The COVID-19 pandemic created many unexpected challenges for pharmacists in providing patient care. Some of the issues discussed here have presented as a single challenge in the past, but rarely – if ever – has there been a situation that brought so many challenges simultaneously. Several articles have described the incredible stress that was placed on community pharmacists, hospital pharmacy operations, as well as pharmacists in positions of infectious disease and hospital policy development.1–3 This editorial will focus on unique challenges that were encountered in caring for cardiac patient populations.
Early in the pandemic – before transmission and communicability were well known – there was tremendous concern about virus exposure in our procedural areas such as the cardiac catheterisation laboratory. Because of this, many primary percutaneous coronary intervention (PCI) centres were faced with the challenge of managing COVID-19 patients who presented with concern for acute coronary syndrome (ACS). The American College of Cardiology’s Interventional Council and Society for Cardiovascular Angiography and Interventions released a statement to help assist in assessing the risk and benefits for both the patient and staff involved.4 In turn, this led to patients receiving thrombolytic therapy at a much higher frequency.
This was the first time that I personally had a patient who presented to a primary PCI centre undergo lytic therapy for an ST-elevation MI instead of immediately being taken to the catheterisation laboratory. Many community and rural hospital systems that do not offer 24-hour PCI availability often use thrombolytic therapy before transporting the patient to a PCI centre.5 Staff at these centres have a much higher level of practice experience with these medications compared with primary PCI centres.
At our centre, we did not have drug files for alteplase built into our pump infusion libraries for the indication of MI. Additionally, cardiology providers and nursing staff had to be educated about the contraindications for thrombolytic therapy and the monitoring that is required during and after the infusion. This experience emphasised the importance of monitoring drug medication files and their indications continually within a hospital system. Additionally, institutions must be able to act quickly to update these files in instances when an absence is discovered or when a medication is approved for a new indication. Because we had these review processes and protocols in place before the pandemic, we were able to quickly address this issue without having to administer a high-risk medication without the appropriate safety guardrails in the infusion pump. The pharmacists in the emergency department and cardiac intensive care unit (ICU) have a close relationship with the nursing educators for these units. An education effort was quickly implemented to update staff on the administration and monitoring procedures for these patients.
Another unique challenge related to protecting staff was how to respond to in-hospital codes. Because this was still early in the pandemic, as described above, it was imperative to protect our staff as much as possible. At our institution, we have a pharmacist on our multidisciplinary cardiopulmonary resuscitation committee. Through that committee, a plan was implemented to help reduce the number of staff entering a patient’s room when COVID-19 was suspected or confirmed, as well as to reduce the number of times that staff would leave the room. We developed code bags that could be accessed from our medication dispensing cabinets to avoid having to take the entire code cart into the patient’s room. These bags contained two code syringes of epinephrine, two vials of amiodarone and an atropine syringe. The initial code team would take this bag into the room at the initiation of the code. The code cart with other medications would then be stationed just outside the patient’s room. When a new person would enter the room to relieve the person doing compressions, they would then bring in a new bag of medications. This was accomplished through great collaboration with all the different provider groups involved in hospital code response. Additionally, pharmacy operations played a vital role in developing these code bags and in keeping them stocked on the floors.
Monitoring of outpatient heart failure patients and warfarin anticoagulation was another unique challenge presented by the COVID-19 pandemic. Goal-directed medical therapy and the related pharmacological regimen is the backbone for patient survival and quality of life.6 Patients with heart failure are at a very high risk of serious complications from infection with SARS-CoV-2.7 Consequently, many patients expressed fear about coming to clinic appointments or presenting to the emergency department when experiencing an exacerbation of heart failure because of fear of exposure to the virus. During the initial lockdown period of the pandemic, our institution had many days on which most of our heart-failure clinic patients would cancel or not attend. These are important appointments, particularly for medication optimisation; it is essential that patients are up-titrated as tolerated and that they are being maintained on an appropriate diuretic regimen. Furthermore, many medical centres rely on pharmacist-led warfarin anticoagulation monitoring.
In response to these issues, telehealth and telemedicine opportunities expanded exponentially.8,9 Providers were now able to connect to patients in the safety of their own homes. There are challenges in implementing these technologies into patient care.8,9 However, faced with the alternative of limited or no medical follow-up, many patients embraced this opportunity and it provided a very good way to help these high-risk patients. Without the pandemic, it would be difficult to envision an expansion to implement this technology at the rate that was seen during these past 2 years. Unfortunately, this did not solve all the issues as there was still difficulty in reaching many of our patients, emphasising the importance of communication with our patients in the community and finding other unique ways to reach them.
There were other very difficult challenges during the pandemic. Identifying drug–drug and drug–disease interactions and their appropriate monitoring was especially complicated. At the very beginning of the pandemic there were early reports of hydroxychloroquine having antiviral properties that would help to prevent or treat COVID-19. Although clinical trials later demonstrated that this was not an effective treatment, many patients were prescribed or self-administered hydroxychloroquine.10 Because of QT prolongation that this medication can cause, there were many reports of patients having serious adverse effects because of an interaction with either an underlying prolonged QT or medications they were already taking that prolonged their QT.11,12
Once Food and Drug Administration (FDA)-approved medications were introduced, new challenges with drug–drug interactions arose. The antiviral regimen nirmatrelvir/ritonavir is a very strong cytochrome P450 and P-glycoprotein inhibitor that can substantially change the pharmacokinetics of vital medications. Tacrolimus, clopidogrel, ticagrelor, rivaroxaban, apixaban, dabigatran, edoxaban and amiodarone are just a few examples of medications that should be co-administered only under close supervision due to significant dose adjustments or increased therapeutic drug monitoring that may be required.13,14 Because these treatment regimens are so new, it is very easy to not identify a key interaction when prescribing or dispensing, in particular when the patient is prescribed and dispensed the medication outside their normal hospital care network.
As of this publication, many of these medications have only been available in limited quantities. As they become more widely available, hopefully, there will be a better system to help flag these interactions. There has been substantial improvement with the electronic medical record having access to insurance claims and third-party prescriptions; however, there is a great opportunity to use it at its full potential. Admittedly, as a pharmacist using these resources daily, they are not intuitive, and it can be very difficult to access some major health centres such as the Veterans Affairs system. I hope we can use this pandemic as a way to continue to push for better development of more transparent medical records systems. This also highlights the importance of a thorough patient interview in the clinic or upon patient admission to screen for these serious drug–drug interactions. Finally, it is important to educate patients receiving critical medications such as tacrolimus to check with their transplant pharmacist or transplant clinic to ensure there are no dangerous interactions if they are started on a new medication.
An additional key area of patient monitoring where the COVID-19 pandemic created a challenge was anticoagulation management. The partial thromboplastin time (PTT) is a crucial measurement of clotting time that is used for the management of many cardiac conditions. Patient-specific coagulation has been shown to be greatly variable in patients positive for COVID-19.15 Many hospital systems use the assistance of their pharmacy department to monitor and titrate anticoagulation therapies. This could be for indications such as ACS, AF, deep venous thrombosis and pulmonary embolisms, all of which carry a risk for further cardiac complications. Because of this variability in patient’s baseline PTT before anticoagulation initiation, alternative monitoring strategies had to be quickly implemented. These changes were reviewed and approved by our institution’s anticoagulation committee – a multidisciplinary group comprising haematologists, emergency department physicians, clinical pharmacists, pharmacy informatics specialists and administrators. Hospital protocol changes that would normally take months to change were modified within days to permit monitoring and adjustments based on unfractionated heparin levels (anti-Xa) or thromboelastography.15
One health-system issue further exacerbated by the pandemic was supply chain problems. In the area of pharmaceutical manufacturing, the medication supply chain has become increasingly reliant on single manufacturers of medications. Third-party supply of packaging, containers and materials has led to drug manufacturers being unable to keep up with the demands of production. However, according to data from the FDA, the number of new drug shortages has declined every year since 2019.16
The past 2 years have introduced unprecedented challenges to healthcare providers. The collaboration and work done by groups from all over the world have been inspiring. Among the lessons learned that can hopefully continue in the future is the close communication between intra-department and multidisciplinary teams. During the height of the pandemic, there were daily emails sent to our entire pharmacy department. These emails would outline, for example, patient census information (ICU expansion and new COVID-19 intake locations), drug updates (treatment and shortages) and policy changes (visitor policies, code responses). This was very helpful keeping the staff updated on a constantly changing landscape and also allowed pharmacists to give updates to the multidisciplinary committees they worked in. Additionally, in these committees, there would be questions that would arise about possible drug shortages or successful treatment regimens that the pharmacist could then relay to their management or the appropriate team so we could anticipate changes. This level of communication contributed to the implementation of changes to our infusion pumps, code response and drug inventory at a better rate, which hopefully led to better patient care.
Another change that will hopefully be continued is the use of telehealth. This can be a significant way to maintain meaningful relationships with patients that can lead to medication optimisation and prevention of readmissions. The convenience of telehealth can reach our more rural patient populations and prevent appointment cancellations and patients lost to follow-up if implemented properly. There are drawbacks that will need to be addressed, but, with continued support, these changes can be made so that other patients are not left out. A third lesson that was learnt was to help and support the healthcare community. It was moving to see how – at a moment’s notice – colleagues from different departments, different specialities and in different parts of the world did everything they could do to help. Many of these colleagues are now having difficulty with burnout and have lost the desire to be in medicine. I feel that we are starting to realise the impact that this pandemic had on our healthcare community and it is going to take a lot of work and support for it to recover.