Notes from the Epicenter

Arash Dabestani
Senior Director of Pharmacy, NYU Langone Health

I am sharing lessons learned and some of the issues we have faced in these past weeks. I really hope this is helpful for those not yet impacted or minimally impacted by the coronavirus.

Staff Protection

• Arguably, the most challenging issues we have encountered during this crisis. Ensure your staff that they are receiving the same level of protection as any other hospital employee depending on the exposure level. Encourage them to use their own masks as some N95 masks are still available in stores (as long as this is not in violation of your internal policy)
• Ultimate goal should be to reduce a) Presence, and b) Movement within the hospital and more importantly inside isolation areas. Many of you have pneumatic tubes. Consider using the code system to tube controlled substances to reduce hand deliveries
• If you already have clinical or satellite staff within the isolation areas (ED, ICU, etc.), consider tubing the stock and asking them to stock the ADCs (Automated Dispensing Cabinets) to reduce overall exposure and preserve PPE
• Start drafting compressed scheduling models for your staff. Many advantages to shifting to a compressed 10 or 12 hour model and work from home assignments
• Consider establishing specific guidelines for staff calling out sick during the crisis as a 12 hour call-out is a significant gap to fill
• Your existing procurement/purchasing/buying team WILL BE overwhelmed. Assign a few others to this team

Operations

• Plan for additional refrigerators. Some antivirals and NMBs need to be refrigerated and you will be using quite a lot
• Communicate your daily inventory levels of COVID-19 meds to your ID and senior hospital leadership as they will need this information to make certain decisions. Additionally, you can avoid 10s of emails during the day requesting such
• May need Automated Dispensing Cabinets to safeguard your hospitals' stock of PPEs and some COVID-19 meds
• Increase med Par levels in isolation areas to reduce stocking frequencies
• Crash carts are in high demand due to the number of codes. Plan for extras
• Plan for the process of cleaning and replacing crash carts from isolation areas
• Identify a room and a process to quarantine returned meds and med trays from isolation areas for a few days
• Consider placing 3-4 most commonly used code meds in a zip lock bag to avoid contaminating the crash cart for every single code
• Wipe down code carts before returning to pharmacy
• Consider converting some of your decentralized units to cartfill to conserve ADCs
• Plan for additional staff in your clean rooms due to the increase in the number of drips
• Develop a strategy to conserve clean room PPE and cleaning supplies
• If you use connectors, adaptors etc., contact those vendors and order extras as the demand on these will increase
• Prepare for additional units converting to COVID-19 units. Prepare a list of meds or entire ADCs to simply roll into these units. For instance, if a pediatric unit is converted, most of the drugs in the peds ADC are of no use to COVID-19 patients 

Team Management

• You can't hold huddles to keep your team informed so plan a system of live communication aside from email
• Staff and managers should learn how to initiate and use Webex, Zoom, etc.
• Plan for staff parking if public transport is shut down or curtailed
• Plan to re-purpose and re-allocate resources from closed or condensed areas such as procedural areas, am care etc. Examples: for IV compounding, PEP preparation and dispensing, etc.
• Consider staffing a manager in your main pharmacy around the clock. Due to the increase in the number of "exceptions" and emergencies, the presence of a manager is highly recommended
• Draft a plan for dispensing and delivering exposure prophylaxis and discharge meds to coronavirus + patients and exposed staff. You don't want them running around to multiple pharmacies (potentially exposing more people) since most retail outlets have already stocked out
• Consider 90 day fills or early refills for chronic meds (retail pharmacies)
• Plan to ramp up your mailing and courier deliveries for outpatient meds
• Plan for safeguarding COVID-19 meds. We have internally assigned CII status for one of commonly used meds
• Significant role of clinical pharmacy staff – They have been here around-the-clock pulling 18-20 hour shifts due to all the unknowns and fluidity of COVID-19 treatments, doses and interactions, codes, etc. Also the number of codes.This is not to take anything away from operations, etc., who have also been working similar hours. The take away point here is that the toll and demand on the clinical staff has been well above and beyond our forecast

Inventory Management

• Limiting nebulizers has had a drastic impact on MDIs. All are on shortage now. Plan to dispense these for discharged patients to take home. This is not the time to be sharing or re-using MDIs
• Please try to refrain from asking heavily hit hospitals to borrow their meds. It places us in a very tough spot with a potential ethical dilemma to deal with on top of everything else
• Some staff can work from home. Check with your IT department for at home access to your EHR
• You likely have stocks of critical meds in procedural and low acuity areas currently closed or under-utilized. Try to establish a comprehensive inventory for your entire health system. On that note:
• Your clinical team will need daily inventory counts for about 20 critical meds so they can rapidly prioritize, manage, convert, etc. Designate one of your staff to provide this report at least daily
• Close the reception area or significantly limit the number of patients inside your retail pharmacies
• I did not include any medication names. This is intentional to avoid contributing to practice of hoarding
• Many clinical trials with large Ns are taking place. Prepare your investigational team for receiving, documenting, and more importantly distribution of these meds 

Finally, EVERYONE has been extraordinary in responsiveness. This includes vendors, pharma execs, pharmacy automation and operations vendors, wholesalers, GPOS, smaller distributors of generics, 503B, pharmacy organizations, retired pharmacists and I am sure I left out a few others. Nearly everyone has been returning calls after-hours and on weekends (well, just one weekend so far).

DISCLAIMER

The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s). These views are always subject to change, revision, and rethinking at any time and may not be held in perpetuity.