May 20, 2020

Outpatient Clinical Pharmacy Response to COVID: One Center’s Approach

By Courtney Samuels, PharmD, and Jenni Tobin, PharmD, University of Colorado Cancer Center

Oncology clinical pharmacists have the training and expertise to support providers and patients regarding initial treatment decisions, supportive care, drug interactions, and management of adverse effects. Additionally, clinical pharmacists are essential in managing drug shortages, high-cost therapies, regulatory requirements, and diminishing reimbursement (Donald, Scott, Broadfield, Harding, & Meade, 2019; Holle & Boehnke-Michaud, 2014). The COVID-19 pandemic has brought challenges to oncology clinical pharmacists’ ability to provide clinical services to their care teams and patients.

At the University of Colorado Cancer Center, our outpatient Blood Disorders Center, which covers hematologic malignancies and stem cell transplantation, has had to be efficient and flexible in adjusting to new circumstances. Our pharmacy team made a number of adjustments in a proactive effort to reduce the number of potential patient exposures.

Optimizing Clinic Appointments

Our immunosuppressed patient population is at an increased risk from COVID-19, which has necessitated extra precautions. This has included coordination of patient appointments, lab visits, and infusion appointments. Our myeloma group has made an effort to utilize all oral regimens if appropriate, such as ixazomib oral maintenance replacing bortezomib SQ maintenance. Our retail pharmacies are offering shipment of medications to our patients’ homes to reduce the number of visits to the pharmacy. In addition, we have tried to delay nonessential infusions and consolidate labs appointments or coordinate lab draws with our regional centers with lower patient volumes.

Clinic Presence During Social Distancing

Clinical workflow and processes are constantly transforming to meet social distancing requirements while also maintaining patient care. We have transitioned to more virtual communication during our normal routine. We have taken several approaches to maintain a pharmacy presence, either remotely or onsite, while working to preserve PPE and minimize potential exposures.

Our team has several critical communication platforms. Our electronic medical record (EMR) allows us to communicate with other providers through “secure chat” functionality. This has proven most useful in some of our specialty areas (particularly cutaneous T-cell lymphoma), where all patient visits have been converted to telehealth visits. Additionally, our nurses, medical assistants, and front desk staff use Microsoft Lync messaging. Through these platforms, we can answer questions across our team including those who may be temporarily relocated to different floors due to COVID-19 restrictions.

Patient Education

Despite the global pandemic, patient education is still necessary. Prior to COVID-19, we met with patients in-person prior to first treatment, changes in therapy, or as needed. In addition, we provided patients with written educational materials we developed based on frequently utilized regimens by our physicians.

As stated previously, face-to-face interactions have been minimized and reserved for only those cases that are critically necessary. To maintain our same level of pre-pandemic care, we changed all of our patient education visits to pre-scheduled telephone calls, conducted either from our offices or our homes. Prior to the phone call, patients are emailed educational materials and asked to review them in advance.

We have found it more challenging to interpret patient comprehension when educating by phone. While patients provide verbal signals of misunderstanding, we miss the facial expressions and body language cues indicating confusion or the need to repeat information. Additionally, some patients do not have the technological ability to navigate email and email attachments. For these patients, we have continued to provide verbal education and written materials via postal mail (per patient request) or materials at their infusion appointment.

Our pharmacy team has made efforts to assist both patients and caregivers with their medications and to give them tools to be successful at home. We have offered, and continue to offer, pill box education appointments, in which we help them fill their pill box and provide a “pill box map.” Our goal is to engage patients and caregivers in their care and provide tools that they can use once they are faced with independently managing their medications. Not only does this equip patients for long-term success, but it also minimizes duplicate efforts of other providers and reduces personnel interactions with patients.

Drug Shortages

With the escalation of the global pandemic, there is a potential strain on the health-care supply chain, including oncolytics. While the shortages currently identified include sedatives and paralytics related to intubation, PPE, and ventilators, there is a potential threat to the oncology drug supply. Particular oncolytics are imported from other countries, which may have disruptions in drug supply chains or slow or halt exportation or manufacturing, leading to the formation of “gray markets” and an increase in counterfeit drugs.

These drug shortages are nothing new to oncology practice; in fact, in response to an ongoing shortage of vincristine, the Mitigating Emergency Drug Shortages (MEDS) Act was passed in 2019 to incentivize generic manufacturers to continue production (American Society of Health System Pharmacy, 2020). It may be necessary during this pandemic to continue to loosen government restrictions and incentivize manufacturers, both domestically and internationally. The breakdown of drug supply chains is a global issue and one that will likely need to be addressed across borders.

As we have done in previous shortages, our pharmacists continue to monitor the status of drug shortages, allocate appropriately, and help provide alternatives. However, alternatives can often be costlier and less efficacious. While there are currently no shortages in oncology-specific agents related to COVID-19, this issue requires ongoing monitoring.

Concluding Thoughts

As the COVID-19 pandemic continues and day-to-day practices remain altered, the flexibility of pharmacists as well as that of other health-care providers is required. We encourage providers to be creative in finding the alternatives that best suit the needs of their clinic and patients. We are working through challenging times, but we are learning through the crisis and witnessing the resilience of our health-care teams.


References

American Society of Health System Pharmacy. (2020). Mitigating emergency drug shortages act. Retrieved from https://www.ashp.org/Advocacy-and-Issues/Key-Issues/Drug-Shortages/Mitigating-Emergency-Drug-Shortages-Act?loginreturnUrl=SSOCheckOnly

Donald, G., Scott, S., Broadfield, L., Harding, C., & Meade, A. (2019). Optimizing patient education of oncology medications: A descriptive survey of pharmacist-provided patient education in Canada. Journal of Oncology Pharmacy Practice, 25(2), 295–302. https://doi.org/10.1177%2F1078155217732400

Holle, L. M., & Boehnke-Michaud, L. (2014). Oncology pharmacists in health care delivery: Vital members of the cancer care team. Journal of Oncology Practice, 10(3), E142–E145. https://doi.org/10.1200/JOP.2013.001257

Read more from the APSHO Advance: Special COVID-19 Series