Northern Arizona Healthcare, the largest healthcare system in a region that encompasses more than 50,000 square miles, provides comprehensive healthcare services through clinics, surgical centers, and two hospitals: Flagstaff Medical Center and Verde Valley Medical Center. The health system serves more than 700,000 people in communities across the region, and is committed to continually improving and enhancing patient safety.
Northern Arizona Healthcare’s Flagstaff Medical Center (FMC) is the biggest major medical center in Northern Arizona. The Navajo Nation, the largest Native American Reservation in the country, resides in FMC’s service area. This community was hit hard and early with a significant COVID-19 outbreak. At its peak, the Navajo Nation had a higher per capita COVID-19 rate than all major cities in the U.S. including New York (3.4 percent vs 1.9 percent).
FMC initially bore the brunt of this outbreak, well before the Arizona State COVID-19 Healthcare Surge Hotline was created in mid-May to help balance the load of cases across the state. FMC treated their first COVID-19 patient in mid-March of 2020, and quickly ramped up to more than 30 critically ill COVID-19 patients by the end of the month. They experienced a peak of 51 positive cases (a full third of their census) followed by a second surge in mid-June.
Kristen Bamberg, PharmD, MS, BCPS, BCCCP, Lead Critical Care Pharmacist at FMC, and Andrea Boyce, PharmD, BCIDP, Lead Antimicrobial Stewardship Pharmacist at FMC, were immediately thrust into a fast-paced and highly challenging environment due the influx of COVID-19 patients. They faced constantly evolving therapeutic recommendations, and a continual fight to mitigate critical shortages of medications like sedatives, neuromuscular blockers, and antibiotics.
Bamberg and Boyce had an excellent team behind them working to overcome the challenges presented by COVID-19, but they also recognized that they needed to fully utilize all of their resources in order to continue to provide optimal care to patients.
“We knew how useful VigiLanz’s alerts and reports already were in helping us care for patients on a day-to-day basis,” said Bamberg. “So we turned to them to help us quickly determine how their alerts and reports could be tailored to help us specifically address the needs and demands of the pandemic.”
Ultimately, Bamberg and Boyce worked with the clinical surveillance provider to implement dozens of new rules and alerts. These rules resulted in three key benefits:
Benefit #1: Real-time alerts that led to a more proactive response to COVID-19 patients and helped conserve PPE
At the beginning of the pandemic, FMC immediately recognized that the earlier healthcare providers could be informed of a patient’s COVID-19 status, the better. If a patient tested positive, that patient could continue to be isolated and contact tracing could begin; if a patient tested negative, staff members no longer needed to use PPE when interacting with that patient (which could help combat the PPE shortage).
As a result, Bamberg and Boyce worked with VigiLanz to implement real-time alerts to inform relevant healthcare providers and staff as soon as a COVID-19 test result was available. They also implemented alerts to inform them if a re-admitted patient had a history of COVID-19.
Examples of alerts:
- COVID-19 results: Alerted pharmacists of a new COVID-19 RNA or PCR test result
- Patients with a history of COVID-19: Alerted pharmacists if a patient was re-admitted and had a positive result on a previous encounter in the last 90 days
“The support and responsiveness of VigiLanz to our abundance of requests was incredible,” said Bamberg. “It helped us work through countless therapeutic and workflow issues in real time.”
Benefit #2: Real-time alerts for medication optimization and prevention of adverse drug events
Bamberg and Boyce also worked with VigiLanz to implement several new alerts that helped optimize medication safety for COVID-19 patients.
“These alerts were particularly useful since we were dealing with a new disease and treatments that were continually changing,” said Boyce. “Many of the alerts resulted in the discontinuation of certain medications and helped us flag potential problems.”
Examples of alerts:
- Hydroxychloroquine (HCQ) ordered: Alerted pharmacists to check for drug interactions and assess and follow the risk of corrected QT(QTc) prolongation
- HCQ and weight > 50 kg: Alerted pharmacists to review based on the hospital’s protocol at the time
- HCQ patients at high risk for QTc prolongation with higher than normal doses used for treatment of COVID-19: Alerted pharmacists when patients had HCQ + azithromycin + K < 4, HCQ + azithromycin + Mag < 2, HCQ + azithromycin + scheduled ondansetron.
- Metoclopramide longer than three days: Alerted pharmacists to assess efficacy and potential discontinuation of metoclopramide (which many COVID-19 patients were prescribed due to ileus or significantly reduced bowel motility) in an effort to minimize adverse drug events.
- D-dimer > 1,000: Alerted ICU pharmacists to assess patients (this rule was implemented after a hospital literature review of COVID-19 and thrombosis indicated that patients were experiencing micro thromboemboli and likely required higher than usual doses of chemical deep vein thrombosis prophylaxis). While the hospital eventually abandoned D-dimer as a sole marker of a need for these higher doses, it initially helped the pharmacists make recommendations to intensivists regarding anti-thrombotic therapy.
- Enoxaparin 0.5 mg/kg SQ Q12H ordered and no Xa level: Alerted pharmacists to monitor patients’ response to treatment, as COVID-19 patients had a higher propensity to clot, a potentially larger clot burden in the form of microthrombosis, and potentially acquired ATIII deficiencies as a result.
- Remdesivir ordered: Alerted pharmacists to monitor patients to adhere to new protocols (the hospital had a specific Remdesivir protocol in place due to emergency use authorization requirements).
Benefit #3: Real-time alerts to mitigate drug shortages
In addition to ensuring optimal medication usage for COVID-19 patients, Bamberg and Boyce also used VigiLanz to help FMC manage medications in short supply.
“We always need to make sure that we have the right medications on hand for each patient, but this process became even more challenging when COVID-19 hit,” said Boyce. “VigiLanz helped us manage many of the unprecedented shortages we faced, especially when it came to necessary medications like sedatives and antibiotics.”
Examples of alerts:
- Ketamine ordered: Alerted pharmacists to determine if a more concentrated bag could be used, or if alternative medications were appropriate
- IV famotidine ordered: Alerted pharmacists so that, if appropriate, they could recommend an IV alternative or switch the patient to oral
- Doxycycline more than five days: Alerted pharmacists to assess patients’ antibiotic therapy and recommend possible discontinuation as appropriate
- Albuterol inhaler PRN, not on isolation: Alerted pharmacists to assess whether a non-COVID-19 patient with an active order for an albuterol inhaler could be switched to nebulization
FMC’s ability to quickly respond to the COVID-19 pandemic is a testament to the dedication and innovative ideas of all of its frontline staff—with Bamberg and Boyce playing a critical supporting role. During a significantly challenging time, they were able to think outside the box and use the information they received from VigiLanz to enhance patient care.
Overall, this led to:
- Earlier identification of positive and negative COVID-19 tests, which helped conserve PPE and enhance patient treatment
- Earlier identification of readmitted patients who previously tested positive for COVID-19, which helped the health system protect non-COVID-19 patients and staff
- Optimal medication usage for COVID-19 patients, which enhanced patient treatment
- Enhanced monitoring of medications in short supply, which led to more targeted and judicious use of medications
“We were among the first and hardest hit hospitals by COVID-19,” said Bamberg. “We worked with VigiLanz to be proactive in tackling this challenge, and it made a significant difference to our patients and community.”
To learn more about how VigiLanz helps hospitals improve their patient safety and clinical surveillance, visit https://vigilanzcorp.com/ today.