COVID-19: Treating and Preparing Here and Now

Ramy Elshaboury, PharmD, BCPS, AQ ID, discusses the process of putting COVID-19 guidance in place using currently available literature and data.

Segment description: Ramy Elshaboury, PharmD, BCPS, AQ ID, Clinical Pharmacy Manager, Infectious Diseases, Surgery & Transplant Pharmacy Services, at Massachusetts General Hospital, discusses the process of putting COVID-19 guidance in place using currently available literature and data.

Interview transcript (modified slightly for readability):

Contagion®: Thanks for joining us for another Contagion® coronavirus video. Today I'm joined by Dr. Ramy Elshaboury, who is from the Massachusetts General Hospital and has been doing some impressive work at his institution putting together some guidelines for COVID-19. Thanks so much for joining us.

Elshaboury: Good morning. Thanks for having me.

Contagion So why don't we just get started? Can you tell me a little bit more about what your primary role in the COVID-19 response has been at your institution?

Elshaboury: Sure. MGH is part of the new tech training and education network, so that is the National Emerging Special Pathogen Training and Education Network. So preparing for biothreats and special pathogens is something we are always training for and it's something that we practice. We have annual drills to accept patients with special pathogens and special infections. Our preparation started obviously a couple of months ago now with the outbreak of COVID-19. Throughout January and February, we started our planning for accepting patients and understanding what each of the department rules will be, including the pharmacy department.

A big part of what we plan for is obviously, what therapeutics we will have available, what clinical trials we will arrange when the time comes to accept and admit with some circumstances, a large number of patients. Our role started thinking about what medications we will have available, what clinical trials the hospital will participate in, and how we can facilitate the clinical trial medication receiving, clinical usage of these medications, clinical monitoring and educating our staff educating our clinical pharmacists on the frontline to use these medications, to understand the dosing, and necessary monitoring and safety of each of these medications. So a lot of what our infectious diseases pharmacy team has been doing over the last couple of months is really trying to absorb a lot of information. Obviously, there's a lot going on and trying to filter through all of the data we have now available, and the rush of clinical trials that we will be presented with, and communicate a lot of that information to our frontline pharmacists, so everyone is aware of what's coming and everyone is aware of our role in ensuring these medications are used according to the protocol and making sure that necessary monitoring is in place and safety measures are being tracked.

Contagion®: Great. So what are the biggest challenges that you're currently facing in your COVID-19 response?

Elshaboury: In my role, I wear a couple of hats. As an infectious diseases pharmacist, obviously we're trying to go through a lot of data, a large volume of data in a very short amount of time. Not just that, but also react to it and adjust our guidance and our treatments as we need to. It's been fast moving. I think there have been a lot of changes already. We're trying to, again, absorb that information and understand what our role is going to be whether we need to make any changes to our initial recommendations and what is our next steps in terms of setting up clinical trials with the hospital teams.

My other hat as a clinical manager, I think one thing we are very concerned about is drug shortages. This is something we are meeting about almost daily, just to manage our ongoing expanding list of drug shortages every day and understanding what the current treatments are necessary. We're looking at the outlook of the drug supply as our supply chain teams have been working, nonstop understanding the extra need for sedatives and other medications for critically ill patients. So this has been a big challenge. We've had to make some changes to our routine practices just to make sure we have enough drug supplies to sustain the rush of patients we've seen in the last few weeks.

Contagion®: So earlier, you touched upon how it's really hard to keep up with all of this emerging literature from different trials and studies and so on. So what are you doing to keep up with all of this information as it's coming out?

Elshaboury: That's a great question. We are a team of 4 infectious diseases pharmacists. So I'm blessed to have my colleagues around me there is really no human way possible to keep up with all of the emerging data as 1 person. I think working as a team and understanding how we can split the work. At MGH, our infectious diseases pharmacy team is part of an inter multidisciplinary team across the hospital. We've had daily calls almost since the outbreak started, a month ago, and part of our daily calls is to discuss some of the challenging cases. But we also dedicate time to review the literature as a group and almost assign different people to present some of the new information on behalf of the team. So everyone is aware of the updates and everyone can stay up to date on some of the changes.

As things have progressed, in the last several weeks, we've also started forming subgroups. We have different subgroups tasked with specific pieces of information, whether it relates to actual management of patients on a day to day or planning any changes based on the data that is coming up. We've had some groups working on immunomodulation and others working on specifically the critical illness needs of the patients. We obviously have a group working on how antibiotics can be positioned for patients with superimposed bacterial infections. We've had different subgroups really going through the data and summarizing some of that information for the larger team and making recommendations to make any changes or not. It's been a lot of data and a lot of noise in the data. It's really taken a large group of people, a big team, to try to understand and dissect some of that information. We can make clinical decisions on the front line.

Contagion®: Sounds like collaboration is key. My next question is: Can you discuss some of your work on developing guidelines for COVID-19 at Mass General?

Elshaboury: So as I said, we started this work 6, 8 weeks ago now. To start, a small team of multidisciplinary professionals, was assembled by our chief of infectious disease division. This team obviously had infectious disease faculty, ID pharmacy, but we also had representation from pulmonary critical care attendings, hepatology, cardiology, and other disciplines within our hospital. This group started early looking at the data and trying to put some guidance in place. As I said, we started splitting into subgroups and each subgroup was tasked with a specific question and specific need for our clinical guidance. As the subgroups formed their clinical guidance, then, that was discussed with a large group of people for feedback. We call our team the CHANT team.

Our focus was on the here and now so that's why we call it that COVID Here and Now Treatment, a CHANT team. This is a living document, something that we almost on a weekly basis continue to refine based on the data that we have available from outside the hospital, but also some of the data we're able to generate internally based on the number of patients we have already cared for. So it is a living document. It is updated on a regular basis. We have this centralized group of people that is multidisciplinary that is bringing more data both internally and from outside resources into the document. In terms of our pharmacy team, our focus has always been on managing drug therapy and making sure that we have the appropriate information for optimal dosing and monitoring of these safety measures, especially for medications that a lot of our pharmacists here in the hospital are not accustomed to be used on a large scale patients like we've seen in the last few weeks. Finally, the clinical trials and understanding some of the new investigational agents that we haven't seen before, making sure that our pharmacists are aware of the safety and monitoring requirements and communicating that with all of our frontline pharmacists

Contagion®: Great, So in the coming weeks, the situation is going to continue to change at a rapid pace with COVID-19. So in your opinion, what do we really need to focus on to prevent the so called second wave of this pandemic?

Elshaboury: I think obviously, it will take a lot of efforts from a multidisciplinary and a number of different local and governmental agencies. I think testing will continue to be something that we are looking forward to expanding. We've had here in the Boston area, a number of our hospital laboratories have really expanded their testing and added capacity. This is something that we will look forward to expanding even further and making sure that testing is widely available in the community and not just in the hospitals. The timing as well. Some of the newer testing methodologies can produce results fairly quickly. This will be fairly significant, especially in the community when you're on the ground or some of the ambulatory clinics to be able to produce these results fairly quickly and identify the positive patients and start the quarantining recommendations. I think our public health colleagues are talking a lot about contact tracing and isolation. This is something that will require a lot of efforts, a lot of technology and a lot of personnel to track positive patients and track their contacts and work on quarantining and isolating positive patients. I think if we can get all of this in place, and if we can have these public health measures, I think we will be able to manage the next wave more effectively. But certainly, it will take a lot of effort from a lot of different people when it comes to testing and additional testing methodologies that are fairly quickly and can produce results a lot faster, to be able to isolate these patients more effectively.

Contagion®: So my last question for you is, do you have any tips or resources to share with other clinicians who are currently responding to this pandemic?

Elshaboury: In terms of tips, I think 1 thing we've learned quickly, is everything is changing quickly, and the rush of patients is not going to slow down, waiting for us to produce guidelines or to finish all the clinical trials, so we have all the answers. So I think one thing we learned quickly is the here and now. What is the information that we have today and how can we position that information to help with our clinical decisions today? I think moving forward, obviously, the clinical trials and a lot of the data that are being generated today will help us in the future, but today, we have to make some clinical decisions for a very large number of patients and a number of them are quite sick. I think the biggest tip I can give people is to think about the here and now and what information do we have today to help with the current situation. Moving forward, a lot of resources are becoming more available. I think just over the weekend, the IDSA, the Infectious Diseases Society of America, published their initial guidelines on the management of patients. It's really reaffirmed the commitment and the recommendation that we need more clinical trials, looking at all of the different therapeutics that have been suggested.

Moving forward, understanding these guidelines will be also a living document and there will be changes to those guidelines in the coming months. But really, the best we can do today is use what we what we know based on the data and understanding that some of the data may not be optimal, and there are a lot of limitations to understanding some of the trials and some of the case series that have been already published. But as professionals, this is the information we have, and we need to make sure that we understand it as best as we can and dissect the information and come up with some clinical decisions that we do and follow today. But also, in the future, we need to support clinical trials. We need to position ourselves in a way that can help us produce more data in the future, more specific data that contains a lot of the different patient demographics and some of the risk factors and why and so. Six months from now we can have a better, more focused way of managing our patients.

Contagion®: That's great. Thank you so much for joining me today. I really appreciate you taking your time out of your super busy schedule to talk with us. Keep up the great work and stay safe.

Elshaboury: You as well. Thanks a lot for having me.