key: cord-0856123-dbm9xvo4
authors: Mercer, Julianne; Liang, Alina; Yoon, Jane; Nguyen, Jessica; Carroll, Joni; Coley, Kim C.
title: COVID-19 pandemic vaccination preparedness strategies for independent community pharmacies
date: 2022-01-06
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2022.01.003
sha: 489068098a1ebd37ee97693c14bdeedd0555f970
doc_id: 856123
cord_uid: dbm9xvo4

Objective To determine independent community pharmacist preparedness for COVID-19 vaccination and to identify strategies for COVID-19 pandemic vaccination implementation in Pennsylvania. Methods This study utilized a complementary mixed-methods approach to recruit independent community pharmacists to participate in an electronic survey and two virtually conducted focus groups prior to availability of the first COVID-19 vaccine. Information was gathered and compiled into five topic areas: (1) workflow; (2) resources; (3) staff and patient safety; (4) communication; and (5) documentation and training. Data collection occurred between October and December 2020. Survey data was analyzed using descriptive statistics. Focus group discussions were audio-recorded and transcribed. A directed, content analysis was conducted to identify strategies for each topic area and supporting quotes were selected. Results Eighty-eight and 11 independent community pharmacists participated in the survey and focus groups, respectively. Because of the small size of most independent pharmacies, participants recommended working with community partners to support offsite mass vaccination clinics. Leveraging partnerships with community organizations and universities could be utilized to support staffing for vaccination efforts. Using an appointment-based immunization model was identified as one tool to optimize patient and staff safety during the pandemic. Pharmacists suggested utilizing existing scheduling tools as well as text messaging and automated phone calls for second-dose reminders. Finally, independent pharmacists recommended further training and process improvements to support vaccine documentation and transmission to Pennsylvania Statewide Immunization Information System (PA-SIIS). Conclusion Recommendations from this study were utilized to support planning and preparation for COVID-19 vaccinations across Pennsylvania. Incorporation of pharmacists’ ideas and recommendations on pandemic vaccination implementation is an important strategy to efficiently expand vaccination administration during pandemics.

• A playbook was developed that supported COVID-19 pandemic vaccination implementation at independent community pharmacies in Pennsylvania J o u r n a l P r e -p r o o f

Large-scale, efficient vaccine administration is an essential component for successful management of pandemics. On December 11 th 2020, the U.S. Food and Drug Administration (FDA) granted the first emergency use authorization for a vaccine intended to prevent COVID-19. 1 Prior to this date, many US states and territories already developed some strategies to distribute COVID-19 vaccines. In Pennsylvania, pandemic vaccination planning began years earlier and included community pharmacies as a major component for vaccine distribution. 2 These early pandemic preparedness efforts culminated with a Memorandum of Agreement between community pharmacies and the Pennsylvania Department of Health to facilitate communication between these entities during a pandemic. 3 Leveraging community pharmacists as part of a pandemic vaccination public health response is an important strategy and results in a more timely and coordinated response to public health emergencies. 4 , 5 Schwerzmann demonstrated through simulation that when community pharmacists are part of pandemic vaccination efforts, the time to reach 80% population coverage is reduced by seven weeks. 6 Community pharmacies are highly accessible to the public with approximately 90% of Americans living within 5 miles of a community pharmacy. 7, 8 There have been increasing numbers of pharmacist-administered annual influenza vaccinations at an average of 20% per season from the 2016-17 to 2018-19 seasons. 9-11 A geographic information system analysis using data across the US demonstrated that approximately 75% of potential COVID-19 vaccine administration facilities were community pharmacies which further implies that pharmacists' must be prepared to actively participate in COVID-19 vaccine administration. 12 Preparing community pharmacists to effectively provide novel vaccines during a pandemic is imperative. Pharmacists need to be experts in all aspects of pandemic vaccines including acquisition, administration, documentation, and education. 13 Pre-existing infrastructure and resources within chain community pharmacies may allow pharmacists in these settings to provide care for large patient volumes. 14 In comparison, independent community pharmacies are often single pharmacy locations or small independently-owned chains that provide specific, niche services to their local communities. 15, 16 More specifically, independent pharmacies are often located in underserved areas, such as rural areas, likely operating as one of few vital pharmacy providers in their communities. [16] [17] [18] Shortly after the COVID-19 pandemic began, it became evident that a plan for COVID-19 vaccination rollout tailored to independent community pharmacies in Pennsylvania was needed. The objective of this study was to determine independent community pharmacist preparedness for COVID-19 vaccination and to identify strategies for COVID-19 pandemic vaccination implementation in Pennsylvania. The strategies identified in this study were then compiled into a COVID-19 Vaccination Playbook for Pennsylvania's Independent Community Pharmacies. This playbook was distributed throughout the Commonwealth as well as more broadly through CPESN USA. 19 

This project utilized a complementary mixed-methods approach and included both an electronic survey and two virtually conducted focus groups. In a complementary mixed-methods study, the results of two methods (i.e., survey and focus groups) are used to clarify and build upon one another. 20 The survey was utilized to collect data on the status of preparedness for COVID-19 vaccination administration in independent pharmacies, and the focus groups were utilized to identify specific strategies to improve preparedness. The research was approved by the University of Pittsburgh's Institutional Review Board.

The survey was conducted between October and December 2020. PPCN is predominantly a network of independent community pharmacies committed to the provision of advanced patient care services. 22 Respondents who practiced in an independent community pharmacy at the time of survey were included. Following completion of the survey, respondents were able to enter into a randomized giveaway including two individually awarded monetized incentives. Descriptive statistics were used to analyze survey responses using IBM®️ SPSS®️ Statistics Version 26. Multiple choice responses were reported as categorical data and Likert responses were treated as continuous variables and reported as means.

Two virtual focus group sessions were conducted in November 2020 via Zoom video communications platform. Potential focus group participants were identified through the survey. Survey respondents who expressed interest in participating in a focus group were directed to a separate survey form where they could provide their contact information. The study team then contacted potential focus group participants to confirm their interest and availability. Focus group participants did not receive any incentives associated with participation in this study. A focus group discussion guide (see Appendix II) was developed and informed by the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. 21 The discussion guide was further refined by members of the study team, and the final guide included 18 open-ended questions. Focus group questions addressed specific pandemic vaccination administration topic areas including (1) workflow; (2) resources;

(3) staff and patient safety; (4) communication; and (5) documentation and training. Both focus groups were conducted by members of the research team and included a designated facilitator and two observers to take field notes. Each session was scheduled for 90 minutes. Focus group sessions were audio-recorded and transcribed verbatim utilizing a commercially available video content management software supplemented with manual review of audio files by the study team to correct and clarify auto-generated transcriptions. A directed content analysis was conducted to identify strategies within the five pre-categorized pandemic vaccination administration topic areas. 23 The research team compiled survey data and the focus group findings by the aforementioned five topic areas. A rapid cycle evaluation strategy was chosen to accelerate the research process and improve efficiency given the need for rapid turnaround of results prior to the COVID-19 vaccine rollout. 24 Strategies for COVID-19 vaccine implementation were developed from these results to inform a COVID-19 vaccination playbook for independent community pharmacies. 25 

Of the 122 anonymous survey respondents, 88 identified themselves as independent community pharmacists and thus were included in the final data analysis. There were 11 pharmacists in total who participated in the focus groups: six participants in the first focus group and five participants in the second focus group. Demographics for survey respondents and focus group participants are included in Tables 1 and 2 , respectively. All survey data that further informed strategies elicited from focus groups were included and organized into five broad categories as outlined below. ." (Pharmacist 11) Appointment-based immunization models were also discussed as a tool to further optimize safety. Pharmacists suggested that pre-appointment screening could be integrated into the appointment-based scheduling process. One pharmacy owner created their own pre-screening form and stated, "We added a simple [pre-screening] 

As of fall 2020, documentation of COVID-19 vaccine ordering and administration with the PA-SIIS requires enrollment and training for all prospective users. About a third of survey respondents reported that their pharmacy had a dispensing system that already interfaced with PA-SIIS to transmit information directly into the immunization information system. Another 31.8% of respondents reported that their pharmacy staff would enter COVID-19 vaccination information manually, and the remainder of respondents were unsure of their current plan for documentation at the time of the survey. Focus group discussions placed an emphasis on the use of portable technology for ease of documentation due to the possibility of off-site vaccination clinics. One pharmacist noted, "If they can remote into the pharmacy management system in real time from the clinic site, they could actually be doing the [documentation] while they're [at the clinic] so you wouldn't have to take it back to the pharmacy and enter all those prescriptions." (Pharmacist 11)

For training needs, pharmacists ranked COVID-19 vaccine-specific training and cold chain requirements in compliance with CDC guidelines as the top two areas of greatest importance. On a scale of 1 to 10 with one being least important and 10 most important, the mean ranking for COVID-19 vaccine-specific training and cold chain requirements was 9.4±1.2 and 9.2±1.5, respectively. Focus group participants stated they preferred to have this training online: "online training can be viewed and done at any time and will be most efficient" (Pharmacist 6).

The overarching goal of this work was to identify strategies to support COVID-19 pandemic vaccination implementation at independent community pharmacies in Pennsylvania. Recent studies identified pandemic vaccine implementation strategies for chain community pharmacies, however, the needs of independent pharmacies are unique. 2, 14 Independent pharmacies in Pennsylvania are often located in more rural settings, and by their nature do not have access to space, personnel and financial resources that are available to larger chain pharmacies. With the emergence of the COVID-19 pandemic, the importance of pandemic vaccination administration planning in community pharmacies that includes strategies for infection control, resource acquisition, and vaccinations became apparent. A study by Carpenter and colleagues revealed that 27% of rural community pharmacies with a disaster preparedness plan felt their plan was inadequate for COVID-19. 17 That study did not address preparedness for COVID-19 pandemic vaccine implementation which was the primary focus for our present research.

Results from our survey and focus groups provide strategies for pandemic vaccination planning for independent community pharmacies in five topic areas: (1) workflow; (2) resources; (3) staff and patient safety; (4) communication; and (5) documentation and training. With respect to workflow, independent pharmacists expressed concerns over the small available space in their pharmacies to provide vaccines for large crowds as part of their normal workflow. Participants recommended partnering with their communities for use of larger spaces for mass vaccination efforts. Independent pharmacies often have strong community ties which can be leveraged during a pandemic. 27 Indeed, during the COVID-19 pandemic, Pennsylvania pharmacies collaborated with a variety of community partners including fire departments, churches, community centers, farms, businesses, schools, and universities. 28, 29 Another important finding from this research was that many independent community pharmacies vaccine storage and temperature monitoring equipment did not meet the requirements set forth by the CDC for COVID-19 vaccines. 30 For example, our survey revealed that slightly over onethird of respondents utilized the recommended continuous temperature monitoring devices such as a digital data logger on their refrigeration units. The Playbook provided vital information on COVID-19 vaccine storage and handling requirements including links to CDC training and other resources. Additionally, as a result of this research, the study team was able to facilitate acquisition of digital data loggers for community pharmacies through a grant from the Pennsylvania Department of Health. By meeting CDC storage and handling requirements, many independent community pharmacies in Pennsylvania were able to qualify as COVID-19 vaccine providers early on in this pandemic. 31 One significant concern for these pharmacies was their ability to provide COVID-19 vaccines efficiently to large numbers of patients considering their staffing constraints. Focus group participants suggested expanding on their partnerships with universities to identify student pharmacists that would be willing to volunteer their time to support vaccination efforts such as patient screening, vaccine education and administration, and clinic workflow. This idea was operationalized in the Playbook by providing student pharmacists from Pennsylvania's seven colleges/schools of pharmacy with a website link where they could sign-up to support vaccination efforts. Between January and April 2021, 90 student pharmacists were connected with 23 independent pharmacies in Pennsylvania to support the provision of COVID-19 vaccinations.

Similar to other community pharmacy pandemic preparedness studies, our pharmacists recognized the need for easily accessible, additional pandemic preparedness training. 2, 13, 17 In a survey by Bahlol and colleagues, only 21.3% of community pharmacists reported having pandemic training, despite pharmacists' roles in emergency pandemic responses largely involving education. 13 Another survey from Zhao and colleagues reported that most pharmacists and pharmacist extenders were willing to be trained in emergency preparedness. 32 Our study revealed that pharmacists were most interested in training on the specific pandemic vaccine and cold chain requirements. Cold chain training was a point of emphasis for much of the pandemic training offered by the investigative team considering that many independent pharmacy survey participants did not meet the CDC's vaccine storage and temperature monitoring equipment requirements for COVID-19 vaccine. The Playbook also provided links to training that was required by the Pennsylvania Department of Health including training on the Pennsylvania Statewide Immunization Information System as well as the CDC's vaccine storage and handling training. The playbook was published in December 2020 and served as a vital resource for independent community pharmacies to prepare for COVID-19 vaccinations (https://www.clip.pharmacy.pitt.edu/2020/12/covid-19-vaccination-playbook-for-pennsylvaniasindependent-community-pharmacies/). 25 It was shared broadly through social media platforms, and by the University of Pittsburgh School of Pharmacy, the Pennsylvania Pharmacists Association, Value Drug Company, the Pennsylvania Pharmacists Care Network, and CPESN USA.

There were several limitations of this study. First, this study was conducted in a single state which may limit its generalizability to independent pharmacies outside Pennsylvania. However, many of the recommendations within the playbook could be implemented widely in many pharmacies. Additionally, because the survey link was broadly distributed through multiple electronic platforms, calculating a survey response rate was not possible. Lastly, the relatively small number of focus group participants and the timing of the focus groups, which occurred prior to the initial COVID-19 vaccine distribution in Pennsylvania, may have limited our ability to identify all barriers and facilitators to pandemic vaccine implementation.

Feedback from independent community pharmacists elicited through a survey and focus groups supported planning and preparation for COVID-19 vaccinations across Pennsylvania. Incorporation of pharmacists' ideas and recommendations on pandemic vaccination implementation is an important strategy for successful vaccination efforts during a pandemic. Insight from this research informs numerous strategies for independent community pharmacies across the nation to optimize pandemic vaccination preparedness. 

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The authors thank the students, faculty, and staff members of the University of Pittsburgh Community Leadership and Innovation in Practice Area of Concentration for their support throughout the duration of this project.J o u r n a l P r e -p r o o f