key: cord-0693396-p73lpaxy
authors: Kang, Kyoung-Sil; Huggins, Charnicia; Diaz-Fuentes, Gilda; Schiller, Lawrence
title: COVID-19 preparedness: A Bronx, New York, inner-city hospital’s experience with medication management and readiness for a second surge
date: 2021-02-13
journal: Am J Health Syst Pharm
DOI: 10.1093/ajhp/zxab017
sha: 4dd344a2961cc2939d15e0570a91898bdef2d489
doc_id: 693396
cord_uid: p73lpaxy

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Workflow changes. We encountered several challenges to the smooth flow of normal pharmacy services. Social distancing as mandated by the governor was difficult to achieve considering limited workspace available in the pharmacy and in medication rooms on inpatient nursing units, coupled with the number of personnel needed to meet our health system's medication needs. Competition for limited elevator space was also a consideration. In addition, employees were fearful of the possibility of infection and inadvertent transmission to vulnerable family members, such as children and older parents. To address these concerns: 1 . Workload shifting was implemented. Major responsibilities usually concentrated during the day shift-medication cart fills, automated dispensing machine refills, and batching of compound intravenous (IV) medications-were allocated to the evening and night shifts.

2. Some employees were moved from the day shift to the night shift to reduce crowding. 3 . A couple of managers were moved to the night shift, which provided oversight for workflow changes and addressed their personal needs. 4 . Registered 503B outsourcing facilities were used to provide ready-to-use packaged drugs because of increased need for patient-specific IV drug preparations. 5 . Staff members with suspected or confirmed COVID-19 were immediately removed from their posts and given the option to assist via remote order verification. 6 . Pharmacy residents were temporarily shifted from their normal learning experiences to daily pharmacy operations, including processing prescriptions and dispensing medications for a limited number of hospital employees with suspected or confirmed COVID-19. 7. Employees were trained on the proper use of personal protective equipment (PPE) and underwent fit testing for N95 masks, which were individually distributed.

Securing medications. During the early days of the pandemic as we experienced a surge of patients, there was a severe national shortage of critical medications. Hospitals across the country ordered medications to fill anticipated and/or current needs in quantities that far exceeded normal drug purchasing requirements, and suppliers were unable to meet such demands. A state of disaster was declared in our hospital on March 15, 2020, and our mobile morgue delivery from the New York State Department of Health arrived shortly afterward as the number of patients requiring intubation steadily increased to nearly threefold, and the average ventilator patient census reached the 80s, peaking at 115. This necessitated our taking the drastic step of converting all AM J HEALTH-SYST PHARM | VOLUME XX | NUMBER XX | XXXX XX, 2021 nursing units into ventilator units and redistributing needed medications accordingly.

Our highest COVID-19 patient load peaked at 255 confirmed cases and 78 under investigation, which accounted for 80% of our census that day. Meanwhile, our hospital was running low on intubating, sedating, narcotic, and paralytic agents, and the allocation from our drug wholesaler, initially predicated on our average drug purchasing history, was insufficient to treat all of our intubated patients. Drug wholesalers were consistently out of stock of most preferred and alternative agents. In addition, as soon as published data suggested benefit of a particular therapy for COVID-19, such as hydroxychloroquine and azithromycin, hospitals rushed to acquire those medications as well. It seemed that the US drug supply chain, which accounts for the movement of medications from suppliers, manufacturers, and wholesalers to hospitals, pharmacies, and patients, was not prepared for this pandemic. The surge in demand for the same drugs all across the country could not be effectively handled by usual means of drug purchasing. To address these concerns, we performed the following: (Table 1) Clinical challenges. Due to the lack of a defined treatment plan for COVID-19, our medical staff had to rely on experiences gained from treating patients during prior outbreaks. Since many patients with COVID-19 presented with rapidly deteriorating renal function and multiorgan failure due to cytokine storm, we used many US Food and Drug Administration-approved drugs (such as tocilizumab, an interleukin-6 inhibitor) for nonapproved indications, based on current best practice recommendations to reduce cytokine storm. The pharmacy and therapeutics (P&T) committee also expanded clinical pharmacists' privileges, authorizing them to adjust medication doses based on renal function. Before the pandemic our pharmacists were required to call physicians before making such adjustments. Other interventions to address our clinical challenges included the following:

1. Consolidation of medication administration to specific times to minimize nurses' exposure to patients with COVID-19:

Previously, medication administration times were concentrated on the day shift (10 am, 2 pm, 6 pm). To minimize repeated exposures by one nursing shift, pharmacists updated medication administration times to 6 am and 6 pm whenever possible, which spread out responsibilities between both 12-hour nursing shifts. pumps outside rooms to further reduce nurse exposure to patients with COVID-19), which later became a concern for tripping hazards and back pressure occlusion.

Administrative challenges. Challenges in keeping medications organized, staying up-to-date with treatment protocols, maintaining daily drug deliveries, being knowledgeable of drug supply chain interruptions, and conducting staff education cannot be overstated. In addition, hospitals in New York City were ordered to increase bed capacity by 50%, which resulted in the opening of new patient care locations requiring additional medications and storage compliance. These challenges were met in the following ways: Preparing for the second surge. Because the Bronx was among the first areas to experience the surge of patients with COVID-19, we are now able to share some of our lessons learned, including the need for the following:

1. Cross-training of staff: Our ambulatory care pharmacy residents, for example, who were already trained in staffing and managerial functions, were redeployed to the main pharmacy where they assisted with in-house operations. This underscores the importance of cross-training in staffing and managerial functions so that all staff can be deployed to areas of greatest need regardless of primary areas of responsibility.

2. Access to remote order verification: This allowed willing pharmacists who were exposed to COVID-19 but had only mild symptoms to remotely assist with larger-than-normal order verification queues during their mandated quarantines. 

This will help to avoid delays, such as we experienced, when wholesalers are unable to meet the demand for medications on shortage. Putting these lessons into practice while continuing with social distancing and implementing creative ways to prevent infection of health care workers and beyond is critical to maintaining readiness for a potential second surge. As AM J HEALTH-SYST PHARM | VOLUME XX | NUMBER XX | XXXX XX, 2021

we prepare for a second surge due to relaxation of social distancing, COVID-19 disaster planning is also necessary ( 

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