Tom Harper, MPH, CPhT, FCSHP

California remains one of the states most affected by coronavirus disease 2019 (COVID-19), with Governor Gavin Newsom declaring a state of emergency on March 4, 2020, in anticipation of a broader spread of the virus and the need for additional resources and emergency legislation.

In line with the need for health care expansion and in acknowledgement of excess burdens being placed on health systems in California, the state’s Board of Pharmacy has authorized multiple waivers of specific provisions of pharmacy law, several of which have had major implications for pharmacy technicians and their scope of practice pre-COVID-19.

The California Society of Health-System Pharmacists (CSHP) has generated insights from pharmacy technicians working in inpatient settings and technicians who are designated buyers for their institutions in an effort to specifically understand how the pharmacy technician role has been affected by COVID-19, some of the insights gathered so far, and how the pandemic has transformed their role in ways not previously envisioned. The testimonies of several pharmacy technicians are provided as both a story of the pharmacy technician profession in transition, the challenges currently faced, and some important insights for pharmacy technicians in other states to consider.

Shortages of medications and supplies before COVID-19 are even more amplified than before

The emergence of COVID-19 has directed media attention over shortages of personal protective equipment (PPE), respirators/ventilators, hand sanitizers, and other cleaning products/solutions that are in desperately short supply across all supply chains. But even before COVID-19, buyers were dealing with general shortages of hand sanitizer, masks, and gowns—the last of which were being globally recalled due to concerns about sterility and safety.

In addition to trying to secure as much supply as possible, buyers are now in high demand as gatekeepers of information, especially when concerning medications in high demand (eg, hydroxychloroquine, azithromycin, ipratropium or albuterol) and the need to stockpile in times of uncertainty. One health-system has now designated quantities of hydroxychloroquine and azithromycin to be monitored similarly to controlled substances.

Another technician working for a health plan acknowledged the difficulty in securing hydroxychloroquine for patients with autoimmune disorders—those with rheumatoid arthritis, systemic lupus erythematosus or porphyria cutanea tarda who had medically necessary reasons to use hydroxychloroquine&mdash;amidst increasing stockpiling across health systems and limited information about hydroxychloroquine’s true efficacy in patients with COVID-19.

Shortages of medications are not just limited to drugs that have been highlighted in the media. Buyers are also scrambling to secure paralytic medications (ie, cisatracurium for patients requiring intubation) and intravenous solutions, both of which have been notably low in supply for some time.

Buyers have had to clamp down on very specific details (number of vials, which vendors hold brand/generic versions, which versions are on back-order, etc) and such specific facets may be less transparent to physicians, pharmacists, nurses, and other health care providers.

Said one technician, “There’s so much involved when someone needs a medication. If other health care professionals worked in a pharmacy before going into their designated field, they would understand why getting medications takes so long.”

Potential changes in buyer practices are being recognized in response to COVID-19, including the role of local communities

Unanswered questions about how COVID-19 is spread and how long it may linger on certain materials (eg, cardboard, linoleum, plastic, or linens/clothing) are forcing health care providers to reconsider definitions of contamination and what to do with the current state of handling materials/medications. One buyer specifically called out code trays that may go into isolation rooms where patients have confirmed disease.

The shortage of medications means re-evaluating previous practices about disposal of drugs after contamination and what best practices can be put in place in the absence of prior information. Extra precautions are being employed in several health-systems, including extra taping over wet-ink labels, wiping down taped areas with alcohol, and wiping down medication delivery bags before and after they return.

Every patient, regardless of confirmed disease or not, may be viewed as a potential carrier. These extra precautions are also contributing to longer times involved in medication preparation in an already-stressed health-system environment. Buyers have also acknowledged how helpful their local communities have been in addressing supply shortages, something rarely considered in the past.

Medical personnel at hospitals are also involved in ensuring that donations from the local community are suitable for patient care, including sterility/safety concerns and appropriate medical setting(s) for the use of these donations. These technicians do not rule out the kindness that their local communities have extended during these shortages, especially concerning the safety of first responders, including pharmacy technicians who must deliver medications to floors that are committed to the treatment of patients with COVID-19.

In the face of uncertainty, pharmacy technicians acknowledge the gravity of COVID-19

Many pharmacy technicians are supervisors who are simply trying to stay in compliance with CDC and hospital guidelines while serving their patients—an all-hands-on-deck approach as one technician noted. Technicians acknowledge that their training instills them with skill sets and versatility across multiple health-systems settings&mdash;from the emergency department to medication reconciliation and transitions of care.

Remarkable stories have emerged of pharmacy technicians going above and beyond to take care of their patients, including technicians helping with curbside delivery of medications to patients too scared to enter hospitals and technicians helping with grocery delivery for patients receiving medications.

Similarly to other health care professionals, pharmacy technicians are facing greater exposure to susceptible health care environments in both inpatient and outpatient settings, with many just as concerned about becoming infected by the virus and unable to help during these times. Some pharmacy technicians who specialize in medication reconciliation were particularly concerned about going into patient rooms and putting themselves at higher risk of becoming infected with COVID-19 before telecommunication options were implemented.

While many people, including other first responders, may not be aware of the presence of pharmacy technicians working behind-the-scenes, many of these technicians also count their blessings seeing how many people are unable to go to work. Some view being an essential worker as a badge of honor during these times, whereas others acknowledge feeling more valued in their technician roles, a movement they hope to continue riding.

Technicians serving as buyers also recognize that although they may not receive the same acknowledgement that other essential workers are receiving, they continue to keep the wheels turning.

Said one buyer, “We want other health care professionals to know that we’re there for them.”

Temporary regulations lifted by the California Board of Pharmacy are unanticipated opportunities for pharmacy technicians

The emergency provisions instated by the California Board of Pharmacy that have greatly affected technicians involve increases in the ratio of pharmacists to intern pharmacists (BPC Section 4114[b]) and pharmacists to pharmacy technicians (BPC Sections 4115[f][1] and 4127.15[c][2] and Title 16, California Code of Regulations, Section 1793.7), as well as remote processing of orders/prescriptions into computers from outside of pharmacies/hospitals (BPC Section 4071.1[a]).

 The loosening supervision ratios across both pharmacy technicians and interns have alleviated health-systems already under excess distress and workload.

Such additional autonomy has allowed pharmacists to focus on more clinical services, including ID-related education to first responders and emergency responses, while permitting technicians the ability to work on more operational day-to-day demands to ensure medications are delivered to hospital floors. This has also allowed pharmacists to continue medication surveillance and verification through telecommunication mediums from outside the pharmacy. It also ensures more operational efficiency without delays or errors while keeping both pharmacists and pharmacy technicians involved in the process.

This process has essentially allowed pharmacists, pharmacy technicians, and interns the ability to work at the top of their licenses. The lifting of regulations has been, as indicated by one technician, “what we need in order to serve the community and our patients during this time.”

There is hope that the loosening of regulations may become a permanent reality, especially at a time in which pharmacists may feel overworked and overburdened, and technicians can expand their scope of practice. The lifting of regulations may potentially be viewed as a learning experience, as questions remain on the benefits of these temporary lifts in restrictions from the Board of Pharmacy.

Whatever the case, questions on the benefits of these emergency provisions may help pharmacy technicians demonstrate new opportunities for leadership and additional capabilities involving the patient care process.

Pharmacy technicians in California want to spread their experiences to technicians outside the state

Coming together to serve patients is the best capacity technicians have available to us, and the technicians interviewed echo these sentiments. Technicians are capable of so much and have the same end goal in mind: to serve patients.

Said one technician, “Don’t be afraid to go outside your comfort zone to take care of patients. Going outside of your comfort zone is what will make this profession more noticeable. When it’s life or death, doing that one kind thing or that one extra service may be what counts at the end of the day.”

Office of Governor Gavin Newsom. California Takes Action to Combat COVID-19. https://www.gov.ca.gov/california-takes-action-to-combat-covid-19. Updated March 27, 2020. Accessed March 29, 2020.

Centers for Disease Control and Prevention. Information for Clinicians on Therapeutic Options for COVID-19 Patients. https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html. Updated March 21, 2020. Accessed March 29, 2020.

California State Board of Pharmacy. Pharmacy Law Waivers. https://www.pharmacy.ca.gov/licensees/emergency_declaration.shtml. Updated March 24, 2020. Accessed March 29, 2020.

, is Controlled Substance Auditor/Diversion Specialist for UC Davis Health.

, is Senior Markets Pharmacy Technician for Blue Shield of CA.

, is Senior Buyer for John Muir Health/Supply Chain.

, is Pharmacy Buyer for Scripps Green Hospital Pharmacy.

, is Pharmacy Tech I at Scripps Mercy San Diego.

, is the CEO of the California Society of Health-System Pharmacists.

, is Editorial Consultant for the California Society of Health-System Pharmacists and Senior Medical Writer, Scientific Communications for Vaniam Group.

Requests for Information: Brandon Samson, PharmD, MPW (bsamson@cshp.org)

Articles

The California Board of Pharmacy has authorized multiple waivers of specific provisions of pharmacy law, several of which have had major implications for pharmacy technicians and their scope of practice.