Oncology Pharmacy and COVID-19: Perspectives from an Early Epicenter

Peter Campbell, PharmD BCOP
Clinical Pharmacy Manager, LeukemiaPGY2 Pharmacy Residency Program Director, Oncology
NewYork-Presbyterian Hospital
Columbia University Irving Medical Center
New York, NY

When SARS-CoV-2 began to snake its way through the boroughs and suburbs of New York City in early 2020, I had been practicing as a board-certified oncology pharmacist and postgraduate year two (PGY2) oncology pharmacy residency program director for several years. I was working mainly in the adult leukemia specialty and was unaware of the impact that the coronavirus was about to have on the city. Like many others, I shrugged off rumors of increasing intensive care unit (ICU) capacity and a new phenomenon called social distancing. Soon enough, I was fully ensnared in a world foreign to my typical daily practice, helping to care for ICU patients suffering from coronavirus disease 2019 (COVID-19).

Big City Becomes Nimble
At the height of the pandemic in April of 2020, New York City was reporting an average of more than 5,000 new SARS-CoV-2 cases per day, with an average of more than 500 deaths per day.¹ Many institutions were quickly overwhelmed by this volume of patient cases and the increased demand for emergency room visits and hospital admissions. Many parts of the hospital conventionally used for other purposes (such as conference rooms, lobbies, and waiting areas) were converted to acute care areas.

In a survey of 72 hospitals, it was shown that more than 90% of responding institutions made adaptations to accommodate patients with COVID-19, including the creation of respiratory isolation units.²Likewise, personnel were redeployed and repurposed to help care for a massive influx of acutely ill patients. With my inpatient leukemia service dwindling, my colleagues and I found ourselves volunteering to provide clinical pharmacy services for the rapidly expanding intensive care unit (ICU) patients. This redeployment of personnel extended greatly beyond pharmacy, with providers of all disciplines being used to fill sometimes novel roles to optimize the care model.³

Residents Learn on the Frontline
While my normal days previously consisted of reviewing chemo-therapy regimens and providing clinical care to oncology patients, I was now reviewing sedative and vasopressor drips and refreshing my knowledge by reviewing critical care guidelines and standard operating procedures. As a residency program director, I developed ways for the residents to be involved in the care of these complex patients, which proved to be both a challenge and an opportunity. Out of necessity, the resident’s learning experiences were augmented in order to juggle the needs of both the institution and their residency requirements. We developed schedules and workflows that allowed residents to assist in clinical care and sterile compounding, while also making sure that no required learning experience was neglected or forgone.⁴

Patient Volume Outpaces Drug Inventories
To further complicate care for COVID-19 patients, there was an onslaught of drug shortages. Some that impacted us the most were intravenous sedatives and analgesics.⁵ Due to the increased number of intubated patients, many pre-mixed sedatives and analgesics became difficult to acquire, forcing hospitals to either admix these agents or switch patients to therapeutic alternatives when possible. The admixture of these agents necessitated a vast shift in staffing resources, as the volume substantially exceeded our normal operations.

In an effort to better manage our drug inventory, processes were also established to allocate agents on shortage to specific patient populations or specified patient care units. Twice weekly meetings were held to ensure all stakeholders were knowledgeable of current inventory levels, to disseminate drug bulletins, and discuss optimal patient care strategies.

An Influx of New Literature
The increasing volume of new literature also posed a challenge. During the height of the COVID-19 pandemic, new literature was being published at a frenzied pace. It has been estimated that over 23,000 unique documents relating to COVID-19 have been published in 2020 alone. While these documents include letters, editorials, and review articles, nearly 50% are original research.⁶ My colleagues and I were responsible for reviewing and interpreting the ever-changing body of literature and resulting clinical management of this patient population. This literature was not limited just to therapeutics targeting COVID-19, but also to supportive care such as anti-inflammatories and venous thromboembolism prophylaxis and treatment.

With such poor outcomes in such a high volume of patients, many providers were desperate to find any therapy that may be beneficial for suffering patients. This desperation proved to be a double-edged sword, as clinical decisions were often being weighed before fully knowing the potential toxicities or implications of using these therapies.

Hydroxychloroquine proved to be the perfect case study in this situation; widespread use of it quickly dissipated as its benefit among hospitalized patients dwindled.⁷ As the flurry of literature continued to prompt questions regarding new therapies and clinical practices, my colleagues and I met twice weekly to discuss the merits and disadvantages, as well as to share anecdotes and experiences. This was in addition to the daily communication occurring amongst smaller groups with more direct knowledge and experience using certain therapeutics. As an oncology clinical pharmacist, I leaned heavily on the experience and expertise of my critical care and infectious disease clinical pharmacist colleagues to better care for these patients. I also contributed my oncology pharmacy knowledge to the debate by routinely discussing the pharmacotherapy of agents such as tocilizumab with my infectious disease colleagues, who had less experience using these agents.

Ultimately, a New Normal
As the rates of new infections and deaths began to fall throughout New York City, our normal clinical duties resumed. While the pandemic spread and ravaged other parts of the United States, a new normal was established, a normal in which vigilance and caution reins the day. Eventually, patient volumes returned to pre-pandemic levels and we all returned to caring for patients within our own specialties but we won't forget the lessons learned and experiences gained during a fateful, and now infamous, 2020.

REFERENCES

1. New York City Department of Health and Mental Hygiene. COVID-19 data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page. Accessed September 25, 2020.
2. Auerbach A, O’Leary KJ, Greysen SR, et al. Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. J Hosp Med. 2020 August; 15(8):483-488.
3. Kumaraiah D, Yip N, Ivascu N, Hill L. Innovative ICU Physician Care Models: Covid-19 Pandemic at NewYork-Presbyterian. NEJM: Catalyst. 2020. Accessed May 5, 2020.
4. Campbell P, Witenko C, Dzierba AL. Perseverance in a pandemic: a unique pharmacy residency learning experience. Am J Health-Syst Pharm.