COVID-19: ID Pharmacy From the Frontlines

Segment description: Jeannette Bouchard, PharmD, infectious disease pharmacy fellow, University of South Carolina and Prisma Health, discusses how ID pharmacists are taking on new responsibilities and working collaboratively to respond to COVID-19.

Interview transcript (modified slightly for readability):

Contagion®: Thanks for joining us for another Contagion® coronavirus video. Today we are joined by Dr. Jeanette Bouchard, who is with the University of South Carolina and Prisma Health. Thanks so much for joining us.

Bouchard: Yeah, not a problem at all. Happy to be here.

Contagion®: Great. We're happy to have you. Dr. Bouchard is an infectious diseases pharmacy fellow. We're going to be talking to her a little bit about what she's been seeing on the frontlines of response to this pandemic. So the first question is, can you speak to what your roles and responsibilities have been in regards to COVID-19?

Bouchard: Of course, like many probably have found themselves right now, my roles and responsibilities have certainly been interesting and very fluid throughout this process. Being a fellow here at the university as well as Prisma health, I started out this process at one of our smaller community hospitals doing stewardship. When we first started to see patients in our area, I was doing stewardship but then also kind of swinging to help with clinical work and ICU clinical work.

At our smaller institution, the stewardship pharmacist typically does the ICU and stewardship at the same time. I was balancing that plus having 2 students and then our COVID cases started to hit. Our students got bumped off campus and started to do distance work. Then, we started rolling out different investigational agents and trying to get a handle on how we're going to manage these patients and the PPE issue. I found myself running 2 codes and being more of a PPE steward and being a liaison between the infection prevention physicians as well as our ID physicians at this smaller hospital.

So it was definitely quite the role to take initially, all while in the background, helping our larger ID group in our larger infection prevention group sort through literature and look through all of the theorized therapies that we're using, as well as how these patients present, what we can do for these patients, what's the best supportive care for them. So, I found myself doing a lot of background, larger hospital communication work as well as working more on the frontlines from a clinical side right up front, which was definitely a good experience to say the least.

Contagion®: Are you currently being exposed to using any of the investigational agents for COVID-19?

Bouchard: I definitely am. So we're fortunate to be one of the larger academic hospitals in the area. we were able to become a part of one of the remdesivir trials through Gilead. We're currently working through getting convalescent plasma for some of our patients, as well as working through a couple of other different study avenues as well. And trying to maybe do some studies of our own at our own campus, not just going in on one of the larger studies. We have a smaller Investigational Drug Services Department. We only have 1 pharmacist and I've been helping her a lot with getting some of these studies up and running and gathering the data on them and the communications. I've become kind of per secondhand woman in that process and me and her are tag teaming a lot of the different protocols and initiations and communications with the investigational drugs.

So I'm getting a little bit of a dab in what being an investigational drug pharmacist is on a super fast and furious scale because these trials are not conventional for what they normally do. When speaking with anyone who's in IDS or Investigational Drug Services, they'll certainly tell you that clinical trials don't roll out this fast. They're on quite the escalated scale of rolling out within a month, when normally it takes 6 to 8 months to even get site visits and things like that up and running. It's been quite a lot of fun, a lot of learning and a lot of questions have to be asked in order to make sure everything's running smoothly and safely for our patients.

Contagion®: Can you provide us with some information on how your institution is managing patients with COVID-19?

Bouchard: Right now, we're primarily focused on making sure that everyone is educated about all of the information that's coming out. So we're providing a lot of education to physicians about the theorized medication options for COVID. There's a lot of talk about hydroxychloroquine and chloroquine, remdesivir. We're trying to keep education on the forefront and make sure that people are making informed decisions when having treatments.

We don't have set in stone guidelines for our physicians and it's up to their discretion how they want to be treating these patients. But, we want to make sure that they're as educated as possible. So that's kind of what we come with and how we're managing our patients. Supportive care is definitely first. A lot of the management upfront that we were doing with these patients was how we're going to manage a whole floor of these patients going forward.

We started cohorting them as well as figuring out ways to kind of steward as I was saying before with the PPE so the personal protective equipment. It's difficult to have a lot of these COVID patients mixed in with other patients. So working on supportive care, making sure that the patients are cohorted to certain areas of the hospital or certain hospitals within the area, and making sure that everyone's using educated approaches to treatment with these patients, in terms of the theorized options out there.

Contagion®: As someone who's on the front lines of this situation, what has been the hardest part for you so far?

Bouchard: That's a great question and one I often think about I think when I go home is the hardest part of my day. A lot of family members, I think typically also ask this question. Initially, the hardest part was just the sheer amount of data that was coming out and still is coming out and having to dig through that on a daily basis. Pandemic aside, you're already digging through a lot of literature and a lot of the new stuff that's coming out. Email and online journals make it really easy for people to publish data. Now adding COVID on top of this in the amount of information people want right away, it's hard to dig through all of that data and really impossible for one person to do.

I think Matt [Davis] was saying before that it's like drinking from a firehose and you kind of hear that effect anytime you're thrown into something that's a lot to handle. It's definitely what this situation has become so trying to gather trusted colleagues to critique this data and relying on their opinion...but also looking through when you can is super important. Often the hardest part of this time period right now is we don't know what we're doing. We're having to sift through a lot of data that's somewhat helpful or not helpful at all. Trying to figure out which ones are really not helpful is one of the hardest parts.

Then, from a personal side, I think definitely the most difficult part is watching the number of families like full families that come into the hospital. We see a lot of patients who are really sick on a daily basis, but it's not too often that you see a whole family come in who are sick and so that's probably one of the hardest personal problems that I have throughout the day. Watching these whole families come in and having to talk to them over the phone and give them information and help them sort through the information in the media and then compare it to their loved ones. It's a very difficult thing to be doing right now, especially when there's not a whole lot of information you can provide people.

Contagion®: Can you speak to the critical role of the pharmacist in this evolving pandemic situation?

Bouchard: There's a number of different roles that I think are really critical for a pharmacist right now in this situation. One is true to our original design as a pharmacist, and that's drug acquisition. Right in the beginning, when you had all of these different ideas about what strokes would work the best for COVID, there was a lot of drug shortages happening and there still are drug shortages. So drug acquisition and making sure you have the right medications to be treating these patients, not just from an antiviral side, but also supportive care sides.

You'll see a lot of critical care pharmacists asking for sedation and intubation medications that are going on shortage, just because of the sheer number of patients who are needing them right now, all at the same time. It's not just the theorized antivirals, but also the supportive care side, which is the side that's most important right now. Pharmacists can definitely help there and helping their hospitals kind of manage that aspect of it. It's a very important part in coming up with alternative pathways. When you run out of one drug, what drug goes next and what are the different things to be worried about? But that's a big part right now of our pharmacist job. But they can also help in the investigational agents areas.

Like I was saying before, we have our IDS, pharmacist or investigational pharmacist helping out a lot. So her job kind of ramped up pretty quickly, especially with our trials rolling out. They can help there as well as helping with dosing of these agents. Looking into a lot of data there about which dosing is going to work best what to watch out for in certain patients, making sure you're evaluating the literature and keeping up on these different therapeutic options and we're not causing more harm than good in certain areas. There's a lot of different ways a pharmacist can help right now.

I think the most important thing is to just throw yourself in there and kind of help where you can and do what you can to help right now. I've kind of got my hands in a lot of different pots for that reason. Wherever someone needs me, I am there because I'm a post-grad trainee. So I don't have a full on position at this hospital so I have that extra time to kind of do what I can in certain areas. A pharmacist can be a part of nearly every aspect of this situation. You just have to find your niche and go in there and get it.

Contagion®: Absolutely. And it sounds like you're definitely doing that. So my last question for you is do you have any resources or tips to share with other clinicians who are starting to, you know, see an increase in the number of patients with COVID-19?

Bouchard: Certainly. There are tons of different resources online. I use SIDP, which is the Society of Infectious Diseases, Pharmacists a lot. They put out great podcasts, great literature reviews. Contagion has also been like a good source for their people's experiences, as well as reviews of some of the antiviral or anti-COVID treatments that people are looking into. IDSA just put out guidelines for management of COVID patients. The IDSA is a really good place to look, as well as CDC. They put out guidance that can help with certain areas of managing COVID patients. But also, I think talking with your colleagues and making sure you're setting up discussions for literature review and talking with other team members will definitely help you manage these patients better.

I'm hyper focused on all of the infectious disease related information for COVID, because that's where I like to learn and that's what I do. But I have a colleague who's a critical care pharmacist, and she's hyper focused on all of the things that an ICU pharmacist would need and making different sedation pathways. I have a lot of discussions with her about how she's managing a patient from an ICU standpoint and what we can do from an infectious diseases standpoint to help her. Then also having conversations with nurses as well as respiratory therapists and working together as a team to piece together what everyone needs. Everyone's in the dark right now. So if you can work together as a team and take a multidisciplinary approach, that's probably one of the best ways to start managing these patients better as soon as you start to see them come in is just try to get the whole team on board. In terms of what you best want to do and what strategies you should take.

Contagion®: Well, this has been great. Dr. Bouchard, thanks so much for taking time out of your schedule to join us. We really appreciate all your insight and we wish you the best of luck in handling this situation.

Bouchard: Thank you so much. I appreciate it.