The ongoing COVID-19 pandemic continues to present new challenges for health system leaders, many of whom are facing critical shortages of personal protective equipment (PPE), medications, and other important supplies.
At Sharp HealthCare, the integrated delivery system based in San Diego, clinical IT professionals are using VigiLanz, a clinical surveillance software, to maximize the use of the supplies they do have, while also creating alerts that are helping healthcare workers on the front lines. Although less than 100 San Diegans have died from the virus as of April 22, patient care leaders and their IT teams understand that collaborating to monitor supply and drug shortages will still be necessary during this pandemic.
Mike Kruse, PharmD, manager, pharmacy clinical services at Sharp HealthCare, recently spoke with Healthcare Innovation about these concerns and the process behind setting up and managing alerts for the organization’s providers. Below are excerpts of that discussion.
There’s a lot going on with shortages of drugs and supplies at healthcare organizations these days. How is Sharp using clinical surveillance technology to respond to some of these challenges?
In mid-February, I started to notice in the news that Italy was having some issues with COVID, and discussions began to shift at Sharp about the virus was coming to the U.S. Then, when cases started hitting the West Coast, on March 6 I submitted a ticket to VigiLanz to build out a rule looking for our first patient who had a COVID test sent out. At the time, we didn’t have a specific lab order built out in our EHR system. We wanted our antimicrobial stewardship pharmacists to follow these patients and get familiar with what’s clinically going on with them, so we can serve that population as they come in. We created a VigiLanz rule with a free-text query of EHR documentation. In the next few days, we revised the rule as the lab orders were built out.
Since that time, with the growth in testing, we have adjusted our use of the rules. Some [of our] sites want to see all patients tested. Others want to know just when a positive result is returned. In addition, we can combined the rule into other rules. An example of this is with rules dedicated to hydroxychloroquine.
When hydroxychloroquine started to become a popular treatment, we wanted to add a level of safety. Initially, we looked at the amount of the drug we had on the shelf—until now it has not been a common drug—and we saw that we had about 39 courses worth of the drug, meaning we could treat 39 patients with the dosage mostly commonly prescribed in COVID-19. We began to monitor any hydroxychloroquine drug that came across so that we could look at if patients [were using it] for home chronic therapy, or because they were a patient under COVID investigation, or had a positive test. We layered in QTc-interval monitoring. Vigilanz rules pulled from the chart a patient’s QT intervals so we could assess at baseline, or during the course of their therapy, there was any increase in their QT interval. If a negative COVID-19 result returned, pharmacists are notified, and the drug can be stopped.
A third area we have explored has been around how we can protect our nurses and also conserve protective equipment. We assess medications such as famotidine or heparin which are given two or three times daily to see if patients can be converted to once-daily alternatives. The goal is to reduce the number of times a nurse has to go into the patient’s room where they might be exposed, while also needing to gown up and use equipment for each of those drug administrations.
Can you discuss the need to balance the benefit of alerts versus too much alert fatigue for your providers?
Let’s say you looked at a rule that only fired to show all the patients on hydroxychloroquine. On day one you will have a few [alerts] because of our limited supply. However, after receiving free medication from Teva, literally half your patients who come in with COVID are being prescribed this medication. These rules become less relevant to the patient’s care. When you add the QTc breakpoints from the American College of Cardiology, we have only a few patients for which there are alerts for. So that’s how you get away from that alert fatigue—by combining more than one element in your chart to make the rules more and more specific. It is common to evolve alerts over time.
What shortages are specifically being dealt with today at Sharp?
Prior to COVID-19, we have hosted weekly drug shortage phone calls to manage drug supply. For COVID-19, we had about one month to plan for a potential surge. But California has not had a surge yet. In San Diego, we have only about 2,000 patients who have been diagnosed with COVID, though I am sure a lack of testing [plays a role in that number]. In terms of our drug supply, we are watching the same things others are. Our wholesaler said everyone was initially worried about inhalers and a few other things. Then, after a week, nationwide, everyone started worrying about their drips—opiates, sedatives, and neuromuscular blockers. That’s the same list Sharp is watching. We are doing well; we’re seeing a slight surge at one of our hospitals closest to the border. We’ve shifted to daily calls to share what’s coming in and what our usage is.
How do you handle the needs for non-COVID patients during this crisis, especially when some of these drugs and other supplies might be needed for both COVID and non-COVID patients?
Looking at our hospitals now, our ICUs are 70 percent full, and half of those are non-COVID patients. Patients are still coming in with heart attacks and traditional pneumonia, rather than viral pneumonia. We are fortunate that no one is going without drugs. To align our drug supply with patient needs, we have shifted modality in some ways. As an example, nebulizers are used for respiratory treatments in non-COVID patients. Metered-dose inhalers are reserved for COVID patients so we won’t disperse virus in the air.
Looking at the ICU, where we do have the risk of running out of critical care drips, there is overlap in treatment approaches for COVID and non-COVID patients. More COVID-19 patients are expected to experience acute respiratory distress syndrome. We have created a tailored algorithm to give patients what they best need at that moment while still preserving drugs. We especially need to reserve neuromuscular blockers and some of the deeper sedatives for the worst respiratory failure.