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COMMENTARY
Maintaining comprehensive pharmacy services during Downloaded from https://academic.oup.com/ajhp/article-abstract/doi/10.1093/ajhp/zxaa194/5857206 by Biblioteca Nacional de Salud y Seguridad social user on 09 July 2020
a pandemic: recommendations from a designated
COVID-19 facility
Am J Health-Syst Pharm. 2020; XX:0-0 resulting in overwhelmed hospitals, treatment areas, conversion of critical
Jonathan H. Sin, PharmD, BCPS, healthcare staffing issues, and crit- care units, and the disposition/transfer
Department of Pharmacy, University ical supply shortages including drugs. processs. This knowledge will provide
Hospital of Brooklyn, SUNY Downstate Medication management remains an advance notice to deploy resources
Health Sciences University, Brooklyn, NY
I. Ian Richards, PharmD, Department important aspect of care for patients with timely and efficiently. Examples in-
of Pharmacy, University Hospital of COVID-19, including management of clude modifying medication inventory
Brooklyn, SUNY Downstate Health novel and experimental pharmacologic in preexisting automated dispensing
Sciences University, Brooklyn, NY
Maria S. Ribisi, BS, RPh, CPh, FPE, agents, pharmacotherapy to support life- cabinets (ADCs) to match the needs of
FASCP, Department of Pharmacy, sustaining and critical care treatments, the patient population, redistributing
University Hospital of Brooklyn, SUNY and drugs needed to treat underlying or adding emergency supplies such as
Downstate Health Sciences University, comorbidities and for chronic disease crash carts and intubation trays to more
Brooklyn, NY
management. acute care units, and reallocating clin-
Address correspondence to Dr. Sin The University Hospital of Brooklyn ical services to accommodate areas of
(jonathan.sin@downstate.edu). at SUNY Downstate Health Sciences highest need.
University, a tertiary care urban aca- During these communications, the
Keywords: clinical pharmacy demic medical center in Brooklyn, NY, department of pharmacy should have
services, COVID-19 pandemic, disaster
medicine, emergency preparedness, was declared a designated “COVID-19 a venue to regularly report on specific
hospital pharmacy services, pharmacy -
administration only” treatment facility by the gov changes or trends in medication usage
ernor of New York State, the epicenter during the COVID-19 pandemic, clinical
of the US outbreak. The hospital lead- guidelines, staffing plans, and updates
© American Society of Health-System ership, department administrators, and on critical drug shortages and inven-
Pharmacists 2020. All rights reserved.
For permissions, please e-mail: journals. frontline staff worked collaboratively tory management. As the circumstances
permissions@oup.com. in order to prepare for the influx of pa- unfold and develop, the department of
DOI 10.1093/ajhp/zxaa194 tients with COVID-19. The department pharmacy should concomitantly be cre-
of pharmacy was tasked with devising ating plans for eventual recovery and
and implementing a sustainable action plans to be implemented in the event
plan for continuity of pharmacy services. of a potential resurgence, with delin-
n the event of a disaster, pharmacists are Herein, we provide recommendations on eation of action items and responsible
Icapable of undertaking crucial roles in maintaining comprehensive pharmacy personnel. The specifics of these plans
hospitals and health systems, including and medication management services may be modified as a result of additional
various actions within the 4 phases of during the COVID-19 pandemic. hospital plans, new clinical information,
Emergency preparedness and -
disaster management: prevention/miti changes in resource allocation, and les
-
gation, preparedness, response, and disaster management. The depart- sons learned.
1 ment of pharmacy should be routinely Operational pharmacy services.
recovery. Previous events have high-
lighted pharmacists’ endeavors to ful- involved in emergency preparedness A surge of patients with COVID-19 is ex-
fill needs of their patients, institutions, and disaster management on the insti- pected to correlate with increased needs
8-10
and communities as part of the disaster tutional level. This involvement may for operational pharmacy services. As
2-7 -
medicine response. The rapid spread include conference calls with the hos such, medication dispensing functions
pital leadership, providers, and admin- -
of severe acute respiratory syndrome must be maintained, and available auto
coronavirus 2 (SARS-CoV-2) and coro- istrators of other departments to discuss mation resources should be a focus
navirus disease 2019 (COVID-19) is no the evolving COVID-19 situation and/ of optimization. For institutions with
- or direct involvement with the hospital ADCs, more rapid turnover of supply
exception, and it was declared a pan
demic by the World Health Organization incident command system. It is crucial and higher incidences of stock-outs
in March 2020. In addition to infectious for the department of pharmacy to re- can be expected; thus, it is prudent to
risks and a lack of definitive treatment(s) main knowledgeable of hospital plans monitor drug utilization and make real-
or an approved vaccine, challenges as they are being deliberated, including time adjustments, such as modifying par
include surges of COVID-19 cases plans for bed management, opening of levels and adding delivery/restocking
AM J HEALTH-SYST PHARM | VOLUME XX | NUMBER XX | XXXX XX, 2020 1
COMMENTARY GUIDANCE FROM A ‘COVID-19 ONLY’ FACILITY
13
runs when resources allow. Similarly, Compounding—Sterile Preparations”) Clinical pharmacy services.
the high clinical acuity of some pa- - Clinical pharmacists promote safe and Downloaded from https://academic.oup.com/ajhp/article-abstract/doi/10.1093/ajhp/zxaa194/5857206 by Biblioteca Nacional de Salud y Seguridad social user on 09 July 2020
should be followed, but pharmacy per
tients with COVID-19 may result in more sonnel involved in sterile compounding effective medication management in
rapid turnover of emergency supplies, should remain vigilant of new communi- patients with COVID-19, who often
including crash carts, airway/intub have comorbidities in addition to their
- cations regarding BUD or PPE conserva-
ation trays, and other institution-specific tion strategies from USP, their respective presenting illness. The pharmacy lead-
boxes and kits. Turnover and usage can state boards of pharmacy, and other ership should collaboratively assess pa-
be tracked manually or with automated regulatory bodies issuing recommenda- tient care needs with providers and the
kit tracking solutions, if available. The tions or waivers during the COVID-19 hospital leadership to develop a plan
department of pharmacy may need pandemic. Before implementing changes for continued delivery, allocation, and/
to assess the number of carts and kits to sterile compounding procedures, it is or modification of clinical services.14 For
that are deployed to patient care areas important to consult with appropriate example, select specialty services (eg,
in conjunction with providers and ad- bodies and review applicable laws and ambulatory care, hematology/oncology,
just quantities accordingly. Additional requirements. solid organ transplantation services)
pharmacist, pharmacy intern, and phar may temporarily decrease their census
- -
Under normal conditions, oper
macy technician resources may be re- ational pharmacy personnel are often or not be accepting new patients. If eli-
quired to ensure adequate restocking of present on patient care units and gible, clinical pharmacists specializing
depleted emergency equipment items, nursing stations to deliver, restock, and in those areas may be reassigned to in-
followed by accurate verification. For retrieve medications and medication- patient teams caring for patients with
institutions that involve multiple de COVID-19 but should still maintain
- related equipment. In order to minimize
partments in restocking crash carts (eg, potential exposures and movement involvement and open communica-
pharmacy, materials management, and - tion with providers from their specialty-
central sterile departments), it may be throughout patient care areas, insti specific service lines. Expansion of
worth initiating a conversation to agree tutions with pneumatic tube delivery critical care and emergency medicine
on the most efficient workflow during systems can utilize them to decrease treatment areas may warrant additional
the COVID-19 pandemic. the number of physical deliveries by clinical pharmacy services to assist in
Another operational area expected sending supply either directly to nursing managing increased patient volume
-
to be impacted is sterile compounding. stations or to the nearest inpatient satel and/or acuity to positively impact clin
lite pharmacy, if applicable; acquisition -
For institutions that are increasing bed ical outcomes.15,16 Clinical pharmacists
capacity for critically ill and step-down of additional empty carriers may be con- in other specialties who may have prior
patients with COVID-19, the need for com sidered, depending on the system’s max- critical care or emergency medicine
- imum capacity. Staff required to visit
pounded sterile preparations (CSPs) such patient care or isolation areas should be training or experience can be called
as continuous-infusion and piggyback provided with adequate PPE according upon to provide extra coverage and
medications will likely grow. Inpatients to the expected level of exposure and support.
with documented or suspected COVID-19 Pharmacy extenders can play an im-
-
pneumonia may potentially be instructed institution-specific guidelines. For medi portant role in ensuring continuity of
to take nothing by mouth for a variety of cations and medication trays returned pharmacy services. Pharmacy residents
-
clinical reasons, further increasing the de- from COVID-19 isolation areas, a sep who are licensed as pharmacists have the
arate secure location for quarantining of ability to function independently and as
mand for CSPs. Depending on the sterile -
compounding workflow and available those items for an appropriate period of sume clinical and operational responsi-
resources and technology, increasing time before recirculation back into active bilities in tandem with their preceptors,
the batching frequency for non–patient- inventory can be identified. Crash carts allowing more widespread coverage and
specific doses of CSPs may be an option returned to the department of pharmacy pharmacotherapy oversight for a greater
to minimize wastage and improve oper should be cleaned with approved disin- number of patients. Residency program
-
11,12 fectants. It may be prudent to agree upon leaders can consider switching residents
ational efficiency. Candidates to con-
sider include commonly used critical care an accepted disinfecting process with out of or postponing non–direct patient
medications (eg, vasopressors, sedatives, individuals who handle and transport care learning experiences during the
-
neuromuscular blocking agents) and crash carts (eg, nursing, security, trans COVID-19 pandemic. Program directors
antiinfective drugs. Beyond-use dating port team personnel) and to determine and credentialed preceptors should still
(BUD) and personal protective equip where carts should be located to min- remain cognizant of requirements and
-
ment (PPE) conservation strategies are imize contamination of carts and their competency areas, goals, and objectives
also vital considerations during the pan- contents, including detailed discussion to ensure pharmacy residents remain on
demic. Compliance with the standards of cart storage in patient care areas and track for timely residency completion.
set forth in United States Pharmacopeia specific cart placement during an active Another important area of consideration
general chapter 797 (“Pharmaceutical resuscitation. for residency program leadership is the
2 AM J HEALTH-SYST PHARM | VOLUME XX | NUMBER XX | XXXX XX, 2020
GUIDANCE FROM A ‘COVID-19 ONLY’ FACILITY COMMENTARY
Points of discussion may include feasi 21
potential impact of disaster manage- - strained. This disruption may include
ment on resident stress levels, burnout bility and consistency of pharmacist suppliers, manufacturers, and wholesale Downloaded from https://academic.oup.com/ajhp/article-abstract/doi/10.1093/ajhp/zxaa194/5857206 by Biblioteca Nacional de Salud y Seguridad social user on 09 July 2020
risk, and other professional and personal emergency response coverage, staffing distributors. Drug shortages add further
obligations.17 Tactics such as improved requirements, concomitant operational layers of complexity to medication man-
planning, scheduling, communication, and clinical patient care responsibilities, 22
agement during a public health crisis.
and utilization of resources should be staff protection and exposure, and pres
- Critical drugs that have already been im-
discussed. If the experiential site and ervation of PPE. pacted include opioids, sedatives, vaso-
affiliated college of pharmacy have al- Clinical pharmacists should be pressors, neuromuscular blocking agents,
participating in guideline develop
lowed for ongoing student experiences, - respiratory agents and inhalers, and
pharmacy students can be incorporated ment in partnership with providers numerous antiinfectives; experimental
into the department of pharmacy and and content experts for management COVID-19–targeted agents have also been
provide supplementary services. With of COVID-19 and associated mani impacted. On an institutional level, the
-
proper oversight from preceptors, phar department of pharmacy should collab
- festations, as well as development of -
macy students may assist in executing guidelines for use of therapeutic alter- orate with the pharmacy and therapeutics
clinical activities such as obtaining natives and usage restrictions during committee, providers, clinical content
best possible medication histories, experts, and other stakeholders to dis
critical drug shortages. A major chal- -
managing drug information inquiries, lenge is being able to manage the seminate timely drug shortage communi-
conducting follow-up telephone calls amount of knowledge and literature cations. For example, use of oral opioids
with discharged patients, and delivering released regarding SARS-CoV-2 infec
- and adjunct sedative-analgesic agents
educational presentations regarding tion and pharmacotherapies, including can be promoted to potentially minimize
treatment options and supportive care novel treatment approaches and repur- the need for intravenous rescue therapy.
for COVID-19. posing of older medications. Since the Intermittent bolus dosing of opioids,
Resourcewise, it may not be possible beginning of the pandemic, emerging sedatives, and neuromuscular blocking
for every medical team or service to have clinical manifestations and additional agents can be considered in preference
dedicated clinical pharmacy coverage; disease complications have been dis to continuous infusion drips as a conser
- -
this highlights the importance of col
- covered in pediatric and adult patients, vation strategy, if clinically appropriate.
laboratively discussing which targeted which will affect treatment options. Guidelines for critical drug shortage re-
services (eg, antimicrobial stewardship, Moreover, in the highest-acuity pa- commendations may include approved
medication profile review, review of tients, various other factors, such as restrictions and/or alternative pharmaco-
high-risk medications, therapeutic drug multiorgan dysfunction, pharmacokin 23
- therapy options, if applicable.
monitoring) can be feasibly delivered. etic and pharmacodynamic changes, Inventory and supply chain man-
An additional approach could be to use of extracorporeal therapies, and agers should remain in constant contact
leverage “pharmacy acuity” (medica- underlying comorbidities, need to be with wholesale distributors to determine
considered, further impacting treat product availability, product allocation,
tion regimen complexity) scoring tools -
to prioritize patient care needs, if the ment criteria and complicating drug se- and the status of incoming shipments.
institution’s electronic medical record lection. A proactive approach involves The department of pharmacy may also
(EMR) and/or clinical decision sup staying abreast of newly released litera consider contacting manufacturers to
- -
port software possess those capabil- ture, assessing evidence with a hospital- obtain personalized availability reports
18,19 and to directly place emergency pur
ities. Depending on the institution’s designated multidisciplinary team or -
pharmacy practice model, clinical workgroup, forming new or modifying chase orders. Keeping a running vendor
pharmacists and pharmacy residents existing treatment recommendations, list with names of representatives and
can participate in decentralized order developing consultation and/or ap contact information for internal use may
-
verification to provide comprehensive proval processes for specific pharma- prove to be beneficial when additional
pharmaceutical care and to facilitate op- cologic agents, and disseminating drug shortages arise or in the event of a
erations of the department of pharmacy. timely information and education to resurgence of COVID-19 cases. Another
In regards to emergency response, there healthcare staff. This process of multi- approach is to collaborate with state
is expected to be an increased number disciplinary evaluation, discussion, and and local healthcare organizations and
of cardiac arrests, respiratory arrests, decision-making is of extreme import advocacy groups to contact the Federal
-
code stroke alerts, and other rapid re- ance to maintain and promote safe and Emergency Management Agency’s state
20 coordinating officers to request imme
sponse calls during a COVID-19 case cost-conscious medication usage. -
surge. Regardless of whether the institu- Drug shortage management. As diate release of available quantities of
tion already deploys pharmacists to par- the demand for experimental COVID-19 critical medications from the Strategic
treatments and medications necessary National Stockpile to a state’s depart
ticipate in these events, it is worthwhile -
to support life-sustaining therapies sky
to discuss or revisit expectations with - ment of health. While seeking additional
resuscitation committees and teams. rockets, drug supply chains will become procurement options, the supply chain
AM J HEALTH-SYST PHARM | VOLUME XX | NUMBER XX | XXXX XX, 2020 3
COMMENTARY GUIDANCE FROM A ‘COVID-19 ONLY’ FACILITY
team and/or other designated indi- are warranted. Pharmacy informaticists, effective, and timely pharmaceutical
viduals should be tasked with keeping pharmacists, and pharmacy residents care during the COVID-19 pandemic. Downloaded from https://academic.oup.com/ajhp/article-abstract/doi/10.1093/ajhp/zxaa194/5857206 by Biblioteca Nacional de Salud y Seguridad social user on 09 July 2020
accurate inventory counts of critical can be part of a multidisciplinary re- Thus, it is key to provide knowledge
medications on at least a daily basis. In search team or task force to assist with and resources necessary for staff safety
doing so they should remain cognizant generating usage reports, data collec and protection during performance of
-
of any closed patient care or procedural patient care duties. Staff education re
tion, data analysis, presentation of re- -
areas, as well as any specialty services sults and recommendations for internal garding institutional procedures should
with a significantly reduced census, as process improvement, and potential be implemented as soon as possible;
those areas and services may have sup- submission of abstracts or manuscripts this includes educating personnel about
to contribute to the medical litera proper hand hygiene and other infection
plies of necessary drugs that can be cen- -
control strategies, social distancing re
tralized and subsequently redistributed ture. If the hospital or health system is -
to higher-need areas. participating in randomized trials of commendations, removal and disposal
experimental therapies for COVID-19, of PPE, and hospital-approved PPE con
Pharmacy informatics and data -
management. pharmacy informaticists may need to
As medication man- servation measures, as well as outlining
agement is crucial for the care of pa- collaborate with investigators to develop scenarios that require specific types of
tients with COVID-19, pharmacists with an efficient process for randomization PPE. The staff should be provided with
expertise in clinical informatics can play notification, investigational drug or official procedures developed by the
-
a substantial role in emergency pre institution’s human resources depart
- dering, and documentation. -
paredness by applying their knowledge When implementing workflow ment, employee health services per-
of pharmacy practice, medication safety, changes and modifying existing pro
- sonnel, and/or the department of health
health information technology, and clin
- cesses, the department of pharmacy regarding asymptomatic and symp-
24 should make an effort to analyze data to
ical information systems. Immediate tomatic employees, potential exposure,
actions involve customized mainten trend activities for continuous process testing availability, and return-to-work
-
improvement. The departmental leader procedures.
ance of the EMR to align with clinician -
needs. Custom ordering templates and ship may modify dashboards or “score- In lieu of in-person meetings, con-
order sets may be built to simplify medi ference calls and virtual huddles may
- cards” to integrate information specific
cation selection for providers caring for to disaster management during the become the preferred method of dis-
patients with COVID-19. For knowledge COVID-19 pandemic. Information gen- seminating information and clinical
delivery, computerized prescriber order erated from activities such as emergency updates in a timely fashion. Pharmacy
entry and clinical decision support sys response and code cart exchanges, department leaders can consider sched
- -
tems can be modified to proactively and order verification, sterile compounding, uling these sessions at routine intervals
interactively highlight drug shortages, drug procurement, ADC turnover and so that staff members can plan appropri-
current restrictions, and appropriate stock-outs, medication regimen com
- ately, with additional ad hoc meetings
alternatives. plexity scoring, clinical interventions, held as needed. Huddles may need to
During disaster-related drug short and safety incidents will be valuable be repeated or recorded to ensure that
-
in optimizing staffing and reallocating all shifts and departmental areas are in
ages, the department of pharmacy may -
receive medications from a new manu operational or clinical resources if
- cluded. The choice of communication
26,27
facturer, new dosage forms or volumes, necessary. platform may vary with the institution’s
or alternative pharmacologic agents. If Functionalities of the EMR and or department’s subscription offerings.
the institution utilizes barcode-assisted business analytics can be leveraged The use of secure messaging software
and/or knowledge-based medication to monitor and trend prescribing pat can be optimized to promote team com
- -
administration technology, pharmacy terns to identify opportunities for thera- munication and smooth patient hand-
informaticists should ensure that the peutic interventions, forecast upcoming offs for optimal care coordination and
technology will recognize previously usage for better inventory management, continuity. Prior to implementation of
unencountered National Drug Code and implement cost-avoidance strat new communication platforms, the de
- -
numbers so that it continues to en
- egies. Medications purchased specif- partment of pharmacy should assess
whether software programs are com
able accurate and safe medication ically for the management of patients -
25
administration. with COVID-19 can also be tracked to pliant with Health Insurance Portability
In the setting of lack of evidence from generate real-time budget variance re- and Accountability Act (HIPAA) privacy
randomized controlled trials, hospitals ports for financial stakeholders and the and confidentiality requirements.
and health systems may wish to gather hospital leadership to maintain fiscal In light of the highly contagious na-
and analyze institution-specific data to awareness. ture of SARS-CoV-2, remote work by eli-
validate current COVID-19 protocols, Staff education and team gible pharmacy staff can be explored as a
identify areas of further investigation, management. Department of phar- way to reduce the risk of virus exposure.
or determine if changes in treatment macy personnel are essential for safe, Pharmacists can remotely participate
4 AM J HEALTH-SYST PHARM | VOLUME XX | NUMBER XX | XXXX XX, 2020
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