Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality Improvement at the American Society of Health-System Pharmacists (ASHP). In her professional role she serves on committees and initiatives with PQA, NQF, and the National Academy of Medicine. We spoke with her about how pharmacist care delivery services have been impacted by COVID-19.
Dr. Kendall Hall: Can you can please introduce us to who you are and your current position?
Anna Legreid Dopp: My name is Anna Legreid Dopp and I am a pharmacist by training. I am the Senior Director of Clinical Guidelines and Quality Improvement at the American Society of Health-System Pharmacists (ASHP). In my role at ASHP, I am responsible for collaborating with our members and external organizations to advance quality improvement efforts where pharmacists are contributing members.
KH: We previously worked with Dr. Legreid Dopp on an Annual Perspective regarding the role of the pharmacist in patient safety. With increased attention paid to medication safety during this COVID-19 pandemic, we reconnected with Dr. Legreid Dopp to gather her perspectives on the topic. How has your role at ASHP changed, if at all, with the COVID-19 crisis?
ALD: All of our roles at ASHP have changed because of COVID. I think everyone’s in healthcare has, so that’s not unique to us. It’s definitely more intense in certain areas. Specifically within the Office of Practice Advancement, a lot of our work is with members and developing resources on behalf of members. We are still responsible for managing the day-to-day activities we had prior to COVID, but it seems like there is something new every day to work on as it relates to COVID. It is all work informed by our members, so as we learn what they are experiencing on the frontline, we are trying to advance more resources for them.
KH: Has the direction of the organization changed as well?
ALD: I would say yes, it has changed because we’re a member-based organization. The best part about being a member-organization is that you learn from- and collaborate with- members and that informs and prioritizes your work. We are consistent in our mission: trying to advance resources and tools to inform pharmacists and pharmacy staff to do their best for their patients. Our focus has been more intensely related to how we can help in this time of COVID. A lot of the outputs we’ve had in the last few weeks are thanks to the willingness and generosity of our members to share their experience and expertise during the pandemic, which enables others to learn from them. Our outputs have fallen into a few big buckets: development of resources; advancing advocacy efforts, including standards setting with external stakeholders within the profession and external to the profession of pharmacy; and finally, education and communication.
KH: What are some of the things you are hearing from members, what are their concerns?
ALD: A priority among members and staff are concerns related to medication shortages. We’ve been dealing with medication shortages for almost two decades now. Prior to COVID, most of the shortages were a result of a supply chain disruption, for example a company’s decision to discontinue a medication or a natural disaster stopping drug manufacturing. Today during COVID, many of the shortages are being caused by the sharp increases in demand due to the surge in COVID patients, especially those patients that require ICU care and mechanical ventilation. This is in addition to the supply chain disruptions which are more pronounced because of COVID. Because of the shortages, decisions need to be made on medications that may be second or third line, which providers may be less familiar with, may be less effective, or may carry more side effects, but that’s what providers and patients have access to.
Another concern is the off-label use of medications. At this time, while the FDA [Food and Drug Administration] has issued Emergency Use Authorization for the use of Remdesivir, we know that there is no FDA-approved medication or vaccine for COVID-19, and we are seeing the use of medications that have a good evaluative use for patients with COVID. We know these drugs have limited safety and efficacy profiles and, in addition, if you use them in combination with other medications you can have some serious potential for patient harm. Just linking back to what I said previously, it’s all thanks to hearing from those members that are on the front line, that are willing to get on a phone call with us at 9 o’ clock at night to talk about what is happening in their systems and with the status of their drug supplies. That helps us know how we can make connections to public health departments or to the FDA to support them.
Beyond medication shortages, our members are having to drastically change their pharmacy operations. There is no one better than pharmacists and pharmacy technicians to be the guardians of the medication-use system. All the way from procuring the medication, preparing the medication, collaborating with the healthcare team to get the right medication to the right patients, to monitoring the safety and efficacy of that medication. COVID-19 has really changed the operations, whether it’s a field/surge hospital or non-hospital setting (like the McCormick Place Convention Center in Chicago, for example), ICU bed expansion, members of the workforce that are working remotely or are furloughed, or keeping up with informatics demands with constantly changing medication supplies.
The last area of concern is a topic that has been important to ASHP for years now – the health and the wellbeing of the pharmacy workforce. This includes workforce members that have been exposed to COVID as well as wrestling with the high demand and the risk of burnout within the workforce. In particular, we are going to be really vigilant about burnout given the known bi-directional relationship between burnout and patient safety. There is a link between a healthcare worker who is burned out and an increased risk of causing medical error. When a provider who went into the healing profession in the first place causes the medical error, it leads to more burnout and you see a difficult cycle there. We need to be mindful about that.
KH: Are your members putting into place new or different patient safety tools to help prevent errors?
ALD: I would say yes and will also mention that one of the things we did very quickly after the pandemic started was to ensure there was a means for members to connect to each other. We have a tool we call our COVID-19 Connect Community that all 55,000 members have access to. This forum is an opportunity for peer-to-peer communication, where members ask questions, share answers, share experiences, and learn from each other. Our members are all very mindful of changes and ensuring patient safety isn't compromised. So we see tips being shared between members very quickly that also include directions on maintaining patient safety. I credit the culture shift over the last 20 years to make sure that patient safety remains front and center. It's about making sure we enable an effective COVID response, but ensuring that we are being safe about it.
KH: Has the role of the pharmacist at the hospital changed with the pandemic in terms of how they are providing care – are they more involved with these patients? Less involved because of the need to distance themselves? Has that changed at all or are we just doing it differently? Like using telehealth setups with one clinician in the room and the rest of the team on the outside and communicating via a telehealth setup?
ALD: If anything, the role has been enhanced. Things that were in place before (for example, team-based care and the pharmacist being involved in those patient care decisions) have been enhanced due to the need for everybody to be practicing at the top of their education during this time. There are differences now in who is allowed in patients’ rooms and if people are working remotely or not. Thanks to advocacy efforts, there has been a relaxation of some regulatory burdens that we considered restrictive to patient access and limited the ability of pharmacist to provide safe and effective patient care. I think that is a positive and there is a great opportunity to enable advances we haven’t seen at this rate of change previously. Hopefully the changes to access and efficiency won’t be temporary and can become permanent. The use of telehealth is a great example.
Something concerning we have heard from our members is that the prioritization of personal protective equipment (PPE) has not been universally applied to the healthcare team. We’ve heard from members that physicians and nurses have access to it first and then the pharmacists and respiratory therapists and others second. They are still seeing the same patients, still going into the same rooms for the same procedures, but don't have access to that same level of PPE. So that's something that we've been trying to manage and advocate on behalf of our members so they have the protection that they need, even if they are working more on the non-acute side in the outpatient setting, whether it’s in ambulatory clinics or in pharmacies. They don't necessarily have access to the PPE they should have even though they are frontline workers being exposed themselves.
KH: In thinking about ambulatory care, I think there is some sense that people are postponing doctors’ visits or reducing their medication adherence during this time. There is a fear of not being able to get to the pharmacy. Are you hearing anything about these patients and if so, what is the response of pharmacist services?
ALD: Some of our members work in outpatient pharmacies and ambulatory settings, in addition to inpatient settings. What we have heard from those members is that their roles have been elevated when it comes to chronic disease management, through things such as telehealth and phone calls to ensure that chronic care needs are being met for patients. We’ve heard about some measures being taken to allow for less exposure within a traditional dispensing pharmacy, such as encouraging drive-up or curbside pickup or shifting prescription volume to mail order to allow for social/physical distancing. One exciting thing that came out of HHS is that pharmacies are now authorized to order and administer tests for COVID. That is a huge opportunity to allow for a community response to COVID and not have patients going to the emergency department and continue to overwhelm the hospital. This allows for more of that community outpatient management of COVID patients who are less acute and have less severe illness. I think there is a great opportunity for pharmacies to step in now that they can be a part of the test-and-triage or test-and-treat model. That high, local touch that pharmacists can offer is, and can be, a community asset as long as their skills and expertise are leveraged.
KH: If you had to pick one or two medication safety challenges that you see on the horizon as a result of COVID, what would those be?
ALD: First and foremost is consistent access to medication. Then the safe use of those medications, as we were just talking about – ensuring safety of those medications that are considered second or third in line or the use of medications that are being used off-label. What is most important here is the need for consistent ADE [adverse drug event] reporting and surveillance. We have been urging our members to be vigilant about reporting suspected ADEs though the FDA MedWatch form. Using this data, we can look for safety signals, especially for medications that are being used off-label where we don’t have information on how medications might interact or what their effects are going to be on patients with COVID.
Finally, as I mentioned, the overall safety of the healthcare workforce helps to ensure they are able to be their best and operate at the top of their education. This all ties to patient safety.
KH: Are you thinking about how to bolster the workforce or how to ensure that if the workforce is affected, it doesn’t disrupt the workflow?
ALD: I think the silver lining in all of this is that COVID is offering tremendous opportunities. We are seeing pretty remarkable innovation and unique collaborations. All of these things have elevated the capacity for the entire workforce, including within the pharmacy profession. There are huge opportunities when everyone is practicing at the top of their education, challenged to contribute to such a critical cause like COVID, and looking for best practices to carry forward beyond the pandemic.
We recently released something called “ASHP CareerPharm Rapid Connect.” This is a free service to help alleviate staffing shortages. It allows for people to voluntarily submit their name if they are available to work and in what capacity they can work. It also allows all employers, healthcare systems, or pharmacy departments to look at those volunteers to see how they can pull individuals to where they are needed. We are trying to connect and match people. We’ve also talked about the fact that there could be some elevation of practice there and some transition in specialty as a result of people learning new skills. To enable competency development, we opened up a critical care certification course to members, non-members and people internationally. Over 35,000 people accessed it during that open access period. There’s certainly opportunity to learn new things as a result of COVID.
KH: Is there anything we did not cover that you would like to discuss?
ALD: There are some resources we developed, in collaboration with members and on behalf of members, that we are really pleased with and proud of. The power of that collective expertise, experience, and passion is remarkable. A highly used resource is an evidence assessment of the medications that are being used to treat COVID. This resource is updated twice weekly, and it has information and evidence summaries for a host of medications that are being considered for treatment. We have stewardship guidance for medications that are being used off-label. We have also developed different assessment tools and checklists to keep pharmacy departments whole and to keep pharmacists and pharmacy technicians safe at work and when they go home. We have a COVID-19 resource center that’s open access and we also are allowing public access to our product called “AHFS Clinical Drug Information.” This is the longest published federally designated drug compendia that’s issued and managed by a professional society. One final example of resource developed by members on behalf of members is a Business Recovery Toolkit, aimed at informing next steps as the nation opens back up. We’re really pleased that we are able to open up all of these resources, not just for our members but everybody who is trying to do their best to care for patients right now. We have a consumer website called “safemedication.com” that offers medication tips and resources and even includes medication information search tools for patients. On that website, there is a page dedicated just for patients related to COVID-19.
To learn about federal resources addressing recommended treatments, the latest evidence available for COVID-19 care, and current drug shortages, please consult the National Institutes of Health COVID-19 Treatment Guidelines and FDA Drug Shortages Database.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this product as an official position of AHRQ or of the U.S. Department of Health and Human Services.