The COVID-19 pandemic is having a devastating effect on the nursing homes for dependent older people. The difficulty of management of this crisis is aggravated by the frailty of the people served and by the specific characteristics of the care area, mainly the fact of not being integrated into the health system.
The objective of this work is to describe the pharmaceutical care developed by a hospital pharmacy service established in a nursing home and, from a more global perspective, analyze the strengths and weaknesses found from the various experiences of hospital pharmacy in all spanish autonomous communities to deal with this pandemic.
Specialized pharmaceutical care has provided rigor in the validation and treatments review processes from a comprehensive perspective, maximizing safety and collaborating in the establishment of the therapeutic intensity degree most appropriate to the individual situation, has ensured the availability of all necessary medications, has collaborated in the acquisition and management of personal protective equipment, has been able to adapt the dispensation processes to the internal nursing homes sectorization and has facilitated the coordination between the nursing home and the health system.
It is clear that the crisis casued by COVID-19 has put relevance of the need to integrate the social-health level into the health system. And also, the contribution of specialized pharmaceutical care in improving healthcare coverage and coordination with health services has highlighted the urgency of developing the current legislation, prioritizing the establishment of pharmacy services able to provid specialized and specific care for this area, so that it meets healthcare needs and is integrated into the health system.
La pandemia COVID-19 está teniendo un efecto devastador en las residencias de personas mayores dependientes. La dificultad de la gestión de la crisis se ve agravada por la fragilidad de las personas atendidas y por las propias características del ámbito asistencial, principalmente el hecho de no estar integrado en el sistema de salud.
El objetivo del presente trabajo es describir la atención farmacéutica especializada desarrollada por un servicio de farmacia hospitalario establecido en un centro sociosanitario y, desde una perspectiva más global, analizar las fortalezas y debilidades encontradas desde las diversas experiencias de la farmacia hospitalaria en el conjunto de comunidades autónomas para hacer frente a esta pandemia.
La atención farmacéutica especializada ha aportado rigor en los procesos de validación y revisión de los tratamientos desde una perspectiva integral, maximizando la seguridad y colaborando en el establecimiento del grado de intensidad terapéutica más adecuado a la situación individual de la persona afectada, ha asegurado la disponibilidad de todos los medicamentos necesarios, ha colaborado en la adquisición y gestión de los equipos de protección individual, ha sido capaz de adaptar los procesos de dispensación a la sectorización interna de las residencias y ha facilitado la coordinación entre la residencia y el sistema de salud.
Resulta evidente que la crisis provocada por la COVID-19 ha puesto de relevancia la necesidad de integrar el ámbito sociosanitario en el sistema de salud. Y asimismo, la contribución de la atención farmacéutica especializada en la mejora de la cobertura asistencial y de la coordinación conlos servicios sanitarios ha puesto de manifiesto la urgencia de desarrollar la legislación vigente, priorizando el establecimiento de servicios de farmacia capaces de proporcionar una atención especializada y específica para este ámbito asistencial, de forma que cubra las necesidades asistenciales y quede integrada en la estructura sanitaria.
The COVID-19 pandemic is having a devastating effect on nursing homes (NHs). According to data reported by the Spanish Ministry of Health, as of April 30th, 16,649 EH residents had died with COVID-19 or compatible symptoms in Spain, accounting for 67.84% of the total number of deaths1.
In addition, remarkable differences were observed between Autonomous Communities (ACs), in line with the global impact of the epidemic. Based on the number of places in NHs2, the estimated rate of mortality of institutionalized residents was less than 0.2% in the Canary Islands (n = 10 deaths), whilst Andalusia (n = 459), Asturias (n = 162), Valencia (n = 462) or Galicia (n = 249) did not exceed 2%; and Catalonia (n = 2,966), Navarre (n = 395), Castile-La Mancha (n = 1,944) and Madrid (n = 5,811) reached 5%, 6%, 7% and 12%, respectively.
These data are rough estimates —there are no reliable statistics because each AC used a different method to count cases and deaths. However, the magnitude of the figures shows a clear picture of the situation, taking into account that, with some exceptions, only subjects who died with a positive diagnostic test for COVID-19 were counted.
Characteristics of nursing homes in relation to the epidemicIn contrast to hospital and home care settings3, the environment of NHs has differential characteristics that heavily influence the implementation of work procedures and the outcomes of the epidemic:
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The health care provided is not integrated into the health system (in most ACs).
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It assists frail people with complex care needs.
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The model person-centered care is followed, with comprehensive geriatric assessment being the basis for the development of individualized action plans4.
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Priority is given to activities aimed at minimizing the degree of functional and cognitive disability two aspects that condition the design and organization of the facility.
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Pharmaceutical care is very heterogeneous, with coexisting models of provision of services from a community pharmacy (the majority) and from a pharmacy service5.
The aim of this article is to describe the specialized pharmaceutical care (SPC) developed in NHs in the context of the COVID-19 pandemic by presenting the experience of the pharmacy service (PS) of the Burriana NH, as well as to analyze the strengths and weaknesses found, including experiences from other ACs.
Strategic approach followed: specialized pharmaceutical care in an nursing home affected by COVID-19The Burriana NH, a public institution, has 190 beds, 15 of which are used as day center (average age 83.7 years [SD: 9.5]; 76% women). Of them, 85% of residents are frail (IF-CSS>0.2), and 61% are in a moderately-advanced disease stage6. The PS established in this NH includes two specialist pharmacists, a nurse, three pharmacy technicians and an administrative assistant to assist the 450 residents of four NHs.
As the epidemic advanced, successive changes were made to the organization of the NH and the PS, in accordance with the recommendations of public authorities7. Figure 1 shows the evolution of the strategy to prevent contagion, the sectorization by enabling specific areas to assist residents according to their situation, and the drug dispensing system established.
In phase 2 of the intervention, with active COVID-19 cases, work shifts were restructured. Two groups of pharmacy technicians and nurses (48-h shifts) were established to maintain the daily capacity for the preparation and dispensing treatments.
The two pharmacists redistributed their tasks. The former was a member of the COVID-19 crisis management committee. She participated in the reorganization of the NH and in the prevention, sectorization and design of the COVID-19 area. She was in charge of the use and management of individual protection equipment (IPE), including training workers, and managed the pharmaceutical care of institutionalized patients from other NHs affected. The second pharmacist was mainly in charge of the pharmaceutical care of patients from the Burriana NH (both COVID-19 and non-COVID-19) and unaffected NHs.
Procurement was modified by the emergency of cases, the stocks of certain medicines and fluid therapies were increased to ensure the availability of the best treatments and avoid shortages.
Reorganization of the dispensing of treatment and medical devicesThe distribution of medicines and medical devices (MDs) in the different areas had to be reorganized (Figure 1):
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The capacity for self-management of treatment was re-evaluated with personalized dispensing systems (PDS) to facilitate the care of less dependent residents in their rooms, allowing for a greater interpersonal distance in the dining room.
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Daily and weekly dispensing was redistributed in individualized unit doses, with daily modifications in all care areas.
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COVID-19 area:
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A medicine storage unit (Table 1) and a specific MD storage unit (Table 2) with weekly restocking were designed and implemented.
Table 1.Composition of the medicine storage unit in the COVID-19 area
Item No.* NUTRITION Neutral thickener 1 Lemon flavor thickener 1 ANTIPYRETICS/ANALGESICS Metamizole 575 capsules 10 Paracetamol 1g tablets 50 Paracetamol 1g sachets 50 Paracetamol 10 mg/ml I.V. 20 ANTICOAGULANTS Enoxaparin 4,000 IU 20 CARDIOVASCULAR Captopril 25mg tablets 10 ANTIBIOTICS Azithromycin 500 mg sachets 20 Azithromycin 500 mg tablets 20 Ceftriaxone 1g I.M. 10 Ceftriaxone 1g I.V. 20 Ciprofloxacin 500 mg capsules 20 EMERGENCY MEDICINES Diazepam 10 mg vials 5 Diazepam 10 mg enemas 2 Glucagon 1 mg 1 Haloperidol 5 mg vials 1 Methylprednisolone 20 mg 20 Methylprednisolone 40 mg 20 DIGESTION AND METABOLISM Aspart insulin pen 2 Glargine insulin pen 4 Omeprazole capsules 30 CENTRAL NERVOUS SYSTEM Clonazepam 0.5 mg 20 Diazepam 10 mg tablets 10 Haloperidol solution 2 mg/ml 30 ml 1 Quetiapine 25 mg tablets 10 LAXATIVES/ENEMAS Sodium lauryl sulfate rectal applicators 15 Polyethylene glycol sachets 10 Casen® enemas 3 FORMAS TÓPICAS Zinc oxide cream 10% 3 Table 2.Composition of the storage unit of medical devices and fluid therapy in the COVID-19 area
Item No.* NEEDLES/CANNULAS 25 × 0.8 mm biosafety needle 50 40 × 0.8 mm biosafety needle 50 Insulin safety needle 100 I.V. cannula no. 18/20/22 20 24 G biosafety catheter 4 DRESSINGS Protease modulator 20 15 × 20 adhesive polymeric foam 30 6 × 7 peripheral route fixation 50 10 × 10 ionic silver 20 Absorption polymeric foam heels 24 Absorption polymeric foam sacrum 5 5 × 7 sterile with pad 50 10 × 10 mesh hydrocolloid 30 BANDAGES AND GAUZES 10 × 5 folded gauze (bulk) 2,500 20 × 20 sterile gauze 280 50 × 50 sterile gauze 10 10 × 10 cohesive elastic bandage 5 Cotton crepe bandage 10 SYRINGES Sterile two body syringe 2/5/10 ml 100 DEVICES Glucometer 1 Forehead laser thermometer 1 ANTISEPTIC SOLUTIONS Alcohol 70° 1 l 2 Chlorhexidine 4% 500 ml 2 Chlorhexidine 2% 30 ml 1 Sodium chloride 0.9% 10 ml 20 Povidone-iodine 500 ml 1 Prontosan® 2 OTHER MATERIAL Tablet crusher bag 100 Inhalation chamber 2 Mask for inhalation chamber 2 Disinfectant cleaner 1 Hydroalcoholic gel dispenser 3 INFUSION EQUIPMENT 10 cm three-way key with extension 30 I.V. infusion flow regulator 15 150 cm infusion system 90 Luer-lock valve 25 STRAPS 10 × 2.5 cm paper 12 5 × 5cm fabric 6 STRIPS AND LANCETS Lancets 100 Glucose strips 50 MASKS Nasal oxygen mask 30 Oxygen mask with 7 concentrations 30 ISOLATION MATERIAL Non-sterile disposable gown 80 Green slippers 150 Sealed protective goggles 15 Hydroalcoholic gel 5 l 1 Green disposable cap 100 Surgical paper mask 250 FFP2 protection mask 50 Waterproof overall 50 Protective screen 10 Nitrile glove (L) 200 Nitrile glove (S/M) 400 FLUID THERAPY Glucose 5% 1,000 ml 5 Glucose 5% 500 ml 5 Glucosaline 1,000 ml 40 Glucosaline 500 ml 20 Physiological saline 0.9% 100 ml 50 Physiological saline 0.9% 1,000 ml 40 Physiological saline 0.9% 500 ml 10 - –
A weekly-dispensing trolley was fitted out, enabling daily management of treatment changes.
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Disinfection and cleaning procedures were established for dispensing supports prior to their storage in the MD, along with a quarantine of 2-7 days for returned units prior to their reuse8.
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During the first weeks, the procurement of IPE was carried out directly from the MD. When the centralized departmental dispensing cycle was operational, its management was assumed internally.
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The complete treatment of COVID-19 patients was validated and reviewed to detect potential adverse reactions and interactions, and simplify them by eliminating unnecessary medicines and incorporating simpler dosage regimes9 (Table 3).
Table 3.Treatment review in isolated or COVID-19 patients
Chronic treatment Maintaining the medicines considered essential (risk/benefit ratio appropriate to the therapeutic objective and clinical situation) - •
Temporarily removing medicines that can be safely discontinued (e.g. vitamins and minerals; oral bisphosphonates, denosumab)
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Checking treatment intensity (e.g. hypoglycemic, antihypertensive, etc.)
Reassessing —and discontinuing when possible— potentially inappropriate medicines, based on the therapeutic objective and clinical situation - •
STOPP criteria
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STOPP-Frail criteria
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Maintaining medicines for symptom control according to the objective
Reassessing medicines that may increase the risk of adverse events (e.g. withdrawal, dose reduction, replacement) - •
Sedative load, anticholinergic load
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Medicines increasing the risk of pneumonia
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Medicines increasing the risk of falls
Reassessing difficulties in administration (e.g. self-management, dysphagia, dependence, masking) and maximizing safety - •
Selection of dispensing system
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Adaptation and selection of pharmaceutical forms
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Preference for OD-PF, L-PF and transdermal route
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No nebulization
Rationalizing, optimizing and simplifying dose regimens and time schedules for treatment administration - •
Reducing the number of intakes (modified release formulations, once-daily active ingredients)
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Grouping medicine administration to reduce visits
Specific treatment for COVID-19 Reviewing interactions/contraindications/precautions - •
Intervention on chronic treatment
L-PF: liquid pharmaceutical forms (e.g. oral syringes); OD-PF: orodispersible (flash) pharmaceutical forms.
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Daily meetings with the medical staff of the NH and the home hospitalization unit were held to discuss the pharmacotherapy management of the affected patients considering their vulnerability.
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Multidisciplinary screening of patients with compatible symptoms was performed, and fixed analgesic schedules were modified to “only if necessary” schedules to avoid possible masking.
Heterogeneity is the main feature of the environment of NHs. The decisions that public administrations have taken regarding the management of the pandemic and the SPC models and their operation in NHs are not left aside. There are no uniform patterns, and experiences have been different in each case.
In general, the consultations carried out for this work show the capacity of the PS to adapt to the needs of NHs and the difficulties arising from persistent disconnection between the different health and social systems.
Strengths- •
Integration of the SPC into the NHs as part of the assistance and crisis management committees.
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Rigor in the validation/review of treatments from an integral perspective: maximizing safety and therapeutic impact according to the situation of each patient.
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Accessibility to the optimal treatment: antivirals, medicines for hospital use and for palliative use in end-of-life situations.
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Organization of pharmaceutical provision in intermediate resources (e.g. medical residences), established to care for affected people.
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Capacity to reorganize and adapt the dispensing systems according to the internal sectorization of the NH.
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Rigorous training and information to NH workers on the indication and management of the specific COVID treatment and the use of IPE.
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Management of the procurement, supply and protocols for the use of the MD and IPE.
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Communication between the NH and the health system (e.g. hospital, health area direction, public health).
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Lack of pharmacotherapy protocols shared between care levels for this population.
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Limited availability of information and communication technologies (ICTs), personal electronic medical records and other online resources to maintain the remote care activity of the pharmacist (participation in the individualized action plan, connection with the multidisciplinary team, pharmacotherapy review, continuity of care).
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Difficulties in establishing efficient supply lines for IPE and specific COVID medicines and for hospital use in NHs without SPC.
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Difficulties in establishing non-pharmacological and prescription measures due to the changes in care practice resulting from sectorization, including pharmacotherapy follow-up, comprehensive geriatric assessment and individualized action plan for the residents.
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Difficulties in developing global SPC due to a lack of effective integration of nursing homes in the health system.
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Partial or no development of SPC in a high number of NHs, which hampered the management of the pharmacotherapy crisis in these NHs.
Lessons learned. Future applicability in pharmacy services
The health and social breakdown is real and persistent —it has forced improvisation and delayed the establishment of specific measures to provide care according to needs. In this line, with the de-escalation of confinement already under way, there is still no forward-looking strategy for the management of the epidemic in nursing homes. If there is one thing this crisis has shown, that is the need to integrate nursing homes into the health system. Undoubtedly, the pharmacy services providing care in nursing homes have made a significant contribution to improving the quality of care and coordination with health services. This has been possible by incorporating the pharmaceutical care into comprehensive assessment, by carrying out a multidisciplinary evaluation of treatments based on scientific rigor, by being able to adapt to the needs of patients and to the characteristics of social health centres, by facilitating the accessibility of medicines, and by managing the medical devices and the individual protection equipment. Therefore, it is urgent to further enhance the Spanish Royal Decree 16/2012 by prioritizing the establishment of pharmacy services capable of developing specialized pharmaceutical care specifically for this area of care and integrated into the health system. In this way, care and the capacity to deal with future crises would be improved.
We would like to thank the pharmacists who have collaborated on this article by sharing their experience in care in nursing homes: Idoia Beobide Telleria, Cecilia Calvo Pita, María García-Mina Freire, Nuria Iglesias Álvarez, Maite Llanos García, Virginia Saavedra Quirós, and Daniel Sevilla Sánchez.
