Updated: May 22, 2020
- How does COVID-19 spread?
- How do I screen for COVID-19? What do I do if someone appears to be infected?
- How should I prepare my pharmacy premises?
- How do I clean and disinfect my pharmacy?
- What workflow or service changes should I put in place?
- What other protective measures can I put in place?
- What if a staff member is exposed to or infected with COVID-19?
- Do my pharmacy staff need PPE?
- What do I tell patients who ask about wearing a mask?
- Should my pharmacy continue providing professional services (such as injections and immunizations)?
- How do I protect the medication supply?
- If patients can’t come to the pharmacy, how do I continue to provide care?
- Can I still accept post-consumer returns?
- What do I need to know about COVID-19 treatment or therapies?
- How should I prepare my pharmacy team to keep everyone safe?
- How do I support my pharmacy team’s mental health and wellness?
- Will there be any changes to my scope?
- A note about business continuity planning
The SARS-CoV-2 virus which causes COVID-19 primarily spreads from person-to-person by respiratory droplets produced while coughing or sneezing. These droplets can land in the mouths or noses of people who are nearby (within 6 feet) or possibly be inhaled into the lungs. It may also be possible that a person can get COVID-19 by touching a surface or object that has SARS-CoV-2 virus on it and then touching their own mouth, nose, or possibly their eyes. Current epidemiologic information suggests that human-to-human transmission of COVID-19 can occur when an individual is in close contact with a symptomatic case. However, many people with COVID-19 can have mild or no symptoms at early stages of infection and some level asymptomatic and pre-symptomatic transmission is occurring.
Implement passive screening to encourage patients to self-assess their symptoms before they enter the pharmacy or interact with pharmacy staff. Symptoms to be aware of are:
- Shortness of breath/difficulty breathing
- Post signage at the front door instructing patients with COVID-19 symptoms or who have recently travelled outside of Canada that they should not come into the pharmacy. Instead they should go back to their car or home and call the pharmacy for guidance.
- Provide similar messaging on your pharmacy voicemail, sound system, website or in social media communications.
- Consider sharing links to self-assessment tools on your website, on posters or when speaking to patients on the phone.
Implement active screening using the latest case definition to directly assess a patient’s symptoms in person, over the phone, or via other virtual means.
- Consider designating a pharmacy staff member, using appropriate PPE, to screen any patients before allowing entry into the pharmacy.
- Patients who screen positive in person should be immediately instructed to return home and call their public health unit (if well enough). If they appear too unwell to return home, direct them to your designated quarantine space and instruct them to call their public health unit.
- If the patient is in immediate distress, escort them to your quarantine space (wearing appropriate PPE) and call 911. Tell the operator that patient is likely positive for COVID-19.
- Report all suspected cases to your local public health unit.
- Disinfect all surfaces they are likely to have touched immediately, wearing appropriate PPE
- Patients who screen positive over the phone should be instructed to call their local public health unit for further information. Tell your patients that call volumes and wait times are long. Remind patients not to go to their emergency department or assessment centre unannounced.
- Designate a quarantine room for patients with suspected COVID-19 symptoms. The space must not be in an area of the pharmacy that has access to medications and should be equipped with alcohol-based hand sanitizer, tissues and a lined waste container available in this space, as well as a phone if possible.
- Keep alcohol-based hand sanitizer at each patient contact point in the pharmacy
- Consider implementing the use of transparent physical barriers (e.g., plexiglass, acrylic, plastic sheeting) to separate the dispensary from the rest of the pharmacy. Some additional suggestions can be found here.
- Place physical barriers (e.g., tables, chairs) in front of counters to keep patients from getting too close
- Cordon off areas (e.g., OTC aisle) using shelving or rope to redirect patients
- Encourage physical distancing in the pharmacy by using signage, stickers or tape on the floor to instruct patients to approach the dispensary one at a time and always leave 2 meters between all individuals.
- Some pharmacies have closed their pharmacy to foot traffic entirely.
- Implement increased cleaning and disinfecting activities; consider following CDC procedures.
- At least twice a day (and potentially every hour, depending on volume) disinfect all surfaces that are frequently touched (e.g., counter, door handles, pin pads, touch screens, etc.).
- Ensure regular and frequent cleaning and disinfecting of any equipment which may be touched by more than one staff person (terminals, phones, cash registers, pens, etc.)
- Use broad-spectrum virucide-labeled disinfectants with a Drug Identification Number (DIN). 10ml bleach to 990ml water is also an effective disinfecting solution.
- Consider using sanitation verification logs to ensure key areas are cleaned regularly.
- Reflect on all pharmacy activities and consider new workflow options for items that are typically passed from person to person.
- Moving task stations to different locations to spread out staff; consider expanding into other parts of the pharmacy
- Assign workstations terminals, phones, pens, and work areas to specific staff persons; keep frequently used materials in labelled box for each staff person.
- Designate one person to answer phone
- Consider only accepting debit/credit cards to avoid handling money; if required, ask customers to place money in baskets/bowls. Consider contactless payment.
- When speaking with patients at the counter or in the OTC aisle, try to maintain this distance. Don’t pick up products and hand them over, point instead or consider using “reacher”.
- Consider establishing designated pharmacy hours to exclusively serve or book appointments for vulnerable patients (e.g., reserve 8-10am for seniors only).
- Cancel or delay any non-essential events, such as clinic days. Consider suspending cosmetics services and removing all cosmetic and other "testers" from the store.
- Temporarily suspend (where possible) any professional services or activities that require pharmacy staff to be within 2 meters of patients, including physical assessments, blood pressure monitoring, point-of care testing, immunizations or other injections.
- Instruct pharmacy staff to maintain a 2-meter distance from other staff, customers and patients at all times.
Consider dividing pharmacy staff into 2 (or more) teams if resources permit and scheduling them on non-overlapping shifts.
- Pharmacy staff may also consider wearing scrubs or a separate change of clothes while at the pharmacy; if feasible offer laundry service and wash lab coats more often
- Consider limiting the number of people inside the pharmacy at any time.
- Implement/increase the frequency of good hand hygiene practices for all staff. Ensure hand hygiene is followed (at minimum) before and after shifts, and before and after all patient encounters.
In general, all pharmacy staff should follow public health guidelines regarding self-isolation if they have recently travelled, have been exposed to a suspected or confirmed case of COVID-19 or are experiencing COVID-19 symptoms. Symptomatic healthcare workers cannot work. However, every situation is different and at this time we urge you to follow the direction of your public health unit. Be prepared to discuss your situation with your public health unit.
Pharmacy managers/owners will need to determine what staffing levels are required to deliver essential pharmacy services, and at which point the pharmacy must close. Several pharmacy and health care organizations (including Alberta Health Sciences, the Ontario Pharmacists Association and the BC College of Pharmacists) decision tools to help pharmacies determine whether their staff are able continue to work. Consider screening staff at every shift start prior to entering the pharmacy. Alternatively, staff can use this self-assessment tool to screen for symptoms.
If a pharmacy must temporarily close either at the direction of public health or due to lack of staff, follow all procedures as indicated by your regulatory college. Other staffing and business considerations are further provided here.
Best available evidence suggests that droplet protection PPE should be used by health care workers who may be in close contact (i.e., within 2 meters/6 feet) of someone suspected of having COVID. Droplet protection PPE consists of disposable masks, gowns, gloves and face protection. N95 Respirator masks are not required for pharmacy activities.
Pharmacies are reminded that higher levels of protective controls, such as elimination controls (passive screening to eliminate exposure); engineering controls (physical or environmental protective measures such as the installation of plexiglass shields in the dispensary) and administrative controls (policies and procedures that the risk of exposure to staff, such as encouraging appropriate hand hygiene) are all more effective than the use of PPE to protect their staff. Putting such controls in place will help limit the number of scenarios where pharmacy staff may be unavoidably within close contact of a potentially infected patient or staff member (whether symptomatic or asymptomatic).
However, there will be certain scenarios where pharmacy staff will be required to be in close contact with potentially infected individuals and may consider wearing PPE. Pharmacies are encouraged to follow a point-of-care risk assessment approach to determine when and where PPE is required by their staff. If using PPE, follow best practices for donning and doffing. Consult CPhA’s Suggested Best Practices for PPE for more information.
Pharmacies in some jurisdictions are receiving government provided supplies of PPE (masks, gloves, gowns, facial protection). Pharmacists should do their best to obtain a supply of PPE from their distributor according to their anticipated needs. Some pharmacy associations/organizations (including CPhA) are making private arrangements with suppliers to procure PPE for pharmacies; consult your association/organizations.
Educate your patients that wearing a non-medical mask (for example a homemade cloth mask) in the community has not been proven to protect the person wearing it; hand hygiene, physical distancing are still more effective. However, patients may choose to wear choose to wear a non-medical mask, in addition to other precautions or where physical distancing is difficult to maintain, to protect those around them from their own respiratory droplets. Ensure patients understand that such masks have limitations (e.g., loose fit and choice of material often do not provide complete protection from virus particles) and need to be used appropriately:
- Wash hands before and after use
- Do not share with others
- Do not touch face while using
- Change a non-medical mask as soon as it is damp or soiled; cloth masks can be laundered on hot cycle and dry thoroughly; others must be disposed of in a lined garbage bin
- Do not leave discarded or used masks lying around (e.g. on surfaces in the home, in shopping carts, etc.)
- Masks are not a substitute for handwashing and physical distancing
Many patients are still trying to protect their health by coming to their pharmacist for professional services such as medication reviews or minor ailments prescribing. Some pharmacies have temporarily suspended (where possible) any professional services or activities that require pharmacy staff to be within 2 meters of patients, including physical assessments, blood pressure monitoring, point-of-care testing and immunizations or other injections. In general, pharmacists should:
- Consider developing COVID-19 professional services screening forms to screen patients seeking professional services and documenting their screening form in their file
- Use a point-of-care risk assessment approach to each situation to determine the need for PPE to decrease risk of COVID-19 transmission
- Use professional judgement to assess the appropriateness of the service
- In the case where a professional service cannot be performed, provide the patient with alternative solutions (e.g., referral to a different healthcare provider, rescheduling a service, etc.)
Injections that can be administered within a windowed timeframe (e.g., 1-3 months, 3-6 months, etc.) should be postponed to later within that window, whereas injections that are part of a regular schedule should be prioritized to maintain continuity of care. In cases where injectable medications can no longer be administered (e.g., B12, Depo-Provera, Prolia, antipsychotics, etc.), pharmacists can consider switching formulations (i.e., injection to oral tablet), using alternative medications or modifying the treatment schedule where appropriate. (Consult medSask’s suggestions on pharmacist-administered injections for more suggestions.)
Similar to injections, some immunization schedules can be successfully delayed. Individuals with suspected, probable or confirmed COVID-19, and those who are close contacts of a case, should defer immunizations as they pose a risk to the public and health care providers. These patients should wait until they have recovered and/or until the end of their isolation period. Susceptible populations (e.g., infants, immunocompromised patients, older adults, etc.) are at a higher risk of contributing to vaccine-preventable disease outbreaks. Vaccination for these populations should not be delayed and should be provided with appropriate PPE, screening and physical distancing in place. (See interim guidance provided by The National Advisory Committee on Immunization for more information).
CPhA will be providing more information on suggested best practices for influenza immunization in the upcoming weeks.
Patients should be encouraged to maintain adequate supply and should be discouraged from obtaining more medication than usual (requesting early refills or excessive supplies of medications) as this could result in shortages. Reassure patients that their regular supply should be fine, even in the event of a quarantine.
Consider limiting patients to no more than a 30-day supply, and explain why. There may be clinical situations where more than 30 days-supply may be warranted or where a patient may require an early refill or emergency supply of prescription medication for continuity of care. Always exercise your professional judgement to work in the best interest of the patient.
CPhA and medSask have developed a number of tools to help providers manage patient care in the event of the following medication shortages:
Patient Counselling: Encourage all patients to phone the pharmacy instead of coming in person if they have any medication-related questions or need advice regarding symptom management. Follow up with your patients via phone call to counsel.
Medications requiring monitoring (e.g. laboratory parameters, serum drug concentrations): During the COVID-19 pandemic, interruptions and/or delays in regular monitoring for narrow therapeutic index drugs may occur (e.g., lithium, methotrexate, warfarin, clozapine). This may be particularly challenging for pharmacists when faced with increased requests for prescription renewals during this time. Information to help inform a decision on acceptable duration of delays in monitoring may be found in individual product monographs and specialized guidance documents.
Medication Delivery: Consider providing prescription delivery service (see page 13) to patients under self-isolation. Medications should be delivered without any direct contact with the self-isolating individual. While prescription delivery often requires a signature, pharmacists can consider using their professional judgment to determine if an exception can be made to protect delivery staff and patients. The exception should then be documented in the delivery log and prescription record.
Where possible, discuss the delivery options with patients in advance of delivery. Delivery staff can be instructed to call the patient to advise them of the delivery, leave the prescription in a mailbox or closed container (as decided in advance), and should always stay 2 meters way from patients in isolation.
Virtual Care: Many pharmacies are exploring means of delivering virtual consultations (video, phone or email) to patients as alternatives to face-to-face contact. Some examples include medication reviews, inhaler demonstrations, patient education on blood pressure monitoring and counselling on new prescriptions. Virtual consultations will require that both the pharmacist and patient have appropriate technology (internet connection, device with camera and microphone) and the ability to use it. Some jurisdictions are facilitating the provision of reimbursable virtual services (e.g., virtual MedsChecks in Ontario).
As virtual care options become more widely understood, they do present new/greater risks to privacy and protection of patient information. Patients should be informed of such risks and provide consent for any virtual care options. After any virtual consultation, pharmacists should document the reason for the virtual consultation, the patient’s consent and the platform used. Unsecured email, texting and other digital platforms are not acceptable methods to transmit prescriptions. For more best practices, consider consulting the Pharmacy5in5 module on virtual care or the Ontario Pharmacists Association’s guidance document on virtual care.
Pharmacy staff are reminded to ensure they are abiding by all appropriate and jurisdictional standards of practice, codes of ethics, practice guidelines and any legislative requirements relating to pharmacy care and protection of personal health information when providing any level of virtual care.
In order to reduce the potential spread of COVID-19, pharmacies are encouraged not to accept post-consumer returns during the COVID-19 pandemic. This includes controlled substances (including methadone carries), empty bottles and vials, expired or unused medications, or compliance packs requiring modifications
Pharmacists should, remind patients to store these medications securely in their homes, out of reach of children and pets, until such time as returns are accepted.
In some cases, however, pharmacies may choose (or may be required) to accept returns of controlled substances. According to the Office of Controlled Substances pharmacy staff should follow all precautions to minimize contact with individuals and potentially contaminated objects:
- Consider using trays or baskets to accept products, including methadone bottles or cups after observing a dose ingestion.
- Place used patches in transparent bag so they may be counted without being touched.
- Store returns in specific post-consumer returns bin, not with dispensary stock.
- Follow all other regular guidance regarding handling and destruction of post-consumer returns containing controlled substances. Remember to also follow hand hygiene protocols.
Symptom Management: See CPhA’s open access RxTx chapter and latest infographic on managing COVID-19 symptoms
NSAIDS: For treating fever in COVID-19 patients, the recommended option is acetaminophen. NSAIDs such as ibuprofen can be used to treat fever in COVID-19 patients after careful consideration of patients’ individual risk factors. There is no proof that NSAIDs cause problems with COVID-19 infected patients. WHO has retracted its earlier warning and now states that ibuprofen can be used.
Hydroxychloroquine: Hydroxychloroquine has been the subject of great interest but the data do not yet support its use in COVID-19. It should not be dispensed for this purpose.
Treating MS patients: Patients diagnosed with COVID should not stop taking DMT without the consultation of their health care provider
Treating patients with rheumatic disease: Patients diagnosed with COVID should not stop taking DMARDS without the consultation of their rheumatologist
Pregnancy: Current limited evidence suggests that pregnant women do not appear to have an increased risk of COVID-19, and if infected, they do not appear to have an increased risk of severe disease. Similarly, recommendations suggest that pregnant women are similar to other higher-risk groups, and that although ideally they should not be in direct contact with suspected or confirmed COVID-19 cases, this may not be feasible during a pandemic and their services may still be required. Pregnant women with comorbidities including cardiac disease, hypertension and pulmonary disease may wish to contact their prenatal care provider with respect to their risk of COVID-related morbidity and may wish to modify their risk of exposure accordingly. In absence of comorbidities, workplace allowances and workload-carriage for pregnant staff need not be further modified for COVID-19.
Review your written protocols for joint health and safety. Ensure the whole team understands their role and what’s expected of them.
The best defense for all staff and all patients in the pharmacy is practising proper hand hygiene, avoiding touching your face and mouth, cough etiquette, social distancing and regular surface cleaning.
If any team members are unwell or have recently travelled out of country, ask them to stay home and self-isolate for 14 days. Staff should not come to work if they demonstrate symptoms (fever, cough, difficulty breathing) or are confirmed to have a COVID-19 infection. Consider using an assessment tool to assist in determining whether or not a staff member needs to self-isolate.
Consider providing support and tips regarding managing fears and anxiety around COVID-19. Encourage your staff to slow down and take their time. During times like this remember to try your best to keep yourself safe so you can keep your patients safe.
Schedule regular well-being check-ins with your staff (see tips for managing healthcare workers). As the pandemic peaks and wanes, continue to monitor your staff for mental health issues, and provide them with support when needed.
Some organizations, such as the Canadian Psychology Association, are providing free counselling services to front-line health care professionals during the COVID-19 pandemic.
Consult CPhA’s Mental Health and Wellness Infographic for more tips.
Will there be any changes to my scope?
On March 19, 2020, Health Canada issued temporary exemptions regarding prescriptions of controlled substances (including narcotics, controlled drugs and targeted drugs) under Section 56 of the Controlled Drugs and Substances Act (CDSA). Exemptions will:
- permit pharmacists to extend prescriptions
- permit pharmacists to transfer prescriptions to other pharmacists
- permit prescribers to issue verbal orders (i.e., over the phone) to extend or refill a prescription
- permit pharmacy employees to deliver prescriptions of controlled substances to patients' homes or other locations where they may be (i.e., self-isolating)
These exemptions are subject to the laws and regulations of the province/territory in which pharmacists practice. In order to benefit from the exemption, pharmacists must be authorized to conduct the activity included in the exemption (i.e. extend, adapt, renew, transfer) by their provincial/territorial government and regulatory body. Most provinces have moved to implement the exemptions and regulatory bodies in these provinces have issued notices to pharmacists with specific instructions for each activity.
Pharmacies are encouraged to develop broad business continuity plans to ensure they can keep their pharmacy running and provide care to patients in any number of pandemic-related scenarios. Such a plan will help staff act quickly in an emergency, but also enable your pharmacy to recover quickly in the event of unanticipated closures or reduction of hours as a result of staff shortages. A business continuity plan includes a number of elements, including determining essential functions, determining staffing requirements, communications to staff and patients, financial and other business policies and coordination with the community.
Some provincial pharmacy organizations are providing guidance to their pharmacists in preparing business continuity or emergency preparedness tools specific to COVID-19, including the Saskatchewan College of Pharmacy Professionals and the Ontario Pharmacists Association. CPhA anticipates providing some additional resources in this area soon.
These suggested best practices include information that will be useful considerations in putting together your pharmacy’s individual business continuity plan but are not a substitute for planning.
Information in these guidelines has been adapted from a number of sources, including those listed below and all organizations whose tools and resources we have linked to within this information. CPhA gratefully acknowledges the pharmacy community’s support in providing and sharing information.
- COVID-19 Guidance for Pharmacists and Pharmacy Technicians (Alberta College of Pharmacists)
- Novel Coronavirus (COVID-19) Guidance for Community Pharmacies (Ontario Ministry of Health)
- COVID-19 Guide for Community Pharmacy (The Pharmacy Guild of Australia)
- FAQ on COVID-19 procedures for pharmacy (Whole Health Pharmacy Partners)
- COVID-1 Pandemic: A Pharmacists Guide to Pandemic Preparedness (Ontario Pharmacists Association)
- Information material provided directly by pharmacy chains and other wholesalers (e.g., Shoppers Drug Mart, McKesson Canada)
- Multiple resources from PHAC, and provincial public health departments (e.g., Ontario Ministry of Health, Alberta Health Care Services)
- Assessment tool: Pharmacy Staff Affected from COVID-19 (BC College of Pharmacists)
- Cleaning and Disinfecting Procedures (Centers for Disease Control and Prevention)
- COVID-19 Resources (Pharmacy5in5)
This document has been created by the Canadian Pharmacists Association and is intended to support the policy, practice and clinical guidelines being developed by Health Departments, Regulatory Colleges and other associations. We hope that it will answer some key questions you may have as you support your patients on the front lines during the COVID-19 pandemic. We will update this document continuously as new information arises. Please check back often for updates.