Preparing for COVID-19 in States Behind the Curve

Segment descriptions: Lucas Schulz, PharmD, BCPS, AQ-ID, clinical coordinator, infectious diseases, University of Wisconsin Health, discusses how he is preparing for COVID-19 as a clinical pharmacist working in Wisconsin.

Interview transcript (modified slightly for readability)

Contagion®: Thanks for joining us for another Contagion® coronavirus video. Today we are joined by Dr. Luke Schulz. Thanks so much for joining us.

Schulz: You're welcome. Thanks for thanks for the invitation.

Contagion®: So why don't we just get started? As a pharmacist, how have you been preparing for the peak of COVID-19 at your institution?

Schulz: I think it starts with 2 facets of modern pharmacy practice, 1 being operations and 1 being clinical practice. Operations is blocking and tackling, which are the fundamentals of pharmacy. It's about how we get medications to patients safely and efficiently. Following early projections and our early experience combined with the experiences of Washington and New York, and other pharmacists that we've spoken to, we take the best guess at what type of medications that we're going to run short of or run out of, and make sure that we're able to prepare for how to mitigate those shortages and prepare alternatives. Part of the time has been spent in that operations mentality of just making sure we can do the fundamentals of pharmacy. Make sure that we can get patients medication safely and timely. This includes preparing EMR guidance documents on ordering. How do we make sure our IV pump library updates are in place, so that there are guardrails for the administration and the safe administration of medications? On the other hand, our clinical pharmacists, you know, are there making sure patients' medication plan is safe and effective. While clinical pharmacists certainly rely very heavily on our operational counterparts to make sure that the medications that we recommend get to the patients in a sterile fashion or are available to be administered how we expect when we order them in our in our EMR, It's the job done of the clinical pharmacist to account for all those individual patient nuances and adapt the medication regimens accordingly.

We start from a clinical standpoint, thinking about, well, what is the standard of care for our COVID-19 patients? Here at UW, we set that standard through guidelines. Then we give those guidelines teeth through EMR tools and delegation protocols. Our clinical pharmacists are at the bedside making sure that we meet our standards of care, and that every patient receives extraordinary medication therapy.

My role as a clinical coordinator, places me at that interface between operations and on the other side of clinical pharmacy, Clinical Pharmacy Services. Personally, I've been co leading our therapeutics workgroup, and helping to decide what medications should we be recommending? How are we going to mitigate potential drug shortages associated with an increasing number of patients? Our workgroup has been evaluating COVID literature determining what should be our standard of care. Sometimes that means that I'm approving specific therapies, taking phone calls from our frontline physicians, our clinical pharmacists that are caring for the patients at the bedside and helping them decide should we give the patient drug x versus drug? Why? Sometimes that means I'm spending my days developing EMR tools to make sure patients are started on therapy when they're appropriate. How do we make sure we're identifying patients that need therapy and getting that to them in a timely fashion? It really varies by the drug therapy and the needs of the patients that are required to provide optimal therapy. I interface with our operations leadership to evaluate our medication inventory. We meet a couple times a week to talk about, do we have the right amount of drug? How are we going to transition between 1 agent to another, if we do run out, and then kind of on the outskirts of my daily work is interfacing with our regional affiliate hospitals. I think this has been something that I found very interesting and a great opportunity for pharmacists and ICU physicians in our institution is that the COVID crisis is really challenging all of our hospitals to modify their plans for patient care. Historically, a critical access hospital may have treated a patient, got them clinically stable, and then planned for them to transfer to our tertiary care center.

We're working with our ICU and regional antimicrobial stewardship programs to make sure that those community hospitals and critical access hospitals are ready to care for ICU level patients for longer periods of time, and at much higher volumes than they're accustomed to. So my days have been spent addressing the entire spectrum of pharmacy services, and trying to make sure that as many people are prepared to, to care for patients as possible. I am just waiting for my time to go to the frontline.

Contagion®: What are your biggest concerns at this moment in time?

Schulz: My biggest concern right now certainly revolves around the rapidity of emerging literature and the role of social media in how quickly the data is changing. It certainly leads to confusion and wasted resources and ultimately dangerous care recommendations. I think we all want to help patients. I think everyone's acting in their best interest trying to help patients and make sure that patients have the best possible outcome. It's easy to reach for the first promising trial. Very few of us are trained virologists or intensivist so interpreting those studies can be challenging. The peer review process usually protects us from misinterpreting data. However, with so many papers coming out, pre-peer review, you have to approach each manuscript with a with a very critical eye.

The other thing I'm concerned about with that emerging literature is that many people are duplicating work. My time that I've spent working with critical access hospitals, I get a lot of places calling and asking about starting and enrolling patients in clinical studies. They've never done this before, and they want to start now. Again, I really appreciate the desire to provide new information and get patients enrolled into studies. But I think that's needs to be balanced with providing great supportive care.

We need to get patients into studies. We need to study these therapies in a controlled fashion. If you haven't read the JAMA editorial series from Dr. Khalil and Dr. Angus, I highly encourage everyone to read those. What it really points out is that the only proven and recommended therapy for COVID is great supportive care. So can you provide excellent supportive care for your critically ill patients 100% of the time? If not, you should probably focus your resources on providing excellent patient care. You'll realize much more bang for your buck by investing in those strategies than you are with an unproven drug therapy.

Finally, I think that lack of clarity, and the rapidly emerging literature opens up opportunities to sow distrust and make dangerous recommendations. That's occurring at an alarming rate. I see this with my family, with friends calling and [telling] me I saw this on social media. I saw it on Twitter, Facebook, I saw it, unfortunately, in a presidential press meeting. Everybody wants good outcomes for our patients. Unfortunately, we tend to look for a pill to treat that. This is a scenario where maybe doing nothing except providing the best proven and well-studied standard of care is the optimal therapy. So it's a challenging time with all of those changes.

Contagion®: Right. So how are you keeping up with all of this emerging literature on investigational therapeutics and so on?

Schulz: I try to keep up with a with all the emerging literature probably 4 ways. First, I signed up for the tables of contents from all the major medical journals. I've done this for years. So continue to watch for reputable journal publications. I look to society pages. A group of us here have kind of tried to collate some of these society pages. And as of this morning, we'd found 52 national and international societies with COVID information that they're collating. Oftentimes, they're summarizing this into recommendations. Their recommendations tend to be rather conservative, but they are excellent sources of new information. So it's a great place to keep up new information there.

I follow listservs, other professional societies, Contagion IDSA, SIDP, ASHP, Vizient. They are good sources of information as they do provide up to date references and people pull forward. I saw this interesting study. You do also get thoughts from thought leaders but how to interpret and operationalize the information. And then finally, I I've reached out to friends, I've asked all of our clinical pharmacists and my physician colleagues to share new studies with me and share their ideas for improving care for our patients freely. Sometimes this turns my inbox into a mess, but I always do try to show my appreciation. I appreciate everybody sending thoughts and studies my way, even when they send me something I already have I make sure I recognize that they spent time investing and trying to improve the care of our patients as well. Our friends and colleagues are excellent sources of information and resources and trying to find good, good literature and the next way that we can try to improve care for patients.

Contagion®: Absolutely. So what would you say are the most important elements of critical care during COVID-19? case surges?

Schulz: Certainly, as it relates to COVID, I think first and foremost is can we make sure that we can protect our caregivers, our nurses, respiratory therapists, physicians, pharmacists, anybody that's going to be in that room, caring for those patients? They're the frontline group to making sure that that we're able to continue to provide excellent supportive care. The other thing is ventilators. These patients are rapidly deteriorating, and we need supportive care for them. Then, we need patients and people who are trained to use those ventilators. So respiratory therapists and people who are able to care and provide that level of care. The pharmacist in me is certainly monitoring and looking at supportive care of medications including basal active agents, sedatives, paralytics, antibiotics and other drugs that may be treating secondary bacterial infections or the comorbidities associated with critical illness. This is extending my ID experience and taking me back to my critical care training days. I kind of find that this COVID crisis is a great opportunity for me to step back into my critical care training and really blend both my interest in critical care and my experience in ID.

Contagion®: Have you been consulting with colleagues at other institutions or in other specialties to kind of grasp what other clinicians are seeing so far in this pandemic?

Schulz: Absolutely. Nobody can do this alone. I hope that people are always willing to reach out and ask for help in these types of situations. I've absolutely been consulting with other colleagues and at other institutions. I greatly appreciate their thoughts and comments. I think what I'm seeing from them is a mix of feelings for being overwhelmed to some who are waiting for the worst. I put myself in that second category. Wisconsin has been fortunate to be behind the curve in this scenario a little bit. What I have been very impressed with is how calm and cool everybody's been keeping up about their recommendations and looking at looking at literature critically. Stepping into situations where they're out of their comfort zones but using all of those skills we learned as pharmacists and physicians and scientists ultimately, to, to help make the best and safest decisions for our patients. It's amazing to see the work that's been done in Washington, New York, Michigan, Boston, Chicago, New Orleans, those are some that that I've been in contact with, recently, just to name a few of them. Listening to their stories is exciting to hear in their voice, the passion that they've got for caring for these patients and, and really stepping out to try to do what's best for them compared to some of some the other hospitals where we're all preparing and trying to get ready to provide the best care for patients.

I think what they're seeing is the same story over and over again. Patient's rapidly deteriorating. It's important to start therapies early if possible. We can bend that curve, to use the very common statement with COVID. If we can bend that curve in this disease process, hopefully we can keep patients out of the ICU from being intubated and progressing. If we can bend that curve, though, that's all for the best for patients and. One of the things I found very inspirational is listening to those pharmacists and physicians that talk about hope. They all have stories of patients getting better and leaving their ICU. I think those are things that try to stick with me and help me stay motivated through these challenging weeks and months as we're busily and very actively trying to get guidelines and best care standards of care up to speed.

Contagion®: My last question for you is how can we better prepare for a novel outbreak in the future?

Schulz: That's very good question and I think it's a really important thing to start considering. I've been thinking a little bit about this as well. I think it boils down to that the most important thing is that we do need to, is trust the scientific method and trust scientists. I think we need to promote and market good science and good scientific methods to the lay population so that people understand why we take a measured approach to the care of these patients; why we go back to studies that have proven benefit.

We rely on the things we know that we do well. Before reaching out and trying for the miracle cure. We need to explore the miracle cures, but we need to do that in a in a measured fashion. I think the next thing we need to do is that health systems need to be ready to shift into pandemic mode. I think many hospitals are doing that. I think my institution, UW, has done this well. But I think part of that is that we need to look at developing and implementing clinical study designs to ensure that we quickly identify what's working and what's not. I've been very impressed with some of the studies, the adaptive study designs that are being developed. Dr. Angus talks about that in some of his work and. I think he's leading one of the studies that that looks at these adaptive study designs, where they continuously review therapies and start multiple arms and then throw out arms that are not working and replace them with the next potential therapy.

I think these novel study designs, being able to quickly enroll in those is an important thing that we need to look for in the future to identify what's best going to help patients. Then I think though, the last thing is I've been very impressed with the with the response from Gilead and other clinical study funding opportunities. The thing we need to look forward to prevent the next outbreak is minimizing the red tape of doing research and moving therapies through the appropriate steps to develop new medicines in the future. It's not to say that we want to move too fast or move at a dangerous speed. We still need to maintain that caution. But we've made great strides already at moving therapies into practice and I think that's something we can learn from for the next time. I don't think it will be long before we have the next one. We have an impending global issue already with regards to antibiotic resistance. That's not slowing down either. Antibiotic resistance is, appropriately I think, on the back burner during COVID, but the thing to remember is that that burner is still on and it's still cooking. So I think we'll need to use some of these skills and techniques that we've learned during this COVID crisis to, to adapt to addressing antibiotic resistance when all of this is over. I think we've got a lot to learn, but I think we've made a lot of progress and I'm looking forward to seeing what happens as we move forward.

Contagion®: Absolutely. Dr. Schulz, thanks so much for taking the time to join us today. We really appreciate it and we wish you luck.

Schulz: You're welcome. Thank you.