Emergency Medicine Telepharmacy During COVID19

Maria I. Rudis, Pharm.D, DABAT, FCCM ED Clinical Pharmacy Specialist Program Director, PGY2 EM Residency Associate Professor Pharmacy and Emergency Medicine Mayo Clinic College of Medicine and Science Mayo Clinic – Rochester, MN

• List two scenarios whereby ED pharmacist can facilitate care.

• Discuss two barriers during implementation and describe methods by which these barriers can be overcome.

• Describe the planning and implementation of pharmacy services in a field hospital.

• Illustrate pharmacy services that can be consolidated during the COVID-19 restrictions.

Pharmacy technician

• List two scenarios whereby ED pharmacist can facilitate care.

• Discuss two barriers during implementation and describe methods by which these barriers can be overcome.

• List three lessons learned during the provision of care in the ED.

• Describe the planning and implementation of pharmacy services in a field hospital.

©2015 MFMER | slide-3 Background • Telemedicine ramp ups • CMS regulations broadened • Need to work differently • Health care post (first wave) COVID19 • Many factors • Limit / judicious use PPE (all settings) • Reduced Practices – outpatient / ED /procedures / admissions • Focus on Tele vs F2F • Reduced personnel – ill / quarantined; reduced FTE / furloughs • ED volumes – from surge  overwhelmed  low census

• ED Pharm IP Phone to cell • ED Pharm Text Pages to email • ED SASMN Board – R-team flashing • EPIC Banner – add ‘status’ remote • Sign on early and test systems

©2015 MFMER | slide-8 …ED Pharm Remote: Processes / Logistics • Telemedicine / InTouch • Test ‘multi-presence’ with ED MD on Tele • Connectivity (internet speed) • Communication is important • ED Providers in each ED Pod • Epic Secure chats to Providers • ED Pharm on site - plan day & responses • ED Clin Pharm Spec by Skype or Text

©2015 MFMER | slide-9 …ED Pharm Remote: During Resuscitations • Assume “own” the ED – • Answer Qs /verifying orders • Eye on EPIC Track Board & ED SASMN Board • ED Pharm location (room, time) – RFID • Establish plan / debrief

©2015 MFMER | slide-10 ED Pharm Remote: Overall Impressions • Overall - very slow, with low ED census • Not busy or not calling? • Difficult to make prospective interventions • Reliance on current electronic documentation • Absence of benefit of: • Visualizing the patients • Hearing conversations • Retrospective interventions order verification • Option • Scalable • If small ED Pharm group falls ill to COVID • If high risk ED Pharm (?)

©2015 MFMER | slide-13 ED During COVID19: Change in Paradigm for Resuscitations • Minimize team members • Air exchanges / hour in R-Bays • Cleaning / down-time • Provide safe patient care, while • Crowd-control • Exposing the least number of staff, and • Utilizing the minimal amount of PPE

• Isolation Room(s) in ED • Codes • Resuscitation Team (R-Team) activations • Any suspected / confirmed COVID19 pt

©2015 MFMER | slide-15 Using Telepharmacy During COVID19: Making it Work • ED hallway WOWs equipped with InTouch • iPads purchased / brought into patient rooms • ED Staff provided InTouch access for ED devices

©2015 MFMER | slide-17 Telepharmacy During COVID19: Making it Work • Provider roles (in and outside room) determined and shared with team • Anteroom • Staff must knock and allow anteroom PCA to open door • Communication between staff in/outside room • Direct, clear and loud • Near iPad in Room

©2015 MFMER | slide-18 ©2015 MFMER | slide-19 ©2015 MFMER | slide-20 ©2015 MFMER | slide-21 ©2015 MFMER | slide-22 ED Pharmacist • Pharmacist located by recording RN with Code Cart and Bedside Supply Cart • Logs onto InTouch as guest • Obtains and mixes requested medications • Provides consultation to provider

©2015 MFMER | slide-24 Lessons Learned • Adjustments to Paradigm – new way • Everything takes longer – be flexible • Other patients / Simultaneous resuscitations • ED Pharm - staff accordingly • Need a medication runner (e.g. Pyxis, Tube station) • Technology may be limiting factor • Real-time (or after event) problem-solving • Low-tech alternatives – white board/marker

©2015 MFMER | slide-26 Telepharmacy: Other Clinical Opportunities EM Non-EM • Culture f/u • COVID Line / COVID Testing • Post ED f/u • ICU • Rx Refills • Outpatient Practices • Urgent Care • Ambulatory Care, Anticoagulation, PGX, BMT / • EMS SOT • Toxicology • Tele-Tox, Subs Use Disorder, EtOH Withdrawal • 24/7, Surge (ED, off-site)

©2015 MFMER | slide-27 Learning Objectives: Let’s Review For ED Pharmacist providing tele-emergency care in the ED during COVID19: 1. List two scenarios whereby ED pharmacist can facilitate care. 2. Discuss two barriers during implementation and describe methods by which these barriers can be overcome. 3. List three lessons learned during the provision of care in the ED.

• SAEM 2020: Telehealth EM During COVID19 Lessons Learned https://youtu.be/3NknFi4swOQ • Telehealth Visits to Support Medical Toxicology Practice in the Time of COIVID19 https://www.youtube.com/watch?v=t9rlAPYz92U

Matthew J. Maughan, PharmD Disclosure

I have no financial disclosures. Timeline

Jan. 7, 2020 April 6, 2020 Pneumonia Contacted by cases in March 2, 2020 First reported case Massachusetts Wuhan are in New Hampshire, General identified as and first case in a Hospital new rural county regarding Coronavirus Boston Hope Field Hospital

Jan. 21, March 5, 2020 April 11, 2020 2020 Dartmouth- First patients First Hitchcock are placed at Coronavirus initiates Boston Hope case in Incident Field Hospital Washington Command and begins planning for surge Field Hospital’s

Variety of structure Staffing Liability for care Supply of medication and other supplies Payment for care Clinical acuity of patients Boston Hope Field Hospital

• 1,000 patient facility • 500 patients run by Partners • 500 undomiciled patients run by Health Care for the Homeless • ~700 patients we treated on the Partners side • Currently not accepting any new patients

https://www.wbur.org/commonhealth/2020/05/26/boston-hope-field-hospital-stop-accepting-covid-19-patients Boston Hope Field Hospital

• Lessons Learned • Extending EMR to the field hospital • Be clear about what services are available and what is not

• Possibility that field hospitals will become important in Fall or Winter Consolidated Pharmacy Services

• Evaluate what tasks are required to be performed by someone onsite

• Which tasks are flexible on the day of the week Consolidated Pharmacy Services

• Health System • Stand alone facility • Common EMR • Outsource order review • Standardized P&P • Consolidate administrative tasks to • What pharmacy tasks are specific days influencing patient outcome? • Look at staffing ratios to consolidate similar types of patients e.g. ICU’s, ED, General Medicine • Insource or Outsource Order Review Road to Financial Recovery

• Increased OR hours • Increase the pharmacy coverage as economically as possible • Increased weekend surgical volume

• Re-evaluation of all service lines Size and Complexity of Service

Critical Access Hospital Community Hospital Academic Medical Center

Vizient University Health System Consortium │ Date │ 40 Confidential Information Outsourced Order Review

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