“We Are the First Ones They Touch”

By the time this is article is published, we will know the actual numbers related to coronavirus disease 2019 (COVID-19), but as I write this, I can use only projections.

Three quotes from the middle of March are instructive:

“I say straight-faced, we will never ever go back to normal.” —Michael T. Osterholm, PhD, MPH, University of Minnesota, renowned infectious disease expert who has predicted that between 20 million and 60 million Americans, and perhaps even more, will eventually be infected¹

“Currently, experts expect over 1 million deaths in the US, since the virus was not contained and we cannot even test for it.” —Andy Slavitt, former acting administrator of the Centers for Medicare & Medicaid Services, via Twitter²

“We know the high mortality in older people, but for reasons that we don’t understand, frontline health care workers are at great risk for serious illness, despite their younger age.” —Peter Jay Hotez, MD, PhD, professor and dean of the National School of Tropical Medicine at Baylor College of Medicine on CNN’s New Day³

Using wishful thinking, I would project that a month from now, some already available (and tested on COVID-19) medication will be found to be effective. The curve will have flattened, and we will be focused mostly on helping a largely morbid population with a mortality rate less than that of influenza.

But using prudent thinking, I will write under the assumption that you are reading this during perhaps the most overwhelming period of time in our health care system’s history. Emergency departments will be overflowing, everyone except grocers and health care workers will be sheltered in place, and there will be a fight over testing and who is to blame for our not being prepared.

PREDICTING AN OVERWHELMED SYSTEM, YET SLOW TO ASK PHARMACY FOR HELP

Everyone is now familiar with the refrain “We need to flatten the curve by slowing down spread so that we don’t exceed our system’s capacity and we can save maximal lives.”

Yes, this is true. But are we prepared to use our system to the fullest? Experts keep professing the need for intensive care unit beds and ventilators. Hospitals are asking for more than $100 billion in relief to help defray the cost of critically ill patients. Health departments and primary care providers are concerned about backed-up waiting rooms, the constant ringing of phones, and keeping up with the needed throughput with patients they should see and a bunch of patients they believe can wait.

Meanwhile, pharmacies are certainly busy but have, as of mid-March, not been asked to leverage both their presence in the community or their varied and incredibly helpful skill sets. Many groups are working on emergency response, with lots of voices in the room. Pharmacists are part of some groups but not in many, and when they are part of the discussion, it is usually focused on supply chain concerns, not the temporary delivery of needed health care services by capable pharmacies and pharmacists. Our brothers and sisters in health care continue to view us by and large as dispensers, which saddens me.

Ironically, the general population and the media recognize not only our contributions but also our potential. Not burdened by an outdated hierarchical dogma, they have recognized pharmacists as some of our most important frontline early-warning systems and caretakers for hundreds of millions of Americans.

TOUCHED FRONTLINE HEALTH CARE SETTING

How many patients walk into a pharmacy over the course of a year asking about a cough or seeking symptomatic relief? Answer: a heck of a lot more than walk into other health care settings.

Twila Boyd, RPh, owner of Charleston Pharmacy in South Charleston, Ohio, said it best during a recent interview with Scott Simon on Weekend Edition Saturday on NPR: “We are the first ones they touch.”⁴

Pharmacies have more than 1 billion touches related to prescription dispensing each year and billions more for the front of the counter. Here we are, engaged in the health care event of our lives, and it is time to step up. The list of important public health functions for pharmacies is long and includes the following:

After-hours availability. Pharmacies are open in the evening and on weekends. Maintaining availability—whether it’s curbside pickup, drive-through, or home delivery—is essential systemwide.

COVID-19 education. Social media is flooded with COVID-19 information, most on point but much of it not. Pharmacists are trusted local sources of information and opinion, not only for those who are asking but also for those who are not and should be.

COVID-19 triage. Most everyone reading this article serves thousands of chronically ill patients, many of whom will develop a cough or a fever and call pharmacists. Many will not and will call anyway. The CDC has an algorithm on its public website that walks through triage scenarios. Help facilitate its use with patients and staff.

Follow-up and monitoring for patients with chronic illnesses. Diseases other than COVID-19 will still progress, and system availability may get extremely low. Work with care team members, but if they are not available, step in and help.

Follow-up and monitoring for patients with COVID-19. Most patients who test positive or who are even at risk will be told to stay home. Make sure they have a plan of care and follow-up from the health department or primary care. If they do not, step in and help, especially if the patients live alone.

Prospective conversion of chronically ill patients to appointment- based model with home delivery. Any patients with at-risk diseases, including cardiovascular conditions and diabetes, should be put on a schedule and either have their medications delivered to them or have a scheduled time for them to stop by the pharmacy when they can minimize the chance of exposure and maximize the chance for structured interviewing and follow-up.

Treatment stewardship. We all know there will be a run on medications that treat COVID-19, regardless of evidence or timetable. Let’s make sure we all follow the guidance and rules from public health officials and compel our care team partners to do the same, even if they have prescriptive authority.

I hope pharmacies will be allowed to help in other ways. The Trump administration, Congress, and many states are considering ways to allow pharmacies and pharmacists to act as system backstops. Pharmacists who are given that privilege should step up and do what is allowed.

ALL PHARMACISTS CAN HELP

Those of us in our existing settings of care signed up to be health care professionals, so unless we are at risk, we should show up for work. Consider backing up a clinic, facility, or pharmacy in a prior setting of care. Those who work part-time should consider going full-time right now. For those who had stopped practicing, please restart.

Pharmacists should help their local emergency preparedness teams and health departments. We cannot complain about not being heard or able to contribute if we are not there. Show up.

Also, consider volunteering to be a service provider in an emergency scenario locally or at the state level. I just did that. If I get called on, I will provide an update next month.

These are the times when people will remember what we are about. Let’s show everyone who we are.

#pharmacistsprovidecare

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

REFERENCES

• Burcum J. Coronavirus pandemic: what’s ‘normal’ now? what’s next? An interview with Michael Osterholm. Star Tribune. March 22, 2020. startribune.com/coronavirus- pandemic-what-s-normal-now-what-s-next-an-interview-with-michael-osterholm/ 568978932/. Accessed March 24, 2020.
• @ASlavitt. Currently experts expect over 1 million deaths in the U.S. since the virus was not contained & we cannot even test for it. This will be recorded as a major preventable public health disaster. I will try to relate what I learned from a long day of calls about what is happening. March 12, 2020. Accessed March 24, 2020. twitter. com/ASlavitt/status/1238303395448008704
• Howard J. Health care workers getting sicker from coronavirus than other patients, expert says. CNN website. cnn.com/2020/03/16/health/doctors-coronavirus- health-care-hit-harder/index.html. March 18, 2020. Accessed March 24, 2020.
• Simon S. A look at the COVID-19 crisis from a pharmacist’s perspective. NPR website. npr.org/2020/03/21/819439661/a-look-at-the-covid- 19-crisis-from-a-pharmacists-perspective. Published March 21, 2020. Accessed March 24, 2020.