Adaptation of clinical pharmacy services to meet patient care needs during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 has challenged health systems to find innovative ways of delivering patient care while protecting staff from infection with the virus. As the COVID-19 pandemic has continued to evolve establishing "hot spots" in various areas of the country, clinicians have learned more about caring for these patients. This has required the Department of Pharmacy at Thomas Jefferson University Hospital to constantly update the approach it has taken during this time, and the guidance which is provided for the pharmaceutical care of these patients. Because Philadelphia was in the initial stages of the pandemic within the United States, operations within the Department of Pharmacy at Thomas Jefferson University Hospital needed to be redesigned. This brief report provides an example of the swift changes that were made in the pharmacy practice model at a large academic medical center. Herein we describe the impact of the pandemic on the Department of Pharmacy at Thomas Jefferson University Hospital with a focus on clinical and operations aspects. The areas that will be highlighted in this report represent areas that required rapid and transformational change to the operations and/or clinical care in order to protect the health of pharmacists and allow them to continue to provide the necessary level of patient care.

Implementation of an Outpatient HD-MTX Initiative.

INTRODUCTION: Methotrexate (MTX) a folate antagonist is often given in high doses (≥500 mg/m2) to treat a variety of disease processes. While inpatient administration has been the norm, outpatient administration, has been shown to be safe, effective, and patient centered. Here in we describe development of an outpatient HDMTX protocol and our initial experience. METHODS: All patients were to receive their first cycle of HDMTX in the hospital to ensure they tolerate it well and also to use this time to assist in training for home administration. The outpatient protocol involved continuous IV sodium bicarbonate, along with oral leucovorin and acetazolamide. Patients were required to visit the infusion center daily for labs and methotrexate levels. Clear criteria for admission were developed in the case of delayed clearance or methotrexate toxicity. RESULTS: Two patients completed the safety run-in phase. Both patients tolerated treatment well. There were no associated toxicity. Methotrexate cleared within 3 days for all cycles. Both patients were able to follow the preadmission instructions for sodium bicarbonate and acetazolamide. The patients reported adequate teaching on the protocol and were able to maintain frequency of urine dipstick checks. CONCLUSION: We developed and implemented an outpatient protocol for high dose methotrexate. This study largely details the development of this protocol and its initial safety evaluation. More work needs to be done to assess its feasibility on a larger number of patients who receive more cycles in the outpatient setting.