This article will explore the key operational challenges experienced by the pharmacy department in a specialist cardiothoracic centre during the pandemic, and also touches on the emotional impact on staff dealing with these complex issues.
In January 2020, the World Health Organization (WHO) was informed that a novel coronavirus had been identified in Wuhan City, Hubei Province, China.1 WHO declared the outbreak as a pandemic on 11 March,2 and, by 1 July, more than 10.4 million cases worldwide, in more than 188 countries and territories had been recorded.3
The Royal Brompton & Harefield NHS Foundation Trust is a specialist centre for the treatment of heart and lung diseases in London with 480 beds across both hospital sites. It is the largest cystic fibrosis (CF) centre in the UK, treating adult and paediatric patients and is one of the largest and most experienced centres for cardiothoracic transplantation and ventricular assist devices (VADs). Other services offered across the Trust include treatment of interstitial lung disease, cardiothoracic surgery,
a dedicated heart attack centre, and intensive care.
Once the pandemic reached the UK, there became an urgent need for a significant expansion of critical care beds, including an escalation into unusual ward areas. Critical care capacity across the UK is around 4000 adult critical care beds under normal circumstances; however, it was reported that this would need to be increased to 10,000.4
In order to prepare for a large surge in the number of critical care patients at each hospital site, adult and paediatric cardiothoracic and cardiology elective pathways were changed. Adult and paediatric patients with complex cardiac or respiratory conditions such as pulmonary hypertension, CF, asthma, interstitial lung disease, heart/lung transplantation and those supported with VADs were increasingly largely managed as ambulatory care or in the community, to reduce their risk of contracting the virus. At the peak of the pandemic in London in April 2020, 117 patients were concurrently being treated at both the Brompton and Harefield hospitals, 90 of which required level 3 critical care support. The number of patients requiring veno-veno extracorporeal membrane oxygenation support for severe acute respiratory failure due to COVID-19 also reached a new milestone of 27 patients at a single point in time across three critical care units compared with five patients under normal circumstances.
Operational pharmacy changes
Alongside the wider NHS, the pharmacy department had to adapt quickly to the overwhelming challenges ahead. Participation in face-to-face ward rounds and multidisciplinary team meetings moved to more innovative methods of communication using virtual platforms, and senior pharmacists took on additional roles such as replenishing medicine stock lines (usually the responsibility of pharmacy technicians or assistants) to monitor stock levels very carefully and reduce pharmacy staff numbers on the wards. Individuals visiting COVID-19 Red Zones were expected to wear full personal protective equipment and working hours at the weekend were extended to support the medical and nursing teams to focus on their complex case load. Working from home, where possible, was encouraged to reduce footfall within the department and to implement social distancing.
There were also challenges in writing and updating guidelines with evidence as it emerged necessitating a couple of ‘live documents’ that were presented and ratified at bi-weekly virtual Trust committee meetings.
Shortage of oxygen
The demand for oxygen to cater for a surge of ventilated patients was a great cause for concern for the senior pharmacy management team. This is not normally an issue for hospitals as most patients are on no oxygen or low-flow oxygen. A substantially greater proportion of patients requiring oxygen therapy and ventilation was seen during COVID-19.
A patient safety notice from NHS England requested immediate attention to the use of high-flow oxygen therapy devices during the pandemic.5 There was a collaborative effort between Pharmacy, Estates and Clinical Engineering to ensure that adequate oxygen delivery could be provided to all areas with patients with critical care needs.
To monitor oxygen capacity, it was necessary to ascertain the maximum flow rate (l/min) from the vacuum insulated evaporator oxygen tank and a daily review of the number of high flow rate ventilatory systems. Urgent upgrade work was undertaken to increase output of piped oxygen across the organisation, by more than twofold.
Training and support
As the number of critical care patients increased, staff were redeployed to critical care areas, which necessitated timely and extensive training in a very short period of time. This urgent need to upskill staff was recognised both internally and externally by the Royal Pharmaceutical Society and the UK Clinical Pharmacy Association and live seminars hosted by expert panellists on various aspects of critical care on a twice-weekly basis were available/provided. Training was provided to staff required to undertake alternative roles, in addition to internal presentations and support provided by the adult critical care pharmacy team. Nursing staff, re-deployed to critical care wards, were also trained on commonly used drugs on an intensive care unit.
Educating the paediatric medical and nursing teams on medications in adult critical care was supported by the paediatric pharmacy team who upskilled themselves quickly under the guidance of their adult counterparts. A guide to critical care medication for adult COVID patients was created, the most challenging aspect of this being weaning from sedation and managing adults with delirium.
Establishing new pathways for supporting and supplying medicines for shielding patients
All pharmacy teams outside critical care had to adapt their services to provide safe care to long-term patients shielding in the community.
The paediatric pharmacy team were particularly challenged as children were required to be cared for at home to make way for the increase in adult COVID patients and the paediatric intensive care unit (PICU) changed to an adult unit (PAICU).
Children who required home IV antibiotics and would previously have been seen in out-patient clinics were now being reviewed in their own home, via video platforms or telephone clinics, to reduce face to face contact and medication was sent out by post or courier. Independent prescribing scopes of practice were expanded to support the medical teams. Home care arrangements were extended, and new contracts set up, enabling biologics for asthma and other treatments to be undertaken at home.
The respiratory pharmacy team also supported innovative ways to treat patients at home. In excess of 400 patients with asthma were taught how to self-administer biologics at home to reduce the need to attend a face-to-face hospital appointment. Home intravenous therapies were expanded for patients with CF and non-CF bronchiectasis. Out-patient clinics became virtual and medication posted to a patient’s home address to ensure shielded patients did not have to venture out to collect their supplies. Patients requiring regular IV immunoglobulin had dose adjustments to extend the infusion interval and some patients were also switched to a subcutaneous route for self-administration at home.
Cardiothoracic transplant and VAD patients continued to require specialist support in the hospital and the occasional in-person follow-up in out-patients, however, where possible patients were supported at home. The specialist pharmacy team developed new ways of working to support this vulnerable group of shielded patients in their homes by using Telehealth (virtual and telephone clinics), a roll-out of finger-prick testing for the immunosuppressant tacrolimus, expanding homecare service for intravenous antibiotics, and oral immunosuppressants and other medicines as required. Tailored information was provided to patients via SMS texts, patient support groups newsletters and social media platforms. A ‘live webinar’ was established between consultant physicians, a consultant pharmacist and a clinical psychologist to support lung transplant recipients, with approximately 140 patients joining the event; this provided an exciting platform to answer numerous questions and concerns from patients.
The anticoagulation service was also adapted to meet the needs of patients requiring these where appropriate. Patients were switched to direct-acting oral anticoagulants to reduce test requirements, local INR testing with GPs and district nurses for warfarin was actively encouraged, and there was an expansion of self-testing at home to reduce need to attend hospital sites.
Clinical trials
The randomised evaluation of COVID-19 therapy (Recovery) and Remap-Cap are novel adaptive clinical trials that commenced during the pandemic to evaluate several treatments, simultaneously, as new evidence emerged. These trials were adopted into the Trust very quickly, providing huge challenges to the pharmacy clinical trials team. A number of steps were necessary for the successful implementation of a particular domain such as the creation of a dispensing prescription template, design of standard prescription orders on two electronic prescribing systems and dissemination of administration guidelines. It was also necessary to ensure that all staff were familiar with the randomisation process (particularly at the weekend) and ensuring that patients transferred from other NHS Trusts were continued on a particular domain or standard of care arm. It was also necessary to respond to substantial amendments when treatments were suspended, or new arms created.
In line with NHS guidance at the time, clinical teams were also discouraged from using novel therapies (hydroxychloroquine, remdesivir, angiotensin 2, azithromycin) outside of clinical trials due to unproven benefit and risk of harm to patients and depletion of supply to existing patients with other long-term conditions.
Daily situation report (SITREP) for critical medicines
A SITREP report was set up to identify concerns regarding the supply of critical medicines. This was to assure the senior management and clinical teams in the Trust of drug availability before accepting new patients. A significant proportion of these drugs were supplied on allocation to regions and Trusts, under central control and delivered on a ‘just-in-time’ basis to ensure supplies were shared across all hospitals and to prevent stockpiling. At the height of the pandemic in Europe, stockpiles of essential drugs were depleted and stock within the EU was under pressure from several countries. An example SITREP is shown in Table 1.
In order to create this SITREP table, it was necessary for members of the pharmacy purchasing team to conduct a stock count of critical drugs daily. This table was pivotal in informing clinicians of drug shortages, and clinical teams were very supportive to switching to alternative agents.
A SITREP for dialysis fluid and filter sets was also launched, as it became clear very early on that a substantial proportion of COVID-19 patients requiring critical care support were suffering from acute renal failure that required haemofiltration. Levels were assessed daily to inform clinicians of potential shortage issues. Haemofiltration bags were in very short supply and meetings were held regularly to discuss and monitor the use of renal replacement therapy and citrate haemofiltration was used as an alternative for non-COVID elective cardiac surgery patients. Nurses were supported where they were required to use unfamiliar products and, in some circumstances, additional electrolytes had to be added to bags. A risk assessment of adding high-strength potassium to these bags had to be undertaken rapidly between the pharmacy and clinical teams and gain approval by the Medicines Management Board, which would have taken longer, under normal circumstances.
A doubling of the fleet of nitric oxide machines and cylinders across both hospital sites was necessary as emerging evidence suggested that pulmonary vasodilatation may provide some benefit in the short-term to treat the complications of COVID-19 infection.
Intravenous therapies
Following discussions with the senior nurse management team, it was clear that nurses on the front line were having difficulties with the demand for complex infusions due to the sheer volume and frequency of syringe changes. Pre-prepared drug syringes were outsourced to reduce nursing time in preparing commonly used parenteral medicines and to free up time for other clinical duties. The senior pharmacy management team were ready to deploy pharmacy staff to make up IV drugs on the ward, but the procurement of pre-filled syringes became a more viable option with a longer shelf life. Pre-filled syringes that proved very successful were magnesium injection 20mmol in 50ml, noradrenaline injection 8mg in 50ml and rocuronium injection 500mg/50ml.
Following discussion and approval between pharmacy critical care and clinical teams, other measures were taken to reduce intravenous drug burden and reduce reliance on drug infusion pumps by opting for medicines with longer half-lives (for example, pantoprazole IV 40mg od instead of ranitidine IV 50mg tds) and the administration of drugs as bolus/short infusions in favour of extended infusions (pip/tazobactam IV 4.5g over 30mins and meropenem IV 1g over 5mins instead of over 4 hours as per protocol). Novel ways to administer intravenous drugs in the same syringe, namely sedation, were also explored should the availability of infusion pumps become limited.
Amendment of controlled drug (CD) requirements
Temporary changes were made to the Medicines Management Policy to enable nursing staff to access CD in a more timely manner. The requirement for using the paper register to record entries of administrations was replaced with the use of the electronic register for critical care areas with automated drug cabinets.
The requirement for a second witness check was also temporarily removed for some CDs where a second check was undertaken as part of the administration process. This represented a huge challenge, particularly for a large number of staff re-deployed to critical care areas unfamiliar with local procedures and availability of opioid and sedative agents. Additional guidance was frequently updated and circulated and support made available. Temporary changes were kept under regular review.
Any stock discrepancies which occured during the height of the crisis were resolved in a timely manner by thorough scrutiny of the electronic CD register, dispensary records and paper CD orders. The main factor in the majority of discrepancies was due to unfamiliarity of a particular product line and subsequently it was decided to re-instate the second witness check. Positive user experience meant that electronic register could continue to be used to record CD transactions in automated drug cabinet areas in line with pre-existing project plans.
Psychological impact on pharmacy staff
The COVID-19 pandemic has caused significant loss of life and disruption in every walk of life. For pharmacy staff, it has represented the most intense and stressful time of their career, causing anxiety, near burnout and emotional stress. The critical care pharmacy team has had to deal with a very high number of critical care patients; other teams have re-modelled their services to care for their patients safely in the community and the procurement team have had to deal with very challenging drug shortages. Regular ward stock checks and monitoring of drug shortages to prevent interruptions in therapy were very time consuming and stressful. Teams had to quickly adapt to latest critical medicine drug shortages and communicate this in a timely and effective manner. Coupled with daily uncertainty and an ever-changing landscape, few would argue that this pandemic has presented a situation like no other.
Reflection and conclusions
This challenging period of our careers has provided some positive developments to service delivery, that would normally take months or years to develop and implement. Some of the successes that can be celebrated include the use of virtual platforms for MDT and patient consultations and the use of IT to make processes more efficient, such as record keeping for CDs, ordering of parenteral nutrition and the use of electronic outpatient prescribing.
Information sharing between organisations across various specialties and regions (national and international) was pivotal to help hospital Trusts manage themselves effectively through different stages of the pandemic. Well-established critical care networks across north and south London were vital to update users on critical care bed capacity, guideline updates and drug shortages. As a specialist heart and lung institute, our specialist teams were able to provide advice to other centres on the use of anticoagulation, steroids and pulmonary vasodilators to treat the complications of COVID-19 infection.
Authors
Chris Remmington MPharm PgDip IP
Nicola Holt BPharm
Sukeshi Makhecha BSc (Hons) MSc IP
Elaine Bowman BSc (Hons) MSc IP
Sian Bentley BPPharm PgDipPharmPrac IP
Haifa Lyster MSc FRPharmS FFRPS
Alastair Hill MPharm PgDip IP
Jaimisha Patel MPharm PgDip IP
Richard Di Palma MPharm PgDip IP
Sharon Clarke
Keith Thompson LLM MPharm MRPharmS
References
1 World Health Organization. Pneumonia of unknown cause – China. Disease Outbreak news, 5 January 2020. Emergency Preparedness. www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/ (accessed October 2020).
2 World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov) (accessed October 2020).
3 COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE). Johns Hopkins University. https://coronavirus.jhu.edu/map.html (accessed October 2020).
4 Anandaciva S; The King’s Fund. Critical care services in the English NHS. www.kingsfund.org/publications/critical-care-services-nhs (accessed October 2020).
5 Use of high flow oxygen therapy devices (including wall CPAP and high flow face mask or nasal oxygen) during the coronavirus epidemic. Estates and Devices Alert. NHSE/I – 2020/001. 31 March 2020.
