key: cord-0715103-tt3p0tki authors: Liao, Yun; Ma, Chunlai; Lau, Alan H; Zhong, Mingkang title: Role of pharmacists during the COVID‐19 pandemic in China ‐ Shanghai Experiences date: 2020-06-14 journal: J Am Coll Clin Pharm DOI: 10.1002/jac5.1288 sha: 9a0f6e6b39db5e7af93bc88782e1bbc6e98f8051 doc_id: 715103 cord_uid: tt3p0tki The roles and contributions of pharmacists in Shanghai during the coronavirus disease 2019 (COVID‐19) pandemic are described in this report. Five pharmacists have been appointed as members of an expert interdisciplinary health care team tasked with taking care of all adult COVID‐19 patients in Shanghai in a designated hospital, the Shanghai Public Health Clinical Center (SPHCC). They work with pharmacists at SPHCC, having responsibilities that include drug supplies, dispensing, pharmacy intravenous admixture services (PIVAS), prescription audits, medication reconciliations, pharmacotherapy, therapeutic drug monitoring, and patient education. Due to the pandemic, pharmacy operations in all hospitals are modified to adhere to guidelines for infection risk mitigation and personnel protection. Community pharmacies serve as the public access point to health care and medical supplies, providing services beyond dispensing and medication counselling. The establishment of internet hospitals (telehealth facilities) provide new opportunities for delivering pharmaceutical care and working with health care professionals. Pharmacists also participate in evaluating new treatments and keeping health care teams informed of new findings for potential treatment considerations. In response to the critical need for health care professionals in Wuhan, 68 pharmacists from Shanghai went there to work with the local pharmacists. Through assuming new roles and adapting existing practice, pharmacists have acquired invaluable experiences for future practice advancement. In order to assume these responsibilities effectively, pharmacists need to be equipped with the necessary skills for meeting the evolving health care challenges. This article is protected by copyright. All rights reserved. Coronavirus disease 2019 (COVID-19) is an emerging respiratory infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It first appeared in early December 2019 in Wuhan, the provincial capital city of Hubei, China. 1 During the period of January 10-23, 2020, a massive human migration took place in China as individuals travelled back to their hometowns for Chinese New Year. More than 5 million people left or returned to Wuhan during this short period. To confine the evolving pandemic, on January 23, 2020, an unprecedented public health intervention was put in place by shutting down all transportation in and out of Wuhan. 2 Between January 23 and February 1, 2020, patients with mild symptoms were placed in home quarantine. With the escalation of confirmed cases, health care facilities and hospital beds were filled to capacity in Wuhan. In order to expand bed capacities rapidly, construction began on January 23 to build the Vulcan Mountain Hospital and on January 26, the Raytheon Mountain Hospital, with 1000 beds and 1600 beds and finished within 10 and 11 days, respectively. On February 2, 2020, an intensified measure was taken to centralize quarantine and treatment. All patients with severe symptoms and those who were critical were transferred to designated hospitals, whereas patients with mild symptoms were treated at a Fangcang shelter hospital. Fangcang, which sounds similar to Noah's Ark in Chinese, is a large, temporary hospital built by converting public venues, such as stadiums and exhibition halls, into health care facilities to isolate patients with mild to moderate symptoms of an infectious disease from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. 3 Patients with suspected infections were housed in designated locations for isolation. This article is protected by copyright. All rights reserved. In Shanghai, as of May 26, 2020, there were 652 patients recovered from the infections (332 domestic and 320 imported cases) and 7 death (all domestic). Ten patients were still hospitalized (2 domestic and 8 imported cases). The mortality rate is only about 1%, which is much lower than the 5.5% in the whole China and 7.7% in Wuhan. The purpose of this report is to summarize the roles and contributions of pharmacists in Shanghai during the COVID-19 pandemic. Also described are how hospital and community pharmacies offer their services to patients during this extraordinary period. Shanghai is one of the largest cities in China, with the highest gross domestic product (GDP). There are about 24 million residents, 359 comprehensive hospitals, 246 community health care centers, and about 6000 family doctors. Five hundred fifty medical professionals and 660 beds were mobilized for treating COVID-19 patients, using guidelines published in the "Expert This article is protected by copyright. All rights reserved. At the direction of the Shanghai Health Commission, a comprehensive multidisciplinary team (MDT) team was organized with about 250 experts from the top 10 comprehensive hospitals in Shanghai. The team consists of specialists in infectious diseases, respiratory medicine, critical care medicine, medical imaging, clinical pharmacy, traditional Chinese medicine (TCM), nutrition support, etc. These specialists work together with the 300+ medical professionals at SPHCC. They meet daily at a conference room located in SPHCC, using telehealth technology to take care of patients in a collaborative manner. This article is protected by copyright. All rights reserved. The 5 pharmacy experts in the MDT are pharmacy directors from 5 comprehensive hospitals in Shanghai. They work with the 35 pharmacists and 5 clinical pharmacists at SPHCC, having responsibilities over drug supplies, dispensing, pharmacy intravenous admixture services (PIVAS), prescription audits, medication reconciliations, pharmacotherapy, therapeutic drug monitoring (TDM), and patient education. According to the criteria stated in the "Expert Consensus on Comprehensive Treatment of COVID-19 in Shanghai", 4 individuals with an epidemiological history (resided in or visited an epidemic area within 14 days) and clinical symptoms (fever or respiratory symptoms, imaging features, decreased lymphocyte count) are considered suspected cases. COVID-19 positive patients are categorized as mild, moderate, severe, or critical according to their clinical presentations and the presence of pneumonia as determined by CT imaging (Table 1) . About 85% of COVID-19 patients are categorized as mild or moderate, whereas about 15% are severe or critical. At SPHCC, patients who are categorized as mild or moderate are housed in buildings A or B, each with 100 beds, whereas severe and critical patients are housed in intensive care units in building C. Relevant clinical and demographic details of individual patients, such as name, age, sex, nationality, admission date, temperature, symptom, oxygen intake, CD4+ count, serum albumin and immunoglobulin M (IgM), and CT scan and assessment, are printed for each medical expert every day for daily MDT consultation. The Shanghai team found that the CD4+ T This article is protected by copyright. All rights reserved. lymphocyte count is an important indicator for early intervention, thereby minimizing the risk for developing severe symptoms or becoming critically ill. 5 Drugs commonly used for COVID-19 treatment include hydroxychloroquine, vitamin C, thymalfasin, ulinastatin, glucocorticoid, omeprazole, and esomeprazole. In combination with Western medicines, traditional Chinese medicines are often used according to guidelines issued in China and South Korea. 6, 7 The role of pharmacists for pharmacotherapy interventions are presented in Table 2 . As members of the expert MDT team, pharmacists focus on issues related to pharmaceuticals, pharmacokinetics, and pharmacotherapy, as well as treatment alternatives due to drug shortages. An infectious disease physician and expert team member, Dr. Bijie Hu, found that irrigation of the nasal cavity and paranasal sinuses reduced the time needed to result in a negative virus nucleic acid detection test. 8 Pharmacists in the team recommended adding ephedrine to the warm normal saline irrigation solution to induce vasoconstriction and also levofloxacin for treating concurrent bacterial infection in the paranasal sinus. In addition, applying negative pressure would help washing the paranasal sinus more thoroughly. 9 These measures have been observed to improve smell and taste sensations as well as magnetic resonance imaging (MRI) of the paranasal sinus. This article is protected by copyright. All rights reserved. Sleep quality and immunologic function have been shown to be linked bidirectionally. Sleep can activate the immune system and promote inflammatory homeostasis through inflammatory mediators, such as cytokines. 10 In order to provide an environment conducive for sleeping, rooms should be dimly lit with a comfortable ambient temperature. Patients are asked to avoid using mobile phones or computers for extended periods, and refrain from using them an hour before bedtime. Some patients may find that having dessert after dinner is beneficial. For mild and moderate COVID-19 patients without pre-existing sleep problems, pharmacists would typically recommend oral vitamin C 0.5 g twice daily or 1 g once daily and ketotifen 0.5 or 1 mg at bedtime. For those with occasional or transient insomnia, oral vitamin C 0.5 g twice daily or 1 g once daily and zolpidem 10 mg at bedtime would be indicated. For those with substantial anxiety, insomnia, tension, or fear, oral vitamin C 0.5 g twice daily or 1 g once daily and estazolam 1 or 2 mg at bedtime are generally recommended. This article is protected by copyright. All rights reserved. During hospital discharge, patients are given access to the online platform, "SPHCC Patient Care", where they can ask questions related to their medications as well as COVID-19. The platform is also set up for follow-up physical and psychological assessments, as well as for adverse drug reaction monitoring. Patients consider this as one of the most valuable professional services offered by pharmacists. Patients with fever or any symptom consistent with COVID-19 have to go to a fever clinic for evaluation. The clinic is an outdoor quarantine station separated from the hospital emergency department. Any individual who has an epidemiological history and clinical symptoms are classified as suspected cases and have to be isolated in the hospital negative pressure ward. After COVID-19 infection is confirmed, the patient is sent to the designated hospital for treatment. Fever clinics and isolation wards are considered high-risk areas for pharmacists working there. They should disinfect their hands before and after handling medical records and paper prescriptions. 12, 13 In order to separate the pharmacy operation from the rest of the hospital, designated staff use a special identification system and supplies, so as to maintain separation between areas for patients with fever from the other hospital patients. Paper prescriptions are sterilized with ethylene oxide before moving to storage. Drugs entering the quarantine zone would not be returned to the general area. 13 Pharmacists are responsible for developing emergency drug formularies for their institutions. They monitor drug supplies, identify suitable alternatives, and resolve drug shortages. Pharmacists also provide free consultation to health professionals and patients via social media (WeChat groups). With the suspension of non-essential clinic visits during the epidemic, pharmacists play an important role in extending the validity of existing prescriptions and providing refills. For those with basic medical insurance, prescriptions can be extended according to the need for therapy with 3 months maximum, compared with 1-2 weeks typically allowed before the pandemic. It is essential for pharmacists to ensure that the extension is appropriate and safe. Certain drug categories, such as psychiatric drugs, are excluded from such extension. During the pandemic, 6 licensed internet hospitals, which are affiliated with large comprehensive hospitals in Shanghai, have been established to provide telemedical services, reducing the need for patients to come to hospitals for treatment and follow-up. Pharmacists can thereby provide online follow-up, process, and dispense electronic prescriptions and then send the medications to the patients. 15, 16 Such a setting provides the pharmacists new opportunities for delivering pharmaceutical care while working closely with the health care team. During the pandemic, community pharmacists are the patients' access point to health care and medical supplies, such as masks, over-the-counter (OTC) drugs, thermometers, disinfectants, etc. These products are often delivered from the pharmacies to the patients' homes. Community pharmacists repack bulk packages of masks into smaller packets with the rationed amount for residents in their communities. They also provide education and This article is protected by copyright. All rights reserved. The 500,000+ community pharmacies in China also help to identify potential infections. The pharmacy staff measures the customers' temperatures and records personal details such as name, gender, age, identification number, phone number, and address. Customers are asked if they have experienced symptoms such as cough and fever. Those who purchased any medicine containing acetaminophen would be noted. Eleven clinical trials for COVID-19 treatment have been conducted in Shanghai and they are In response to the critical need for health care professionals in Wuhan, 68 pharmacists from Shanghai went there to work with the 9817 local pharmacists. They collectively ensured adequate medical supply for the medical teams and compiled drug formularies for local institutions. The group also provided drug information for physicians, nurses, and patients under the direction of more than 100 pharmaceutical experts in China. Because Chinese This article is protected by copyright. All rights reserved. traditional medicines are often used concurrently with Western medicines, pharmacists were responsible for determining optimal dosage regimens, identifying potential drug interactions, and assessing the efficacy of such combination therapy. 17 At the Fangcang shelter hospitals, pharmacists offer medication counselling and as appropriate, emotional support for patients. The COVID-19 pandemic provides a unique environment for adapting practice to a changing health care landscape, requiring rapid decision-making and innovative thinking. pharmacies', not only in tertiary health facilities, but in community health centers, clinics, and pharmacies. Through the assumption of new roles and the adaptation of existing practice during the pandemic, pharmacists have acquired invaluable experiences for future practice advancement. In order to assume these responsibilities effectively, pharmacists need to be equipped with the necessary skills for meeting evolving health care challenges. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. 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