key: cord-0842322-at47pxwg authors: Al Meslamani, Ahmad Z.; Kassem, Amira B.; El‐Bassiouny, Noha A.; Ibrahim, Osama Mohamed title: An emergency plan for management of COVID‐19 patients in rural areas date: 2021-07-05 journal: Int J Clin Pract DOI: 10.1111/ijcp.14563 sha: 7d382654a6ee5e5e6eab199e06fcd4eeff703a48 doc_id: 842322 cord_uid: at47pxwg AIMS OF THE STUDY: To describe the experience of six hospitals in the management of COVID‐19 patients in rural areas through an assessment of proportions, types and clinical outcomes of remote clinical interventions. METHODS: This was a prospective observational study conducted in six Egyptian hospitals over a period five months. An emergency response was implemented in each hospital in order to connect clinical pharmacists with COVID‐19 patients living in rural areas. Pharmacists used phone calls and social media applications, such as WhatsApp(®) to conduct two types of interventions; (a) Proactive interventions and (b) outcome‐based interventions. IBM SPSS V26 was used for data analysis. RESULTS: Of the 418 patients included, 351 (83.97%) recovered, 60 (14.35%) were hospitalised and 7 (1.67%) were deceased. Medication orders per patient, high‐alert medications per patient and prescribing errors per patient were 5.82, 1.45 and 0.74, respectively. Telepharmacy teams conducted 3318 phone calls, 2116 WhatsApp(®) chats and 1128 interventions, of which 812 (71.92%) were process‐based and 316 (27.98%) were outcome‐based. Among these interventions, four significant determinants of improvement in clinical outcomes were found: substitution of a prescribed drug (Adjusted odds ratio [AOR] = 4.03; 95% confidence interval [CI], 2.54‐5.87), adding a drug to the prescription (AOR = 3.15; 95% CI, 1.87‐4.76), advice the patient to stop smoking (AOR = 3.53; 95% CI, 1.98‐5.17) and cessation of drug therapy (AOR = 3.11; 95% CI, 1.25‐4.55). The most common medications involved in drug‐related interventions were Hydroxychloroquine, Azithromycin and Paracetamol. CONCLUSION: Our findings demonstrate significant impact of the remote pharmacist interventions on both medicines use and clinical outcomes of COVID‐19 patients in rural areas. Pharmacists in developing countries should be supported to implement remote clinical services to provide patients in rural places with optimal care. patients in rural areas also suffer from inadequate access to needed health services because of long travel time to healthcare facilities, lack of reliable public transportation, insurance coverage issues and violence. 5 In the USA for instance, rural areas has become more diverse racially and ethnically, and thus different health challenges and social vulnerability to the pandemic among these communities are expected. 6 Amongst the avalanche of studies concerning the devastating effects of COVID-19, evidence have emerged demonstrating pharmacists as potential key players in emergency response, since they are the most accessible healthcare professionals and can reduce the burden on healthcare systems by working directly with the public, 7,8 providing care for patients with chronic health conditions, [9] [10] [11] and providing pharmaceutical care for COVID-19 patients. 12 More specifically, pharmacists' scope of practice during COVID-19 included providing drug information for healthcare personnel, patient counselling, optimisation of drug therapy, support infection prevention and control practices, monitoring laboratory results and drug inventory management. 12, 13 The use of information technology to exchange medical data between two sites is called telemedicine and it has gained much more attention during the ongoing crisis. 14 Applying this concept to pharmacy practice produces telepharmacy, which strategy allows pharmacists to provide their services without direct physical contact with costumers. 15 Before this pandemic, telepharmacies applied in the United States (US) hospitals improved patient access to pharmaceutical care and contributed to engage hospital pharmacists more in patient-centred care. 16 In Europe, hospital telepharmacy was a useful tool in remote outpatient consultation, home delivery of medications and coordination between healthcare personnel. 17 However, the vast majority of published articles on this topic are descriptive in nature and did not provide compelling evidence relating to usefulness and benefits gained from implementation of telepharmacy as an emergency response plan. Therefore, a strategy was needed with the focus on improving access of underserved population to proper care, while reducing the risk for COVID-19 transmission. A multidisciplinary expert team, comprising a group of clinical pharmacists, infectious disease specialists and nurses developed a response plan to standardise patient care in six Egyptian hospitals. The purpose of this strategy was to connect pharmacists with both physicians and self-isolated COVID-19 patients in rural areas using information technology tools. However, there were limited resources to create full telepharmacy model. Therefore, pharmacists mainly used phone calls and social media applications to initiate their response plan. The current study provides evidence on the outcomes of remote pharmacist interventions carried out to manage COVID-19 patients in rural areas. To describe the experience of six hospitals in the management of COVID-19 patients in rural areas through an assessment of frequency, nature and clinical outcomes of remote clinical interventions 2 | ME THODS This cross-sectional study used prospective data from six hospitalbased telepharmacies in Egypt over 5 months (from June to November 2020). Clinical pharmacists reported their interventions upon drug therapy of COVID-19 patients living in rural areas and clinical outcomes of those patients. Participants included were informed about the purposes of the study and verbal consents were obtained. COVID-19 patients who met the confirmatory laboratory evidence issued by the Ministry of Health in Egypt, and lived in rural areas were included in the study. Those who had no access to phone calls, moved into the urbans during the study, or not willing to be involved were excluded. The model was simple, clinical pharmacists who had full access to patient records communicated virtually with physicians and patients ( Figure 1 ). In this model, physicians prescribed medication orders for each patient using handwriting. Pharmacists reviewed the prescribed medications against the clinical data available from patient records. Then, medications were dispensed to patients' representatives. Pharmacists followed-up with patients on a daily basis using phone calls, social media applications such as WhatsApp ® . Secure network connection, electronic prescribing system, electronic patient records, automated drug dispensing cabinets, cloud services and home delivery services were not available. Thus, we asked each pharmacist to record his/her interactions with patients and physicians on an excel sheet designed by the principle investigator. • COVID-19 has severe negative consequences on patient safety, especially in rural areas. To describe virtual interactions carried out between health providers and patients, and categorise remote pharmacist interventions, several operational definitions were adopted, tailored to the study aims, and constantly updated based on the interim guidance issued by governmental entities and international pharmaceutical organisations, and based on published articles. Some of these definitions are listed below: • Rural areas: there is no global standard definition for rural areas. In Egypt, they are defined as "very distant places where public transportation and services are lacking." 18 • Recovered COVID-19 patients: Clinical pharmacists considered patients as recovered from the infection when fever disappeared for more than 72 hours, other symptoms including but not limited to: cough, chest pain, sore throat and difficulty in breathing disappeared or significantly improved, and the results of a minimum of two consecutive Polymerase Chain Reaction (PCR) tests conducted at least 24 hours apart were negative. At the beginning of the research project, five online meetings were C Validation and conflict of interests: Three research associates were asked to supervise the data collection. They were assigned to perform double check for reported data, exclude any ambiguous information, try to get the missing information without prescribing errors (PEs), of which 287 were corrected. There were no significant differences in the incidence of PEs between cured, hospitalised and deceased patients ( and cessation of drug therapy (AOR = 3.11; 95% CI, 1.25-4.55). summarised in Table 4 . Of the 1128 interventions conducted by telepharmacy teams, 743 (65.86%) were drug-related. The top five drugs affected by pharmacist interventions were Hydroxychloroquine (14.93%), Azithromycin (13.99%), Paracetamol 12.51%, Corticosteroid inhalers 9.95%, and long-acting beta agonist (6.86%) (Figure 3 ). using WhatsApp ® and short messages services (SMS). The findings of this study indicate that telepharmacy teams reduced potential adverse drug events (ADEs) by identifying and correcting prescribing errors (PEs) before reach patients. In addition, most of telepharmacy interventions were process-based. A recent study indicates a growing need for a proactive approach to minimise inappropriate medicines use. 20 Adjusting the dose of a prescribed drug (Ref) A 32-year old female patient took Nifuroxazide tablets to control diarrhoea, but it was failed and even worsened. The pharmacist stopped the Nifuroxazide and dispensed a combination therapy of Ciprofloxacin and metronidazole Outcome-based intervention/cessation of drug therapy/initiation of new drug therapy The diarrhoea was controlled after two days of starting the new therapy and the patient was recovered on day 15 A 64-year old female patient with COVID-19 and with history of diabetes mellitus type II and hypertension. The patient had high D-dimer value and suffered from hypoxia during her daily life activity. She was on Azithromycin, vitamin C, zinc supplement, actoferrin and oral prednisone. The telepharmacy team noticed a spike in blood glucose level after seven days follow-up. The processed intervention was stopping prednisone and further follow-up for glucose level and oxygen saturation Outcome-based intervention/cessation of drug therapy The blood glucose level got back to normal after 7 days and the patient was recovered on day 18 F I G U R E 3 Drugs that pharmacists intervened upon during the study electronic prescribing system and electronic patient record in response plan affects the nature of patient-provider interactions, and may induce doubts in the minds of patients. Third, because of scarce resources, it was impractical to perform two consecutive PCRs for all patients who considered recovered from the infection. Third, the privacy issue was beyond the scope of the study's aims. Some patients refused to participate in the study for privacy reasons, and this could compromise the efforts of telepharmacy. Health authorities and professional bodies could solve this issue by drawing up regulatory procedures and guidelines that encourage patient engagement in telepharmacy. Implementation of hospital telepharmacy services reduces irrational medicines use and improves clinical outcomes of COVID-19 patients in rural areas. Pharmacists in developing countries should be supported to implement remote services to provide patients in rural places with optimal pharmaceutical care. We thank clinical pharmacists, health informatic specialists and physicians who participated in the study. Their efforts in data collection are much appreciated. The authors declare no conflict of interest. All authors have significantly contributed to the concept design, provision of data collection, statistical procedures, visualisation and drafting. The Institutional Review Board of Damnhour University approved the research project (No. 221PP31). Deaths from COVID-19 in rural, micropolitan, and metropolitan areas: a county-level comparison Health care disparities across the urban-rural divide: a national study of individuals with COPD Medication management and adherence during the COVID-19 pandemic: perspectives and experiences from low-and middle-income countries Treating COVID-19 in rural America COVID-19: how can rural community pharmacies respond to the outbreak? Centers for Disease Control and Prevention. Rural communities. 2020 SARS-CoV-2 outbreak: how can pharmacists help? Recommendations and guidance for providing pharmaceutical care services during COVID-19 pandemic: a China perspective Pharmacists' readiness to deal with the coronavirus pandemic: assessing awareness and perception of roles Community pharmacist in public health emergencies: quick to action against the coronavirus 2019-nCoV outbreak Role of Canadian pharmacists in managing drug shortage concerns amid the COVID-19 pandemic Role of pharmacist during the COVID-19 pandemic: a scoping review COVID-19 pandemic: Response plan by the Johns Hopkins Aramco Healthcare inpatient pharmacy department Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19) Telepharmacy: a new paradigm for our profession Evaluating the impact of telepharmacy Pharmaceutical care to hospital outpatients during the COVID-19 pandemic Governance of rural development in Egypt Rural community pharmacies' preparedness for and responses to COVID-19 Reducing harm from potentially inappropriate medicines use in long-term care facilities: we must take a proactive approach Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies Telepharmacy: a pharmacist's perspective on the clinical benefits and challenges An emergency plan for management of COVID-19 patients in rural areas