medicine training or experience can be called upon to provide extra coverage and support. Pharmacy extenders can play an important role in ensuring continuity of pharmacy services. Pharmacy residents who are licensed as pharmacists have the ability to function independently and assume clinical and operational responsibilities in tandem with their preceptors, allowing more widespread coverage and pharmacotherapy oversight for a greater number of patients. Residency program leaders can consider switching residents out of or postponing non–direct patient care learning experiences during the COVID-19 pandemic. Program directors and credentialed preceptors should still remain cognizant of requirements and competency areas, goals, and objectives to ensure pharmacy residents remain on track for timely residency completion. Another important area of consideration for residency program leadership is the potential impact of disaster management on resident stress levels, burnout risk, and other professional and personal obligations.17 Tactics such as improved planning, scheduling, communication, and utilization of resources should be discussed. If the experiential site and affiliated college of pharmacy have allowed for ongoing student experiences, pharmacy students can be incorporated into the department of pharmacy and provide supplementary services. With proper oversight from preceptors, pharmacy students may assist in executing clinical activities such as obtaining best possible medication histories, managing drug information inquiries, conducting follow-up telephone calls with discharged patients, and delivering educational presentations regarding treatment options and supportive care for COVID-19. Resourcewise, it may not be possible for every medical team or service to have dedicated clinical pharmacy coverage; this highlights the importance of collaboratively discussing which targeted services (eg, antimicrobial stewardship, medication profile review, review of high-risk medications, therapeutic drug monitoring) can be feasibly delivered. An additional approach could be to leverage “pharmacy acuity” (medication regimen complexity) scoring tools to prioritize patient care needs, if the institution’s electronic medical record (EMR) and/or clinical decision support software possess those capabilities.18,19 Depending on the institution’s pharmacy practice model, clinical pharmacists and pharmacy residents can participate in decentralized order verification to provide comprehensive pharmaceutical care and to facilitate operations of the department of pharmacy. In regards to emergency response, there is expected to be an increased number of cardiac arrests, respiratory arrests, code stroke alerts, and other rapid response calls during a COVID-19 case surge. Regardless of whether the institution already deploys pharmacists to participate in these events, it is worthwhile to discuss or revisit expectations with resuscitation committees and teams. Points of discussion may include feasibility and consistency of pharmacist emergency response coverage, staffing requirements, concomitant operational and clinical patient care responsibilities, staff protection and exposure, and preservation of PPE. Clinical pharmacists should be participating in guideline development in partnership with providers and content experts for management of COVID-19 and associated manifestations, as well as development of guidelines for use of therapeutic alternatives and usage restrictions during critical drug shortages. A major challenge is being able to manage the amount of knowledge and literature released regarding SARS-CoV-2 infection and pharmacotherapies, including novel treatment approaches and repurposing of older medications. Since the beginning of the pandemic, emerging clinical manifestations and additional disease complications have been discovered in pediatric and adult patients, which will affect treatment options. Moreover, in the highest-acuity patients, various other factors, such as multiorgan dysfunction, pharmacokinetic and pharmacodynamic changes, use of extracorporeal therapies, and underlying comorbidities, need to be considered, further impacting treatment criteria and complicating drug selection. A proactive approach involves staying abreast of newly released literature, assessing evidence with a hospital-designated multidisciplinary team or workgroup, forming new or modifying existing treatment recommendations, developing consultation and/or approval processes for specific pharmacologic agents, and disseminating timely information and education to healthcare staff. This process of multidisciplinary evaluation, discussion, and decision-making is of extreme importance to maintain and promote safe and cost-conscious medication usage.20 As the demand for experimental COVID-19 treatments and medications necessary to support life-sustaining therapies skyrockets, drug supply chains will become strained.21 This disruption may include suppliers, manufacturers, and wholesale distributors. Drug shortages add further layers of complexity to medication management during a public health crisis.22 Critical drugs that have already been impacted include opioids, sedatives, vasopressors, neuromuscular blocking agents, respiratory agents and inhalers, and numerous antiinfectives; experimental COVID-19–targeted agents have also been impacted. On an institutional the department of pharmacy should with the pharmacy and providers, clinical content and other to timely drug For example, use of and agents can be to potentially minimize the need for of opioids, sedatives, and neuromuscular blocking agents can be in to as a conservation if for critical drug recommendations may include approved restrictions and/or pharmacotherapy if and supply should remain in with wholesale to determine allocation, and the of The department of pharmacy may also consider to and to directly emergency a with of and information for use may to be when additional drug shortages or in the event of a of COVID-19 Another approach is to with state and healthcare and to the state to of available quantities of critical medications from the to a department of additional the supply team and/or other designated individuals should be tasked with accurate inventory of critical medications on at a In they should remain cognizant of patient care or areas, as well as specialty services with a as those areas and services may have supplies of necessary drugs that can be and to As medication management is crucial for the care of patients with COVID-19, pharmacists with in clinical can play a role in emergency preparedness by their knowledge of pharmacy medication health information technology, and clinical information actions involve of the to with and order may be to medication for providers caring for patients with COVID-19. For knowledge delivery, order and clinical decision support systems can be modified to and drug and appropriate During drug the department of pharmacy may medications from a new new or or pharmacologic If the institution and/or medication technology, pharmacy should ensure that the will Drug that it to accurate and safe medication In the of lack of evidence from hospitals and health systems may to and institution-specific to COVID-19 areas of further or determine if changes in treatment are Pharmacy and pharmacy residents can be part of a multidisciplinary team or to assist with usage of and recommendations for process and potential of or to to the medical If the hospital or health is participating in of experimental therapies for COVID-19, pharmacy may need to with to develop an efficient process for drug and implementing workflow changes and modifying existing the department of pharmacy should make an to to activities for process The leadership may or to information specific to disaster management during the COVID-19 pandemic. from activities such as emergency response and code cart order sterile drug turnover and medication regimen complexity clinical and will be in staffing and reallocating operational or clinical resources if of the and can be to monitor and to for therapeutic usage for inventory management, and for the management of patients with COVID-19 can also be tracked to real-time for and the hospital leadership to maintain of pharmacy personnel are for and timely pharmaceutical care during the COVID-19 pandemic. it is to provide knowledge and resources necessary for staff and protection during of patient care Staff education regarding institutional should be implemented as as this personnel proper and other infection recommendations, and of and PPE conservation as well as that specific of PPE. The staff should be provided with by the institution’s resources health services and/or the department of health regarding and potential exposure, and In of conference calls and may become the of disseminating information and clinical updates in a timely Pharmacy department leaders can consider these at that staff can plan with additional as may need to be or to ensure that and areas are The of communication may with the institution’s or The use of secure software can be to promote team communication and patient for care and to of new communication the department of pharmacy should assess whether software are with Health and and requirements. 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