Adriana Chubaty , Kristen Rowntree , Alice Chan
On October 30, 2009, during the H1N1 pandemic, Alberta Health Services opened the Duggan Influenza Assessment Clinic in Edmonton, Alberta. The clinic had several purposes: to expedite triage of patients with influenza to the most appropriate care venue; to provide timely, accessible clinical assessment services for patients with mild to moderate influenza-like illness; to divert these patients from emergency departments and thus to reserve emergency departments for critically ill or injured patients; and to decrease transmission of disease to vulnerable populations. A multidisciplinary team of health care professionals staffed the clinic.
Initial planning for pharmacy services at the Influenza Assessment Clinic involved the Alberta Health Services Edmonton area pharmacy and was based on a need for dispensary and counselling activities related to antiviral and inhalation medications and maintenance of clinic wardstock. As the processes for patient triage and assessment evolved, additional opportunities were identified for greater pharmacy involvement. On November 23, 2009, the Influenza Assessment Clinic in Edmonton closed because of decreased demand for this service.
This article describes the unique pharmacy practice at the Duggan Influenza Assessment Clinic, explores the challenges encountered and lessons learned through the provision of pharmacy services to the clinic, and recognizes the benefits that arose from this experience.
The Duggan Influenza Assessment Clinic was located in the Edmonton area of Alberta Health Services, which serves more than 1 million people. The clinic was set up in response to an increase in hospital admissions for treatment of influenza-like illness, an increase in visits to emergency departments and urgent care clinics, and decreased availability of staff, because of illness, as well as data from laboratory surveillance indicating that more cases could be expected. Patients were screened before entry to ensure they met approved clinic criteria. A nurse then performed a primary assessment, which was followed by a secondary assessment by a physician or nurse practitioner if required. Before leaving the clinic, patients presented to a pharmacist, who answered patients’ questions about general influenza care and provided antiviral and inhaler medications and counselling if required. If necessary, patients could also be given a few doses of certain limited non-antiviral medications that were stocked at the clinic (e.g., analgesics, antiemetics, antibiotics). The pharmacist also reviewed all new clinic prescriptions for appropriateness, including those that were to be dispensed in the community.
From October 30 to November 23, 2009, about 4200 patients of all age groups visited the Duggan clinic. The goal for each patient’s length of stay in the clinic was less than 2 h.
Over the period of clinic operation, 1676 full courses of antivirals (specifically oseltamivir and zanamivir) were released to adult and pediatric patients. Of these, 51 prescriptions for oseltamivir 75-mg capsules were dispensed to health care workers from various sites in the Edmonton area. Of the remaining 1625 prescriptions, 1615 were for oseltamivir and 10 for zanamivir. Of the oseltamivir prescriptions, 327 were for the suspension, 37 for 30-mg capsules, 58 for 45-mg capsules, 64 for 60-mg capsules (which were mainly dispensed to pediatric patients), and 1129 for 75-mg capsules (dispensed to adults and children > 12 years old).
Pharmacy staff were recruited from 2 large hospitals in Edmonton, the University of Alberta Hospital and the Royal Alexandra Hospital. Overall, 2.8 full-time equivalents (FTEs) for both pharmacists and pharmacy technicians (2 pharmacist FTEs and 0.8 technician FTEs) were required daily for 7 days per week to cover the clinic hours of 0745 to 0015 (divided into 2 shifts: 0700–1630 and 1445–0015). Staff working overtime hours were paid accordingly.
A total of 20 pharmacists worked at the clinic. Each pharmacist was given the clinic orientation manual and received on-the-job training. A site manager (registered nurse) was available for site orientation and to answer administrative questions.
Antiviral medications were provided from the national stockpile, and their distribution was coordinated by the Alberta Health Services Pandemic Steering Committee. Other wardstock medications (e.g., analgesics, antibiotics, inhalation therapy) were supplied by the Royal Alexandra Hospital pharmacy, with funding from Alberta Health Services. In selecting medications to be included in wardstock, consideration was given to treatment of other causes of flu-like symptoms, current treatment recommendations and guidelines, treatment of other influenza symptoms, treatment of possible adverse reactions to medications, and treatment of severely ill patients requiring transport to the hospital. These wardstock medications were updated continually as feedback and data on usage were received.
Written information for patients was developed by Alberta Health Services before the clinic opened. Forms for patient records, influenza screening and assessment, and prescriptions were preprinted.
It was initially planned that the pharmacists’ responsibilities would be limited to the following: assessing all antiviral and other prescriptions written in the clinic for accuracy and appropriateness, dispensing antivirals, providing drug and influenza-prevention counselling, teaching inhaler technique, and managing inventory. Over time, and as clinic processes improved, the role of the pharmacist evolved to include acting as a drug information source for physicians, nursing staff, and patients; dosing and administering wardstock medications; recommending drug therapy or dosing for secondary infections and complications of influenza; and identifying and resolving drug-related problems. The literature has shown that physicians’ prescribing practices are influenced by the storage location of medications,1 and pharmacists in the Influenza Assessment Clinic were able to optimize prescribing practices by streamlining wardstock to include only those medications and doses recommended in the most current guidelines and practices.
The duties of the pharmacy technicians included filling prescriptions for antivirals and other medications and maintaining the clinic’s medication stocks and dispensing records.
A short satisfaction survey was conducted in July 2010 with a small number of pharmacists and other health care professionals who had worked at the clinic (Tables 1 and 2). Each of the 8 pharmacists surveyed had worked between 1 and 6 shifts while the Influenza Assessment Clinic was open.
Table 1.
Results of Satisfaction Survey for Pharmacists (
n
= 8)
Table 2.
Results of Satisfaction Survey for Other Health Care Professionals (
n
= 7)
Pharmacists and other staff faced several challenges during the implementation and operation of the Influenza Assessment Clinic. They also took note of several lessons learned that could be of benefit for future clinics of this type.
The announcement of the clinic occurred about 2 weeks before the clinic was to open, and the urgent need for pharmacy services at the clinic placed staff in an unprecedented environment that afforded little time for training and orientation. The pharmacist’s role within the clinic was developed on the basis of the assumed needs of the patients who would be presenting to the clinic. There had been no previous clinics of this nature at this location, nor were there any descriptions in the literature to aid in estimating pharmacy workload, resource requirements, or ultimate roles and responsibilities. Pharmacy staff agreed to work at the clinic with limited knowledge of their role and the work environment. This uncertainty was a source of stress, as noted by the pharmacists who responded to the survey.
It was hoped that the challenge caused by uncertainties about roles and responsibilities would be addressed by assigning a dedicated pharmacist (A.C.) to work at the Influenza Assessment Clinic during the first 5 days of the clinic’s operations. This pharmacist developed an information package for pharmacy staff who would be working at the clinic and provided basic orientation and training to pharmacists working the evening shifts for those initial 5 days. Scheduling allowed for an overlap in the 2 daily shifts, which in turn allowed time for training and orientation. However, because of the busy nature of the clinic, training time was still limited. The addition of a technician to the clinic also helped to address this challenge, as this measure increased the number of experienced pharmacy staff working in the clinic.
Other potential interventions to improve training and orientation were identified in the survey responses. Additional suggestions were to ensure that the morning shift was always staffed by someone with previous experience at the clinic, to pair any new pharmacy staff member with an experienced staff member, to develop a checklist for training to be completed by new staff, and to create a “mock” clinic pharmacy to help identify potential problems.2
Pharmacy staffing for the Influenza Assessment Clinic relied heavily upon personnel who were willing to sign up for clinic shifts in addition to their regular working hours. Initially, large numbers of patients were seen at the clinic, and staff would arrive to find long lineups of patients waiting. Initially, only one pharmacist was scheduled per shift, which meant that the pharmacist on duty had an extremely busy shift and it was difficult to take breaks. The addition of a technician shift allowed pharmacists to perform more clinical functions and improved workflow.
Lack of breaks was identified as a potential risk to staff and patient safety.3,4 Therefore, after the first day, it was decided that pharmacy staff, like other staff in the clinic, would take mandatory breaks during their shifts. No food or drink was allowed in the clinic, and staff wore scrubs, gloves, masks, and face shields while working. These requirements further supported the need for planned, mandatory breaks. When pharmacy staff were on break, patients were told that they could wait for the pharmacy staff to return or they could have their prescriptions filled by a community pharmacist.
We believe that if the clinic had remained open for much longer, staff burnout and a decrease in sign-up rates would have become apparent, despite indications to the contrary reported in the survey of pharmacists. Nonetheless, other options for staffing an influenza assessment clinic during a pandemic should be taken into consideration for the future. Temporarily suspending provision of certain noncritical clinical pharmacy services and redeploying those pharmacists to the Influenza Assessment Clinic was part of the regional pandemic plan. However, this measure was not necessary during fall 2009, as staffing levels did not drop to the point at which this process would be activated. Other alternatives might include using community pharmacists to staff the clinic, creating a video of antiviral and influenza counselling to be played continuously in the clinic, using pharmacists with additional prescribing authority, and having a technician for all shifts.
Once the clinic was opened, there were constant changes and updates to procedures. However, because the clinic was not staffed 24 h/day, direct communication could not occur at every shift change. Direct communication was also hindered by having clinic pharmacy staff from a number of different hospital sites. To aid with these communication challenges, frequent email updates were sent to clinic workers, updated information was printed and stored in the pharmacy area, shift overlap for communication handover was scheduled between the morning and afternoon shifts, and a communication log was implemented to relay information to future shifts and to provide examples of types of and solutions to problems that occurred. Other possible improvements would be to recruit all clinic workers from 1 or 2 sites or to use a core group of dedicated clinic staff.
Some of the health care workers at the clinic had no prior experience working with pharmacists. However, all of the other health care professionals surveyed were aware that a clinical pharmacist was working at the clinic, and most used or consulted the pharmacy services either all or most of the time (Table 2). One of the pharmacists who responded to the survey reported that one of the physicians had not wanted to use the services of the clinical pharmacist. Most other comments in the surveys characterized the collaborative experiences as positive. Collaboration with other health care providers might have been enhanced if the pharmacists’ role and practice scope had been outlined before the clinic was opened. This information could have been included in the general information package that was distributed before clinic opening. Collaboration might also have been enhanced by having a core group of pharmacy staff to provide consistent care and to enhance the building of rapport. Some examples of collaboration that led to enhancement of patient care included nurses seeking pharmacists for administration of and education about pediatric inhalers and nurses and physicians seeking pharmacists’ opinions about giving additional doses of medications to patients who were vomiting. These collaborative interventions helped to improve the timeliness and efficacy of treatment, as well as helping to prevent toxic effects of medications.
The pharmacy area of the Duggan Influenza Assessment Clinic was an open corner next to the exit. Because the clinic was located in a health centre that did not usually have a pharmacy area, the pharmacy department had to bring in additional resources necessary for operation. The treatment area had only 2 telephones and a single computer with Internet access, and neither of these devices was located in the pharmacy area. After the first few shifts, it was apparent that the availability of resources had to be improved. Staff undertook to improve the organization of the work area and relocated medication stocks to more accessible locations. Print copies of a few key tertiary drug references were brought to the clinic, and pharmacists were encouraged to bring mobile electronic devices loaded with drug information software. A cell phone was dedicated to the area.
If the Influenza Assessment Clinic were to reopen in the future, these resources should be considered mandatory for the pharmacy area. As well, a dry run to observe the logistics and traffic flow of the clinic would help in anticipating problems. In addition, improved layout of the work space and a designated private area were identified as beneficial for future clinics.
Despite the many challenges encountered at the Duggan Influenza Assessment Clinic, many additional benefits were derived, along with dispensing of medications, counselling of patients, and management of inventory. Anecdotally, many of the pharmacists recalled averting medication errors by double-checking prescriptions. In addition, pharmacists identified and resolved a number of drug-related problems. They also played a role in enhancing responsible prescribing through provision of oseltamivir guidelines to the physician group and provision of recommendations on appropriate use of antibiotics. Pharmacy input also ensured that the most appropriate medications and doses were stocked, to help enforce current guideline-based recommendations. For example, levofloxacin 500-mg doses were replaced with 750-mg doses in accordance with the most recently published guidelines from the Infectious Diseases Society of America for treating community-acquired pneumonia.5
The dedication and usefulness of pharmacy staff and services were recognized by other health care providers. All of the other health care professionals surveyed characterized their experiences with the clinical pharmacist in complimentary terms, and most felt that the pharmacist had a positive impact on patient care and provided a valuable service. The survey respondents were also able to identify examples of pharmacists’ involvement in care. As a result of these positive interactions, other health care professionals and decision-makers expressed interest in pharmacy involvement in future projects. Many patients also expressed their gratitude to the pharmacy staff before leaving the clinic.
The provision of pharmacy services at the multidisciplinary Duggan Influenza Assessment Clinic during the second wave of the 2009 pandemic H1N1 virus in Edmonton presented operational and clinical challenges for the Alberta Health Services regional pharmacy department. However, the department learned from the experience and was able to have a positive impact on patient care while promoting the profession of pharmacy. This paper has described a novel practice and the provision of enhanced patient care and safety by hospital pharmacists in an urgent, crisis situation.
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We would like to thank the following for their hard work, dedication, and guidance in preparing this paper for publication: Deb van Haaften, BScPharm, Executive Director, Pharmacy, Edmonton & Area, Alberta Health Services; and Theresea O’Donnell, Unit Manager/Emergency, Alberta Health Services. We also thank Carla Policicchio, Site Director, NECHC/HFS, for proofing the manuscript and for assistance with the satisfaction survey.
Canadian Journal of Hospital Pharmacy , VOLUME 64 , NUMBER 1 , 2011