COVID-19

Charnicia Huggins, PharmD

How do you prepare for a pandemic? That was the question facing hospitals all across the country as COVID-19 spread with seemingly lightning-like speed from China across the world. In January 2020, the United States confirmed its first case in an overseas traveler returned home; 1 month later it was identified in a California resident without any travel history. Since then, COVID-19 has been diagnosed in nursing homes, correctional facilities, and aboard cruise ships as well as among  churchgoers in Arkansas, choir members in Washington state, and conference attendees in Massachusetts. There are now more confirmed cases (800,000+) in the United States—including all 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and the Northern Marianas—than in any other country. Were U.S. health-system pharmacists prepared for this spread?

“Honestly, we’ve never experienced something like this before,” Onisis Stefas, PharmD, MBA, vice president, chief pharmacy officer at Northwell Health, told Pharmacy Today. “I don’t think anyone was anticipating that rise that quickly,” he said. Northwell Health, based in New Hyde Park, NY, is an integrated network of 23 hospitals, 800 physician practices, and 10 outpatient pharmacies throughout New York City, Long Island, and Westchester. New York, with more than 250,000 confirmed COVID-19 cases, mostly in the densely populated New York City, has the highest prevalence of community spread in the country.

Reacting quickly

Some of the first questions Stefas had to answer in the wake of this unprecedented outbreak were “What medications do we need? And in what quantities?” He also had to consider staffing needs in light of both additional patient volume and illnesses among pharmacy staff. “You have an increased number of patients in your hospital, and now infected staff has to get quarantined at the same time,” he said.

As Stefas and his colleagues in other states began battling the disease, others were taking notes. “One thing that has been helpful is that we weren’t the first state to experience it,” said Irina Polotskiy, PharmD, BCPS, director of pharmacy services at CarePoint Health Bayonne Medical Center in Bayonne, NJ. This small community hospital has a typical census of 100, but it is located in the state with the second highest number of confirmed cases in the United States—more than 92,000 at last count.

“To a certain extent we were prepared,” Polotskiy said, describing how she stocked up on medications and personal protective equipment, “(but) to another extent I didn’t believe.” When confronted with the idea of stocking up on acetaminophen, for example, Polotskiy disregarded it. “Tylenol? I’m not going to buy extra Tylenol—that’s nonsense,” she remembers thinking. “Next thing you know there’s no Tylenol,” she said. She was quickly able to get it from another distribution center, however, averting a potential disaster.

Across the country in Oregon, where COVID-19 diagnoses are less common than in the Northeast, Yen Pham, RPh, BS, MBA, chief pharmacy officer for Oregon Health & Science University’s (OHSU) pharmacy department, said they prepare for COVID-19 by envisioning “the worst-case scenario.” With just over 2,000 confirmed cases, Oregon has less than a 10th of the number reported by neighboring California. Yet Pham insisted that they will not get complacent. “Here in Oregon it sounds like we’ve flattened the curve, but we don’t know,” she said.

Eric Maroyka, PharmD, BCPS, senior director of the American Society of Health-system Pharmacist’s Center for Pharmacy Practice Advancement, agrees that no organization can be completely ready for a crisis of this magnitude. “It is exceeding difficult to be fully prepared for every imaginable scenario while working in an inherently complex and demanding health care system” he told Today via e-mail. “And in this case, we may be dealing with a once-in-a lifetime, perhaps even a once-in-a century type of event that is stressing our capability and capacity to provide services.”

One of the main things that can stress pharmacists’ capability to serve is the lack of an adequate drug supply.  “Keeping up with that has been challenging,” Polotskiy said. “I’ve literally had to stalk the McKesson website. Every half hour I refresh my back-order page in the hopes that something comes in stock.” Polotskiy said her two biggest fears are that she becomes exposed to COVID-19 and unknowingly infects her loved ones and that she “will not have enough medications for (her) patients.”

Maintaining an adequate drug supply is a concern also shared by Stefas. “We’re all basically going after the same medications,” he said, describing his need to rely on “critical care doctors and clinical pharmacists to come up with alternate therapy.” For those areas of the country that are expecting more cases in the future, he advised, “You have to ensure that you have multiple venues to get access to medications.”

Treatment options and myths

The classes of medications that hospitals across the country need to access when treating patients with COVID-19 range from pain relievers like acetaminophen to sedatives like midazolam. Treatment options are also frequently updated as new information becomes available. Initially, the antiretroviral drug lopinavir/ritonavir (Kaletra—AbbVie) was touted as one of the recommended therapies for COVID-19, Polotskiy explained, but “now it’s hydroxychloroquine and azithromycin—that’s the mainstay.” 

These treatment variations can be challenging in the United States, where evidence-based medicine is the standard of care. According to Adam Berman, MD, associate chair of the emergency department of Northwell Health’s Long Island Jewish Medical Center (LIJMC) in New Hyde Park, NY, “not enough data exist to make solid conclusions about a lot of therapies.”

Pham, of OHSU, agrees with this sentiment. “There’s no clinical proof that hydroxychloroquine is going to treat COVID-positive patients,” she said. Heralding the benefits of such unproven therapy can actually do patients a disservice, asserts Pham’s colleague, Lam Nguyen PharmD, MBA, OHSU’s assistant director for pharmacy services. “Truly we do need it for approved indications,” but when it is broadcast as a potential COVID-19 cure, “it is really impacting our patients negatively,” he said. Pham added, “We know if this rumor becomes a fact, from our patients’ perspective, it can disrupt our supply.”

To dispel such rumors, Pham’s team of infectious disease pharmacists compiles weekly e-mails for pharmacy staff that detail myths and facts about COVID-19 treatment. Hospital leadership also steps in when necessary. “We’ve taken it as a health system to say there is no evidence, and we will not be providing this medication despite the requests,” Nguyen said. Such was the case with the antirheumatic drug tocilizumab (Actemra—Genentech), which is thought to play a role in reducing coronavirus symptoms, despite a lack of evidence.

Pearls of wisdom

A silver lining of the pandemic is that  everyone involved has learned lessons that can be passed on to those who have yet to experience the surge in patients already seen in New York and New Jersey. “Make sure you have additional flex staff, per diems that can meet the demand for the surge,” Stefas advises. He also recommends that pharmacies have ample space for medication storage and availability of back-up medication carts and automated dispensing machines, and that they work with information technology departments to allow for seamless conversions of new areas into COVID-19 units.

Polotskiy values such advice from those with experience treating COVID-19 patients. She also relies on listservs for guidance, such as those compiled by APhA, ASHP, or the Medication Safety Officers Society, and recommends that others do the same.  “It really has helped being part of these listservs to hear what others are experiencing and how they’re handling it.”

In addition, Pham emphasizes the importance of keeping one’s wits about them. “Be calm, be transparent with your staff, constantly communicate, and anticipate the worst-case scenario,” she said.

Teamwork on the front lines

A recurring theme among these pharmacy leaders is the level of dedication shown by staff amid the stress of the pandemic. “The whole hospital is banding together,” said Stefas, mentioning pharmacists, nurses, physicians, and respiratory therapists. “People don’t want to leave. They want to stay at work because they know what a major impact they’re having on patient care. My whole team has impressed me.”

Nguyen at OHSU has observed similar loyalty at his institution and has been “very comforted” by the level of support provided by staff. Despite the balancing act between staying true to the pharmacist’s oath versus tending to the needs of loved ones, “everybody really stepped up and is trying to do the best they can,” he said.

Polotskiy also remarked about the sense of camaraderie she has witnessed. “I think there is an idea of teamwork, working together. Everyone’s pitching ideas and doing their best…while being scared at the same time.”