General:

• You need to use automated dispensing cabinets (ADC) to safeguard your stock of PPE and some COVID-19 meds.
• Develop a strategy to conserve cleanroom PPE and cleaning supplies.
• Plan for safeguarding COVID-19 meds. We have internally assigned CII status for the main one.
• The ultimate goal should be to reduce A.) Presence and B.) Movement within the hospital and more importantly inside isolation areas. Many of you have pneumatic tubes. Consider using the code system to tube controlled substances to reduce hand deliveries.
• Draft a plan for how you will dispense and deliver exposure prophylaxis and discharge meds to coroanvirus + patients and exposed staff. You don’t want them running around to multiple pharmacies looking to fill their meds since most retail outlets have already stocked out.
• Consider 90-day fills or early refills for chronic meds (retail pharmacies).
• Communicate your daily inventory levels of COVID-19 meds to your ID and senior hospital leadership as they will need this to make some decisions. Additionally, you can avoid an influx of emails during the day requesting such.
• Please try to refrain from asking heavily hit hospitals to borrow their meds. It places us in a very tough spot with a potential ethical dilemma to deal with on top of everything else.
• Close the reception area or significantly limit the number of patients inside your retail pharmacies.
• Plan to ramp up your mailing and courier deliveries for outpatient meds.

Supply/Logistical:

• Plan for additional refrigerators. Some antivirals and NMBs need to be refrigerated and you’ll be using quite a lot.
• If you use connectors, adaptors etc., contact those supply companies and order extras as the demand on these will increase.
• Increase med par levels in isolation areas to reduce stocking frequencies.
• Plan to re-purpose and re-allocate resources from closed or condensed areas such as procedural areas, am care etc.
• Prepare for additional units converting to COVID-19 units. Prepare a list of meds or entire ADCs to simply roll into these units. For instance, if a pediatric unit is converted, most of the drugs in the peds ADC are of no use to COVID-19 patients.
• Identify a room and a process to quarantine returned meds and med trays from isolation areas for a few days.
• You likely have many of the critical meds you need for your busy ICUs stocked in procedural and low-acuity areas currently closed or under-utilized. Try to get a comprehensive inventory for your entire health system.
• Your clinical team will need daily inventory counts for about 20 critical meds so they can rapidly prioritize, manage, convert, etc. Designate one of your staff to provide this report at least daily.
• Many clinical trials with large Ns are taking place. Prepare your investigational team for receiving, documenting and more importantly distribution of these meds.
• I did not include any medication names. This is intentional to avoid contributing to practice of hoarding.

Equipment:

• Consider converting some of your decentralized units to cartfill in an effort to conserve ADCs.
• Crash carts are in high demand due to the number of codes. Plan for extras.
• Plan for the process of cleaning and replacing crash carts from isolation areas.
• Consider placing three or four of the most commonly used code meds in reclosable bags to avoid contaminating the crash cart for every single code.
• Wipe down code carts before returning them to the pharmacy.
• Limiting nebulizers has had a drastic impact on MDIs. All are on shortage now. Plan for discharge patients to take these home. This is not the time to be sharing or re-using MDIs.

Staffing:

• Staff protection – This is one of the most challenging issues we’ve encountered during this crisis. Ensure your staff they are receiving the same level of protection as any other hospital employee depending on their exposure level. As long as it is not in violation of your internal policy, encourage them to use their own masks as some N95 masks are still available in stores.
• If you already have clinical or satellite staff within the isolation areas (ED, ICU, etc.), consider tubing the stock and asking them to stock the ADC (Automated Dispensing Cabinets) to reduce overall exposure and preserve PPE.
• Consider staffing a manager in your main pharmacy around the clock. Due to the increase in the number of “exceptions” and emergencies, the presence of a manager is highly recommended.
• Start drafting compressed scheduling models for your staff. There are many advantages to shifting to a compressed 10 or 12-hour model.
• Consider establishing specific guidelines for staff who call out sick during the crisis as a 12-hour call out is a significant gap to fill.
• Some staff can work from home. Check with your IT department to make certain they have the appropriate access.
• Your existing procurement/purchasing/buying team WILL BE overwhelmed. Assign a few others to this team.
• Plan for additional staff in your cleanrooms due to the increase in the number of drips.
• You can’t hold huddles to keep your team informed so plan a system of live communication aside from email. Staff and managers should learn how to initiate and use Webex, Zoom, etc.
• Plan for staff parking if public transport is shut down or curtailed.
• Recognize the significant role of clinical pharmacy staff – They have been working around-the-clock pulling 18 to 20-hour shifts due to all the unknowns and the fluidity of COVID-19 treatments, doses, interactions and codes, as well as the number of codes. This is not to take anything away from operations, etc., who have also been working similar hours. The take-away point here is that the toll and demand on the clinical staff has been well above and beyond our forecast.
• And finally, EVERYONE has been extraordinary in responding. This includes vendors, pharma execs, pharmacy automation and operations vendors, wholesalers, GPOS, smaller distributors of generics, 503B, pharmacy organizations, retired pharmacists and I’m sure I left out a few others. Nearly everyone has been returning calls after-hours and on weekends (well, just one weekend so far)

I really hope this is helpful for those not yet impacted or minimally impacted by the coronavirus.

Sincerely,
Arash Dabestani
NYU Langone Health