While CarolinaEast Medical Center shifted some of its focus to care for COVID-19 patients, the hospital’s pharmacy was on he front lines of change in the way medications are procured and delivered.
"Part of the problem with the COVID-19 pandemic is that a lot of our medications are on shortage," said Genelle Butz, pharmacy director at CarolinaEast Health System.
To get what patients need, the hospital reaches out to suppliers and manufacturers directly, said Sandi Avery, pharmacy buyer and supply coordinator.
"We tell them what our needs are and they’re trying to supply us with our medications," Avery said. "We’re just trying to make sure we have enough to cover our patients and not take those medications from areas that need it for the COVID patients."
Another hurdle is substituting medications for those unavailable, she said.
"It’s not something we can do in five or 10 minutes," Avery said. "It usually takes days to coordinate that."
Butz said the new medications must be entered into the hospital’s inventory tracking system and electronic medical records so they are compatible with bedside bar code systems used to ensure patient safety.
"It makes it challenging to just bring something in very quickly," she said.
Avery said now that people are having more products shipped to their homes via UPS or FedEx, the hospital is seeing delays in receiving shipments of medications. She said the hospital has started getting Saturday deliveries to ensure needs are met.
Because manufacturers and suppliers are seeing unprecedented demands for certain products, it takes time for them to ramp up, Butz said. As a result, some suppliers restricted access to certain medications, including those routinely used at the hospital, she said.
"Depending on how they restrict these medications, we have to go back to them and say, ‘No, this is what we normally use. We’re not trying to buy too much,’" Butz said. "It has been a lot of back and forth with trying to make sure we’re getting what we need for our patients as well as trying to anticipate the needs of what a COVID outbreak looks like."
As research points to possible new drugs to combat COVID-19, demand for those drugs increases, she said.
Once example is remdesivir, she said. A recent government-sponsored study found that remdesivir shortened the recovery time from COVID-19 by 31 percent -- an average of four days -- for patients hospitalized with the virus.
"All of that medication is going to one wholesaler and the government is identifying where it goes," Butz said. The most recent information she received from the state showed the drug was going to seven hospitals in areas with a high volume of COVID-19 patients. New Bern is not one of those areas.
ICU pharmacist Natalie Merrels said as she and CarolinaEast pharmacy manager Jeff Spray were discussing therapeutic options for patients with COVID-19 early on, they saw the availability of hydroxychloroquine almost disappear in a day.
"Things have changed really quickly, and we’ve had to adapt and manage an inventory as the evidence changed," Merrels said. "It has been a lot to keep up with."
Lead clinical pharmacist Amy Copley said her mother takes hydroxychloroquine, also known as Plaquenil, for lupus, an autoimmune disease that can cause severe fatigue.
"I was initially concerned that she would not be able to get her maintenance supply that she takes all the time to keep her lupus in check," Copley said. "I think that has been a common theme with patients who have been on this for a while."
She said her mother has been fortunate that she has been able to access her supply, though that often depends on suppliers and wholesalers of the drug.
"It is a concern for patients who risk flares of their autoimmune disease if they don’t have their supply," Copley said.
She said hospital pharmacists have spent hours trying to stay on top of clinical recommendations for treatment of COVID-19 patients as information came in from hotspots like New York City.
"The last thing you want to do as a clinician is to do nothing and watch someone die," Copley said. "We’ve seen so much change in terms of the initial recommendations to do hydroxychloroquine and then combine that with azithromycin. As clinical pharmacists we have a lot of concerns about the drug interactions with those medications and trying to be cautious and appropriate in the use of that."
Early on, even HIV medications were considered for use against COVID-19, though that quickly was dashed. Still, there was a scramble to get HIV drugs at the time, she said.
"So, then you wonder if there were HIV patients who weren’t able to get their medications because of COVID," Copley said.
Since the early days, organizations such as the Society of Critical Care Medicine and the Infectious Disease Society of America have come out with recommendations that any new medications considered for COVID-19 treatment undergo clinical trials before being used, she said.
Remdesivir seems to offer hope, Copley said, but data is still being gathered on its efficacy as a treatment for COVID-19.
"A lot of things have been tried, but the biggest concern is that we do no harm," she said, "the first rule of medicine."
Merrels said the biggest challenge has been trying to keep up with the latest medical recommendations for COVID-19 while also keeping abreast of how the outbreak is affecting the community and staff personally.
"Safety is one of our biggest concerns," she said. "Safety, drug interactions and thinking about how these new therapies, while we use them safely for other conditions, could have different effects in a COVID patient. Trying to balance all of those things has definitely been a challenge."
While patients hear about treatments being tried elsewhere on the news, Merrels said the reality is those are limited.
"You want to do something so badly for these patients, but we don’t have a lot of good options," she said.
The pandemic also has affected the way the hospital’s pharmacy and staff operate, Butz said.
"Jeff and I have worked to socially distance our staff," she said. "A hospital pharmacy is very different from a retail setting. If someone were to bring in COVID-19 and take out one of our shifts, we would not be able to operate."
Butz said cross-training of staff also has increased so that shifts can be covered in the event of illness getting into the pharmacy.
As the hospital reorganized to provide for treatment of COVID-19 patients, the pharmacy had to determine the best and safest ways to distribute medications and when to do that, she said.
"We want to minimally expose our staff as much as possible," Butz said.
The pharmacy also changed the way personal protective equipment was used in the sterile compounding room to maximize its usage, she said.
"We really need to make sure that we can maintain PPE for sterile compounding, because if we can’t make those meds, then we’re not really good to anyone," Butz said.
Merrels and Copley, who typically work in the intensive care unit and surgical care units, now work in isolated offices, and consult with physicians via Skype.
"It has definitely created challenges and removed some of the ease with which we could communicate our recommendations to providers," Merrels said.
The isolation also creates social loneliness, she said.
"I’m used to being surrounded by the ICU nurses and the doctors sit at computers right next to me and we talk back and forth all day, sometimes about personal stuff – mostly about patient care, but it is a big social change," Merrels said.
Copley said she and some colleagues now work in loaned space in the attic of a hospitalist’s office across the street from the hospital.
"One of our colleagues is very, very pregnant and is expecting a baby literally any day now," she said. "We were so very, very grateful to be able to protect her and her coming baby from having that risk of exposure in the hospital."
Though those in the remote offices are only feet apart, they try to maintain social distancing.
"You kind of feel constantly torn between being grateful to have reduced exposure to the virus – I worry less about taking it home to my family, but it is socially awkward," Copley said. "Trying to do meetings via Skype is awkward at best."
Avery said some pharmacy staff members who have small children at home have taken leave to care for them while the hospital census has been low, saving the hospital money and causing others to take on more tasks.
"It has been helping the hospital and helping each other," she said.