Pharmacists concluded that the workflow could be implemented for any drugs that are in short supply.
In a session at the American Society of Health-System Pharmacists (ASHP) 2022 Midyear Clinical Meeting, pharmacists discussed a case study at their institution in which a pharmacist-driven, centralized allocation of COVID-19 treatments resulted in successful, equitable allocation.
Despite the approval of several outpatient treatments for COVID-19 under emergency use authorizations, there were limited supplies. These approvals included monoclonal antibodies, remdesivir, nirmatrelvir/ritonavir, and molnupiravir, and demand for the treatments was high as COVID-19 continued to spread. Hospitals across the country struggled to quickly implement solutions for distribution.
“After these medications became available, they were distributed throughout the states via health departments to our health systems,” Sydney Rapp, PharmD, BCACP, said in the presentation. “So, essentially overnight, hospitals needed to develop a plan to safely and equitably get these medications to our patients.”
Community Health Network in Indiana implemented a novel pharmacist-led program that has been remarkably successful, according to presenters Rapp and Hita Bhagat, PharmD, BCPS, BCIDP. The network is a large health system with more than 200 sites of care, including 9 hospitals and 7 urgent care facilities. The system also has a robust ambulatory care pharmacy department with 40 pharmacists in primary care and specialty areas who work under collaborative practice agreements.
In designing the program, Rapp said the main priority was allocating treatments to those with the highest risk of adverse outcomes from progression of COVID-19 and hospitalization. Evaluation of patients was also necessary given various restrictions for the medications, such as initiation within 5 to 7 days of symptom onset, potential drug interactions, and considerations for renal or hepatic dysfunction.
In early 2022, pharmacy, medical, and nursing leaders convened to develop a centralized triage team. Ambulatory care pharmacists were given the role of developing a workflow to identify high-risk patients, evaluate treatment options, and coordinate treatment delivery.
The team received medication requests from providers via email, and specific forms were designed to help prescribers identify key characteristics of high-risk patients. The form was designed with the National Institutes of Health COVID-19 guidelines in mind, which prioritized nirmatrelvir/ritonavir, followed by monoclonal antibodies or remdesivir.
“That order form really helped us tackle our larger question—how do we safely and equitably provide medications to our patients?” Bhagat said.
Pharmacists verified the form information using patient records and communicated directly with patients to provide education. They also coordinated with infusion centers and hospital pharmacies to organize administration.
After launching the process in January 2022, Rapp noted that the team expanded remarkably quickly. The team of 2 pharmacists received 100 orders on the first day, underscoring the need for expansion, and experts quickly trained 13 pharmacists in total. They also launched an evening shift to keep up with the demand. Rapp noted that these were primary care pharmacists who were pulled from their clinics.
Importantly, the process was standardized and centralized, but remained flexible to account for changing drug supply and staff support. Triage pharmacists met daily to discuss clinical and operational updates and providers were notified of any changes via weekly newsletters. Request forms were also updated frequently to reflect changes in treatment and risk stratification.
Based on their experiences with the program, Rapp and Bhagat concluded that having a pharmacist-driven, centralized allocation process for COVID-19 treatment in a large health care system enabled equitable and fast distribution of medications. Additionally, the standardized workflow with prioritized identification of high-risk patients allowed ambulatory care pharmacists to efficiently provide care while juggling scarce resources and staff.
“We really concluded that the framework we came up with for this COVID-19 outpatient triage work could be utilized for many other situations where we have a drug in short supply,” Rapp concluded.
Bhagat H, Rapp S. (Management Case Study) Mobilizing Health-System Ambulatory Care Pharmacists in the Treatment of COVID-19. Presented at: ASHP 2022 Midyear Clinical Meeting. December 5, 2022.