Pharmacy uses COVID-19 challenges to drive improvements

From aggressive medication purchasing, to telemedicine, to enhanced safety, ‘change is the accepted practice.’

In Pharmacy, COVID-19 has made constant change the norm.

That comes with challenges, and opportunities to reinforce fundamentals of our culture and do things better.

Traditionally, pharmacists have provided expertise on what medications are effective for any given disease state.

With a new disease like COVID-19, pharmacists are on the front lines of learning about treatments while we live through a pandemic.

Over the last few months, Pharmacy has found new ways to support patient care, perfected their internal processes and focused on clear, transparent communication with their teams to drive successfully through change.

“Change is the accepted practice at this point. People are expecting things to change,” says Jimmy Houpt, director of pharmacy operations. “We are using the collective knowledge of our team more effectively and that will help us with other projects."

STAYING ON TOP OF THE CHANGES

Meeting the medication needs of a health system means a lot of preparation. Pharmacy is used to planning, but preparing for a novel disease as we fight it is new territory.

It has meant a lot of moving targets.

“In the beginning with COVID-19, no one knew what drugs you would need,” Houpt says.

With an early focus on COVID-19’s respiratory effects, Pharmacy started this spring by ordering inhalers. Then, it became clear many patients would need critical care. To support that, they ordered extra IV drips of medications like propofol.

Preparing for a surge quickly maxed out the Omnicell system, even after Pharmacy added a second Omnicell. The overflow is now in a “tertiary storage facility”: Houpt’s office.

“We had to get aggressive with purchasing,” Houpt says. “Buying drugs is not an easy feat when everyone is trying to buy the same things at the same time.”

Pharmacy’s drug shortage team has always been focused on pursuing meds that are in high demand. Early on, before experts had a handle on the most effective treatments, the COVID-19 drug shortage list was longer that all the other shortages Pharmacy tracks for the system.

“People were trying everything under the sun,” Houpt says.

At one point, CoxHealth had 20,000 doses of hydroxychloroquine in house. We returned those medications as treatment strategies pivoted in other directions.

In more recent months, the treatments have become clearer. Maintaining a stock of remdesivir and dexamethasone have become the priorities.

Other drugs are in trials, and Pharmacy is striving to stay on top of the recommended changes.

“We constantly have to make sure we have an understanding. People will come up to the pharmacist and want to know what’s next.”

WHAT WE’RE DOING DIFFERENTLY

As the science and guidance for treating COVID-19 continue to evolve, Pharmacy has made major changes to their practice.

While the changes were driven by COVID-19, Houpt says many will last far beyond the pandemic.

A few examples:

Decentralized pharmacists: Pharmacists have always been a part of the care team, and the battle with COVID-19 has made their presence more important than ever.

On any given day, there are 13-15 decentralized pharmacists in patient care units throughout the hospital. Traditionally, they provide medication consults and patient education in the ED and critical care areas.

Now, they are providing key support in our COVID units.

“Pharmacists have worked hard to be part of the care team. When things get tough, that’s the time to step up,” Houpt says.

Pharmacists are on duty seven days a week, stationed inside the units to preserve PPE. Internal medicine pharmacists have also trained alongside critical care pharmacists, as a line of backup in case of illness or a dramatic surge in volume.

Telepharmacy: Typically, pharmacists have provided patient education on new medications and discharge medications at the bedside. Now, they are relying on one of 2020’s most common trends: telemedicine.

Staff in the units are using iPads to connect patients with pharmacists for medication review and counseling.

It’s a move that is keeping patients safe and saving PPE.

It is also more efficient. In the past, decentralized pharmacists did an average of two to three counseling sessions each evening, alongside their other duties. Now, four pharmacists dedicate a block of time to meet with patients remotely. They are seeing 7-11 education sessions each night.

“We’re thinking outside the box,” Houpt says. “We are making sure patients understand the ‘why.’ We make it clear that having fewer people in and out of the rooms, means patients are safer. Patients can rest and heal better.”

It has been so successful in COVID-19 units, pharmacy is working to deploy telepharmacy in other areas around the system.

“It’s an ongoing innovation we are working through.”

Cleaning and safety: Since the beginning of the pandemic, cleaning and isolation have been key strategies for many departments – Pharmacy is no exception.

Pharmacy launched new protocols to quarantine any medication that is returning to the department from a COVID unit.

“This has added a lot of time, but our number one goal is making sure our team is safe,” Houpt says.

The pharmacy regularly receives unused medications – the end of a course prescribed before a patient was discharged, or a medication that was sent and then discontinued – for example.

Any medications from a COVID unit are sent to a designated area in pharmacy where they are isolated for five days. Medications can be repackaged and reused after the isolation period.

Houpt says in the future Pharmacy plans to expand this procedure to any medication coming back from any isolation room.

COMMUNICATION, TRANSPARENCY ARE KEY

Through all the change, Houpt says the department’s success has depended on two things: clear communication and transparency.

“A team can handle more information if you explain the ‘why.’ Be as transparent as possible. This is not a time to hold anything back. We want to give as much information as we can to our team, so we are all rowing in the same direction.”

Pharmacy launched internal touchpoint meetings to connect with Pharmacy leaders systemwide throughout the week. The meetings mirror the structure of the Incident Command meetings.

“It has given us better communication overall. We are able to talk through clinical trials and what changes we are seeing.”

That enhanced communication structure will be key as vaccine trials continue, and as we head into a busy influenza season.

Even bigger than communication. Houpt says the pandemic response has driven teamwork to new levels.

“The overall collaboration has been exciting to see. With every modality, I’ve been proud to see the collaboration and teamwork.”

He has seen his own teams step up to take on challenges and offer solutions. People have risen to the challenge of the crisis and their input is helping the department evolve.

“Everyone in the department is bought in. Whatever the challenge, if there’s a better way to do it, let’s find a better way.”

WHAT”S NEXT: PREPARING FOR A VACCINE

Pharmacy is been working to stockpile products like Tamiflu as we prepare for a flu season that is paired with COVID-19.

“With the possibility of COVID-19 and flu co-infection, we are looking at what treatment modalities could reduce length of stay,” Houpt says.

Pharmacy is rapidly increasing the number of refrigerators to store vaccine, and prepare for a COVID-19 vaccine.

“When that comes around, that will be a huge game changer.”

Right now, though, the priority is to deliver as many flu vaccinations as possible.

“We don’t want to have to deal with both of those things,” he says. “Preparing as much as we can from a flu vaccination standpoint is what we need to better care for our patients.”