COVID-19: Implementation of a 24-hour clinical pharmacy service in the intensive care unit and general medical unit during the COVID-19 pandemic

The evolution of hospital pharmacy over the decades is astonishing, powered by the imagination, effort and teamwork of many people committed to improving patient outcomes. But sometimes this evolution is driven faster by external pressures – the rapid implementation of a 24/7 clinical pharmacy service at Alfred Health, in response to the COVID-19 pandemic, is a striking example of one such moment. Pharmacy GRIT is pleased to have some of those SHPA members at Alfred Health who made it happen share the inside story from within one of the country’s top-tier hospitals.

By ERICA Y TONG Deputy Director of Pharmacy [1,2]; GAIL EDWARDS Senior Pharmacist, General Medicine [1]; DIANA SANDULACHE Lead Pharmacist, Workforce and Development [1]; GRAINNE HUGHES Senior Pharmacist, ICU [1]; MICHAEL J DOOLEY Director of Pharmacy [1,2]

1. Alfred Health, Victoria 2. Monash University

The COVID-19 pandemic has led to many challenges in designing and supporting the health workforce to provide care to potentially large numbers of patients in a very different practice environment under significant pressure. This, in many cases, has led to significant innovation within clinical teams to best utilise the expertise of all those available. A successful example to illustrate this has been the implementation of a 24-hour clinical pharmacy service in the intensive care unit (ICU) and general medical unit (GMU) during the COVID-19 pandemic.

Alfred Health is a quaternary referral centre, providing State Services for heart & lung transplantation, extracorporeal membrane oxygenation (ECMO), burns and hyperbaric medicine. The Alfred is one of two centres in Victoria providing state services for adult trauma, HIV and bone marrow transplantation. The Alfred ICU is the largest in Victoria and the most complex in Australia

Clinical pharmacy services to the GMU and ICU prior to March 2020 included extended roles such as the partnered pharmacist medication charting (PPMC) model and pharmacist-led therapeutic drug monitoring and warfarin management. A seven-day a week clinical pharmacy service and extended hours service had been in place for many years in both of these clinical areas. Alfred Health implemented an electronic medical record (EMR), including electronic medication management and clinical documentation in October 2018.

In March 2020, during the preparation phase of the COVID-19 pandemic, two key areas were identified as requiring significant increase in capacity at our organisation. These were the ICU and the GMU. Medical and nursing leadership in these areas scoped potential models of care for isolated patients and the expected huge increase in ICU and general medical activity.

During the COVID-19 pandemic, medical, nursing and pharmacy leadership in ICU and GMU identified that due to the established extended and integrated pharmacy service pre-existing in both areas, pharmacists working in ICU and GMU are well placed to ease and streamline some of the workload expected to be placed on medical and nursing staff during the COVID-19 response. A key requirement to accommodate the potential increase to over two hundred ICU beds and the anticipated doubling of hospital admissions was that pharmacists would need to be available within the units 24 hours a day, 7 days a week.

The roles of the pharmacists during the evening and night shifts remains within their existing scope of practice. This includes charting medications in the EMR for administration by a nurse through the partnered pharmacist medication charting (PPMC) model, ordering of pathology investigations on ward rounds, assisting with documentation on ward rounds, reconciliation of medications prior to discharge from ICU to ensure they are appropriate for administration on the ward, attendance at MET calls, generation of discharge prescriptions, and documentation of the medication management plan in the discharge summary.

A practice model was developed with the aim of delivering a 24- hour service, 7 days a week to the GMU and ICU with appropriately credentialed pharmacists able to undertake required roles at all times. Volunteers were sought to participate in the extended hours model from those credentialed to practice in these areas. An overwhelming majority of pharmacists volunteered, with 30 pharmacists credentialed to work in GMU and ICU opting in to participate within 72 hours of the call for volunteers.

[L to R] Erica Tong (Deputy Director of Pharmacy), Gail Edwards (Senior Pharmacist, General Medicine), Prof Michael Dooley (Director of Pharmacy), Diana Sandulache (Lead Pharmacist, Workforce and Development).

The model includes a 3pm to midnight evening shift and a 10pm to 8am night shift in each respective area, GMU and ICU. Pharmacists are rostered to one week of evening shifts and one set of four night shifts every six weeks, working regular hours for the remainder of the six-week period. They have a day off prior to the four night shifts and three days off afterwards.

This model was developed and implemented within one week, an extremely tight turnaround, due to the organisation’s escalating response to the COVID-19 pandemic.

The first pharmacists were rostered to the night shift on the 3rd of April 2020, with overwhelming support from the medical and nursing staff in ICU and GMU. Director of General Medicine at Alfred Health, Associate Professor Harvey Newnham says, ‘Our pharmacists continue to lead the way forward for medication safety at Alfred Health with the recent institution of a 24-hour service for our acute patients. These improvements are particularly appreciated by our busy overnight receiving medical registrars, improving both safety of care and clinician workflows.’

Director of Intensive Care, Associate Professor Steve McGloughlin agrees, ‘The Alfred ICU provides a true 24- hour service with a complete overnight team including on-site intensive care consultants. The addition of an overnight pharmacist has been greatly appreciated by all of the ICU team and has demonstrated the importance of the pharmacists to patient care.’

Some examples of the contributions the pharmacists have made include attendance at MET calls, including ceasing and initiating therapy through the PPMC model. Other examples include liaising with multiple units to initiate tocilizumab for a critically ill patient with COVID-19, and charting of medications for nursing administration on admission to ICU post-operatively for a new heart transplant and new lung transplant patient.

The principle of the 24-hour model was to ensure pharmacists were practicing at their full scope of practice and the implementation was built on an engaged and existing credible and competent workforce. This model was developed and implemented within one week, an extremely tight turnaround, due to the organisation’s escalating response to the COVID-19 pandemic. The support from our colleagues and the pharmacists who have volunteered to participate in this important service highlights the key role that hospital pharmacists play in the multidisciplinary care of our patients. Having pharmacists working alongside our medical and nursing colleagues, providing care to our patients 24-hours a day, is an important step in the progression of our profession.

General Medicine: [L to R] Meng Yap (general medicine pharmacist), Gail Edwards (Senior Pharmacist, General Medicine), Cassandra Monitto (general medicine pharmacist), Linda Shi (general medicine pharmacist).

Image at top of story - Intensive Care Unit: [L to R] Erica Marsom (ICU pharmacist), Simon Du (ICU pharmacist), Grainne Hughes (Senior Pharmacist, ICU), A/Prof Steve McGloughlin (Director of Intensive Care), Ivan Kurniawan (ICU pharmacist).