key: cord-0788933-31jjniio
authors: Visacri, M. B.; Figueiredo, I. V.; Lima, T. d. M.
title: Role of pharmacist during the COVID-19 pandemic: a scoping review
date: 2020-07-02
journal: nan
DOI: 10.1101/2020.06.30.20143859
sha: 8784731101e2abda48d8e11ee75b0be2ea9faa06
doc_id: 788933
cord_uid: 31jjniio

Abstract Background Since the start of the new Coronavirus (COVID-19) outbreak in December 2019, pharmacists worldwide are playing a key role adopting innovative strategies to minimize the adverse impact of the pandemic. Objectives To identify and describe core services provided by the pharmacist during the COVID-19 pandemic. Methods A literature search was performed in MEDLINE, Embase, Scopus, and LILACS for studies published between December 1st, 2019 and May 20th, 2020 without language restriction. Studies that reported services provided by pharmacists during the COVID-19 pandemic were included. Two independent authors performed study selection and data extraction with a consensus process. The pharmacist's intervention identified in the included studies were described based on key domains in the DEPICT v.2. Results A total of 1,189 records were identified, of which 11 studies fully met the eligibility criteria. Most of them were conducted in the United States of America (n=4) and China (n=4). The most common type of publication were letters (n=4) describing the workplace of the pharmacist in hospitals (n=8). These findings showed the different roles of pharmacists during the COVID-19 pandemic, such as disease prevention and infection control, adequate storage and drug supply, patient care and support for healthcare professionals. Pharmacists' interventions were mostly conducted for healthcare professionals and patients (n=7), through one-to-one contact (n=11), telephone (n=6) or video conference (n=5). The pharmacists' main responsibility was to provide drug information for healthcare professionals (n=7) as well as patient counseling (n=8). Conclusions A reasonable number of studies that described the role of the pharmacists during the COVID-19 pandemic were found. All studies reported actions taken by pharmacists, although without providing a satisfactory description. Thus, future research with more detailed description as well as an evaluation of the impact of pharmacist intervention is needed in order to guide future actions in this and-or other pandemic. Keywords: COVID-19; pharmacists; pharmaceutical services; review

professionals are committed to ensuring that the population have access to health services and to minimize the adverse impact of the pandemic. Given the seriousness of the coronavirus outbreaks, health professionals with expertise in public health are essential.

As healthcare professionals, pharmacists can play key role during the pandemic, acting directly with the community, 8 continuing to care for patients with chronic diseases, 9, 10 working in hospital pharmacies and providing pharmaceutical care to patients. 11 Moreover, they may provide reliable information for preventing, detecting, treating and managing coronavirus infections. 12, 13 As a result, several challenges have emerged and innovative strategies are being adopted by pharmacists to overcome them. 14 Since the beginning of the outbreak, many guidelines have been published with recommendations for pharmacists as well as their responsibilities during the pandemic.

However, few describe pharmacists' experiences in this novel context. Therefore, this scoping review is aimed to identify and describe core services provided by the pharmacist during the COVID-19 pandemic.

A scoping review was performed to explore the literature, map and summarize the evidence regarding the role of the pharmacist during COVID-19 pandemic. 15 This review was conducted following the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement for Scoping Reviews (PRISMA-ScR) 16 and the review protocol registered on Open Science Framework and May 20 th , 2020 in order to identify relevant studies. The search strategy included combinations of terms relating the COVID-19 and pharmacy. The full strategies search for all databases can be found in S1 Appendix. Additionally, it was conducted a grey literature search in DOAJ -Directory of Open Access Journals (https://doaj.org/) aiming to identify not indexed studies in the databases listed above. No language restriction was applied. Duplicated studies were eliminated. In addition, references cited in all included articles were reviewed to identify any studies that might have been missed.

Studies that described services provided by the pharmacist during the COVID-19 pandemic were included. In addition, all publication types were eligible for inclusion.

Studies that did not describe the role of the pharmacist during the COVID-19 pandemic; reviews, recommendations, and-or guidelines of pharmacist's role during the pandemic;

presented only pharmacotherapeutic options for COVID-19; and involved graduate students were excluded.

All titles and abstracts were independently screened and selected by the authors. Full-text articles were obtained and reviewed to determine whether the article met the eligibility criteria. If the full texts of the articles were not available in the databases, the corresponding authors were contacted by email or through ResearchGate (www.researchgate.net). Disagreements were resolved through discussion.

This process was performed using Rayyan QCRI, a free web application designed to help researchers working on systematic reviews. 17

For each included study, information such as the: author, date of publication or availability online, publication type, region, workplace of the pharmacist, participants, and results summary were extracted. The pharmacist interventions reported in these studies were described based on key domains in the Descriptive Elements of Pharmacist Intervention Characterization Tool (DEPICT) version 2: 1) contact with recipient (how the contact with the recipient occurs); 2) method of communication with recipient; 3) setting of the intervention (where the recipient received the service); 4) action(s) taken by pharmacist (what is done to address the identified problems); and 5) materials that support action(s) (items developed or provided by the pharmacist as part of the service). 18 The authors independently completed the data extraction, using a preformatted spreadsheet in Microsoft Excel. Disagreements were resolved through discussion.

The results of this scoping review are presented as a narrative synthesis due to the heterogeneity of the studies included. The studies were categorized according to the characteristics of the publication and summarized in tables.

Following the PRISMA-ScR 16 , no quality assessment was performed due to the fact that scoping reviews aim to identify all the available evidence and highlight their main characteristics, regardless of the quality.

The electronic search found 1,189 potentially relevant studies. After removing duplicates and reviewing the titles and abstracts, 62 articles were selected for full-text reading. In addition, no relevant studies were identified from searching the reference lists of the included studies. Of these, 11 studies met the inclusion criteria and were included for review. A flowchart of the literature search is shown in Fig. 1 . The references for the excluded studies, with the reasons for their exclusion, are available in S2 Appendix.

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The copyright holder for this preprint this version posted July 2, 2020. . Full-text articles excluded (n = 51) -Not described activities and-or services adopted by the pharmacist (n = 38) -Reviews, recommendations, and-or guidelines (n = 5) -Pharmacotherapeutic options (n = 4) -Not related the pharmacist professional (n = 1) -Involved graduate students (n = 1) -Interview (n = 1) -No access (n = 1)

Total studies included (n = 11) (n = xx)

Additional records identified through complementary search (n = 0)

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The characteristics of the 11 studies included in this scoping review are summarized in Table 1 . Studies were conducted in the United States of America (n=4) 20, 21, 27, 29 , China (n=4) 22, 23, 25, 28 , Saudi Arabia (n=1) 19 , Taiwan (n=1) 24 , and Macao (n=1). 26 All studies were published in English and reported between February and May 2020. The publication type of the included studies consisted of letters (n=4) 20,21,25,27 , research article (n=2) 19,22 , commentary (n=2) 23, 26 , ideas and opinions (n=1) 24 , discussion (n=1) 28 , and note (n=1) 29 .

The majority of the studies described the workplace of the pharmacist in hospitals (n=8) [19] [20] [21] [22] [23] 25, 28, 29 following the ambulatory pharmacies (n=4) 19, 20, 28, 29 , community pharmacies (n=2) 24,26 , and clinic (n=1). 27 The participants of the included studies were miscellaneous, including the healthcare professionals (n=7) [19] [20] [21] [22] [23] 28, 29 , 19,22,23,28,29 , general inpatient (n=2) 19, 29 , general population (n=2) 24,26 , pediatric patients (n=1) 20 , solid organ transplant patients (n=1) 21 , patients on warfarin therapy (n=1) 25 , and myelofibrosis patients (n=1). 27

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The copyright holder for this preprint this version posted July 2, 2020. . Online review of 20,000 electronic orders; providing online medication consultation for 484 patients using WeChat; providing medication and health education in the WeChat group; use a module radio station to inform the patients about the medication, rational nutrition and diet suggestions for COVID-19, and self-protection and medication guidance after discharge.

Meng et al. 23 Change in mode of drug delivery. Establishing pharmacies from grounds up, including locating the ideal pharmacy location and procuring necessary equipment; compiling drug formulary; cataloging and stocking formulary drugs; resolving drug shortages.

Development of a medicinal dictionary for formulary drugs to be docked into the CDS to provide prescribing support; education for patients on medications taken at the hospital and upon discharge; providing drug information to physicians especially concerning drugs that general practitioners are not familiar with a focus on off-label drug use, and interactions between TCMs and western medicines; medication reconciliation to ensure the safe transition of care. interactions, implementing remote pharmaceutical services; caring out medication review.

Zuckerman et al. 29 Staff redeployment and staffing modifications; sourcing and using of PPE; installation of hand-sanitizing stations and plexiglass dividers in pharmacies.

Developing a list of medications required for treatment of COVID-19 patients to guide the drug supply and calculating medication quantities to purchase; developing new medication and supply storage and delivery mechanisms; creation of a virtual dashboard to clearly communicate current strategic supply inventory.

Participating in virtual meetings and inpatient rounds; patient counseling via smartphones or telehealth visits; participating of the COVID-19 pharmacotherapy working group that provided initial treatment recommendations published weekly on institutions intranet; developing of a guidance for patients receiving biologics who were at risk for COVID-19 acquisition due to immunosuppression so that providers could advise them to suspend therapy if necessary; coordinated many patients' transition from infusions to self-administered medications. 

Studies were conducted for healthcare professionals and patients (n=7) [19] [20] [21] [22] [23] 28, 29 or only patients (n=2). 25, 27 Two studies 24,26 were conducted for the general population and, therefore, were classified as "not applicable". All studies performed one-to-one contact with the recipients and six studies [19] [20] [21] [22] 28, 29 also used the group contact. Different methods of communication were reported, including face-to-face (n=4) 19,24,26,28 , written (n=5) 19,20,22,28,29 , telephone (n=6) 19, 20, 22, 23, 27, 29 , video conference (n=5) 20-23,29 and radio station. 22 One study 25 did not describe how the communication with the recipient has been performed. The studies were conducted at different setting of intervention, such as hospital bedside (n=7) [19] [20] [21] [22] [23] 28, 29 , hospital pharmacy (n=2) 19,29 , community pharmacy (n=2) 24,26 , ambulatory (n=4) 19, 20, 28, 29 , and recipient's home (n=5). 20, 21, 25, 27, 29 Pharmacists had an important role in taking actions to address during the COVID-19 pandemic, including drug information for healthcare professionals (n=7) [19] [20] [21] [22] [23] 28, 29 , patient counseling (n=8) [19] [20] [21] [22] [23] 25, 28, 29 , suggestion for change in therapy (n=3) 19,25,29 , monitoring results report (n=1) 19 , drug supply management (n=6) 19, 20, 22, 23, 28, 29 , safety measures for infection control (n=4) 19, 24, 26, 29 , and application of tools to evaluated a disease (n=1). 27 Regarding the materials that support actions adopted by pharmacists, most studies (n=7) 20-22,24-27 did not report them. Among those that described support resources provided by the pharmacists, educational materials (n=4) 19, 23, 28, 29 were the most reported, following the protocols (n=2) 19,29 , discharge letter (n=1) 19 , and safety alert system (n=1). 19 The description of the pharmacist interventions according to DEPICT version 2 are shown in Table 3 .

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Ying et al. 28 Patient and HPC Abbreviation: HCP (healthcare professionals), NA (not applicable), NR (not reported). In light of these findings, researchers must be engaged to design and report future studies with greater methodological rigor and more detailed description of the pharmacist interventions, in order to support and guide the actions of the pharmacists in this and-or other pandemic.

Most of the studies found in this review were conducted in the United States of America and China. These countries are the second and first in the scientific publication ranking worldwide, respectively. 30 Moreover, China was the first region affected by the COVID-19 infection 1 and therefore first experiences were felt in this location.

Regarding the type of publication, most studies were letters and other rapid scientific communications reporting experiences. These publications did not contain details of the work experiences and are at the lowest level of evidence. 31 However, considering the current pandemic, when there is a need for rapid information for activity guidelines by the pharmacists need to have quick information to guide their activities, these publications are convenient and acceptable.

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The copyright holder for this preprint this version posted July 2, 2020. . The hospital was the main workplace of the pharmacist in the included studies, which was an expected result because the role of pharmacist in hospital pharmacy practice is one of the most consolidated. 32 Pharmacists have a very comprehensive role within the hospital, performing from administrative activities to clinical services. 33 Therefore, they must be involved with all aspects of medicines use and be accessible as a point of contact for patients and health care providers. 34 As a consequence, it is more than expected that they would be on the frontline against COVID-19 pandemic and reporting on their successful experiences.

This review showed that pharmacists may play an important role during the COVID-19 pandemic. The results reported were categorized as "disease prevention and infection control", "adequate storage and drug supply" and "patient care and support for healthcare professionals". These categories are basically the responsibilities that International Pharmaceutical Federation (FIP) has stated that it would like pharmacists to have in both primary care context (i.e. community pharmacies and primary healthcare facilities) and in hospital settings. 12 Other recommendations of the scientific societies are also available and can help to direct the pharmacist intervention. [35] [36] [37] According to the key domains of pharmacist interventions, most studies were carried out for healthcare professionals and patients. Pharmacist-provided interventions with the recipients have been shown to improve patient outcomes and contribute to substantial healthcare savings. 38 In contrast, two studies did not classify as to the recipient of the intervention because the DEPICT version 2 did not predict interventions in the general population. It is important to note that pharmacists can play a role in health education and disease prevention in various ways for the general population. [39] [40] [41] [42] Moreover, the level of pharmacist-recipient interaction varied between studies. Most of them described the use of telephone, written interaction including web-based, and video conference. Studies involving the use of these methods of communication have been successful [43] [44] [45] and these valuable tools may be applied in a social distancing context. In addition, one study reported that pharmacists used a hospital's radio station as a communication strategy in patients who had difficulty in dealing with available technologies, highlighting the creative character. 22 Regarding the setting of intervention, most studies were performed in hospital bedside, ambulatory, and recipient's home. Pharmacist interventions were described in several settings [46] [47] [48] as to improving the quality of care. Unfortunately, only two studies related the community pharmacy as the setting of intervention. A recent study . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 2, 2020 . . https://doi.org/10.1101 discussed the role of community pharmacists during the COVID-19 pandemic, collecting and summarizing the experience of Chinese community pharmacies. 49 It is well known that community pharmacies are an important setting of care in the COVID-19 pandemic period and further studies in this context should be encouraged.

Drug information for healthcare professionals and patient counseling were the main actions provided by the pharmacists identified in this review, similarly with other studies. 48, 50 These actions focus on enhancing the problem solving skills of the patient for the purpose of improving or maintaining the quality of life. 18 In addition, other actions (drug supply management and safety measures for infection control) were also identified in some studies. Gross and MacDougall 51 described these actions (e.g. planning the drug shortages and antiviral stewardship) as vital during the COVID-19 pandemic period.

Moreover, the key domain "Materials that support actions" has not been reported in most studies. Among those that described these resources, most of them used educational materials. These findings are similar to a study that describes the role and impact of pharmacists in Spain. 52 These resources are useful to support the pharmacy services. 18

The lack of this information affected the understanding which tools were used by pharmacists in their actions.

This study has some limitations. It is possible that some studies were missed due to not being indexed in the databases searched or being published in websites of institutions or scientific societies. Moreover, the number of publications on COVID-19 is rapidly increasing in a short time and some studies of interest available after the established search period have not been included. Finally, this review did not analyze the quality of the studies taking into account the inherent characteristic of the scoping reviews.

A reasonable number of studies that described the role of the pharmacists during the COVID-19 pandemic were found. Several methods of communication were performed in different settings of intervention. Moreover, all studies reported actions taken by pharmacists, mainly drug information and patient counseling, although description was not satisfactory. Thus, future research with more detailed description and evaluated the impact of pharmacist intervention is needed in order to guide the actions of the pharmacists in this and-or other pandemic.

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The copyright holder for this preprint this version posted July 2, 2020. . . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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