ER Pharmacist Precautions for COVID-19?

[Monsterdaddy]

Any pharmacists have to work around COVID-19 patients? I normally would not be in my regular job but I help out at a small rural hospital which unfortunately has the largest (per capital) outbreak of COVID-19 in my state (and we are probably 3-4 weeks from our statewide peak). Being such a small hospital, the pharmacist acts as an ER pharmacist when needed (including overnight on-call). Twice I've had to prepare meds near two COVID-19 patients to get them intubated (small hospital, short-handed and once the respiratory folks go in the room they are not coming out!) And of course I had a call in for a Code Blue. COVID-19 patients have overflowed from our ICU and I worry when we won't be able to fly them out to our bigger hospitals when they get full. I go back again this week.

And to make things worse, my regular hospital pharmacy has 3 people out right now with fevers (no additional details).

So what precautions are you guys taking if you're in a situation like mine? I've self isolated myself at home, wife is sleeping in another room and I haven't hugged my kids. I wear a homemade cloth mask whenever I'm around anyone and when I'm working around patients I wear a procedure mask and gloves. And of course, I'm washing hands like crazy. Thanks for any suggestions.

After working at this hospital I can now really appreciate the doctors, nurses and respiratory techs that work on these patients.

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[Rockinacoustic]

Always wearing a surgical mask. N95 if outside a COVID+ room and passing meds through. Preparing RSI and code blue meds ahead of time and limiting pass through into room. Deciding on post intubation sedation and pressors before we intubate them so the IV pump can enter the room with the physician.

And lots of hand washing and workstation sanitizing.

 

[Monsterdaddy]

Always wearing a surgical mask. N95 if outside a COVID+ room and passing meds through.

That's a good point about a N95 that I didn't even think about. Does your hospital have a policy on N95 usage by pharmacists/techs? Wondering if I were to wear one OUTSIDE of the room that I could reuse it since exposure is less and to preserve them.

 

[PharmDizzle]

Yes we are not going in the rooms unless the patient is coding to preserve PPE but do wear N95, face shield, and gloves if passing meds in the room. And I agree with what was written above, I get as much prepared as I can at once, if time allows, to limit opening the door too much. I will send in the intubation meds, a pump set up with a fentanyl and propofol drip, and any other meds I think they will immediately need all at once.

 

[Rockinacoustic]

That's a good point about a N95 that I didn't even think about. Does your hospital have a policy on N95 usage by pharmacists/techs? Wondering if I were to wear one OUTSIDE of the room that I could reuse it since exposure is less and to preserve them.

Our policy is as long as you wear a surgical mask over the N95 and it doesn't appear dirty you can reuse it.

I am doing everything in my power to not wear one to preserve PPE. We are no longer entering rooms for codes and manning the code box outside the room.

 

[RxEvileye]

This thread talks about a lot of precautions:

Single Sign On

connect.ashp.org

Here is one of the posts that was made in case you cannot access:

"Below is our current protocol for code carts, RSI, and patient's own medications

Recommendations for Drug and Supply Conservation During Codes and RSI

• Disclaimer – hospital operations may vary and need to be individualized by the hospital based on available staff and current workflows. The below best practices should be implemented unless there is an equally effective alternative that will result in the conservation of equipment, medications, PPE, and limiting unnecessary staff exposure to suspected or confirmed cases of COVID-19
• Any concerns regarding potential exposure of code carts, medications, or supplies
• Summary of best practices
  1. Code response
     1. Inside Patient Room – maximum of 5 people (the fewer people in the room the better)
        1. Compressors - Plan for two chest compressors to be in the room and a third compressor to be donned in PPE will remain outside of the room until needed to relieve one of the compressors in the room
        2. Physician – limited to physician running the code unless significant justification for a second MD (someone who can intubate)
           1. Physician may be able to stay outside of room if able to communicate with team inside and effectively get needed information
           2. Ideally anesthesia would perform the intubation
        3. Nursing – 2 nurses for compressions, and medication administration, control opening/closing of door to ask for supplies and medications
           1. Possibility of setting up a speaker phone/device to communicate with outside of the room (documentation nurse can stay outside)
        4. Respiratory therapist
     2. Outside Patient Room
        1. Designated personnel – in PPE to receive samples
        2. Pharmacy – (if typically respond to codes) preparing medications, help manage cart
        3. Nursing – help manage cart
     3. Equipment, supplies, and medications:
        1. In the event that there is accidental exposure of the cart or any of its contents (supplies or medications) the following steps are essential
           1. DO NOT MOVE THE CART OR THROW AWAY ANY OF ITS CONTENTS
           2. Notify hospital infection control, central supply, and pharmacy departments
           3. See suggested scenarios provided in below section c
        2. Storage
           1. Place as many medications and supplies into individual sealed bags as possible
              1. Example – bag all amiodarone together, bag some drugs in small groups (2 epis together) or if possible individually, etc.
           2. If exposed, bags may be wiped down and disposed of while the contents can be re-bagged into clean bags (see decontamination and cleaning below)
• Code Management
  1. Inside Patient Room – should be minimized as much as possible to prevent contamination and waste
     1. Defibrillator
     2. Backboard
  2. Outside Patient Room
     1. Code cart must remain outside of the room
  3. Cleaning and decontamination – applies to anything that entered a suspected or confirmed COVID-19 patient's room or that may have been contaminated in the process of code management (e.g., if a responder in the room touched something outside of the room with their contaminated gloves on)
     1. Code Cart
        1. Scenario 1: Accidentally brought into patient room or had accidental exposure (need 2 team members)
           1. Medications and supplies
              1. Leave cart in room and contact pharmacy, infection control, and central supply
              2. All items that are individually bagged OR suitable for cleaning (i.e., glass vials) should be cleaned with alcohol
• Cleaned medications/supplies should be placed into a large rigid container outside of the room (separate box for supplies and separate box for medications)
  1. These containers should be sprayed down/cleaned with alcohol before and after use
  2. Label container "To be sequestered for 10 days beginning on incident date and ending 10 days from incident" total of 240 hours
     1. If patient confirmed to be negative then medications and supplies can be put back into normal stock
     2. The individual site must determine appropriate storage area for sequestered medications
  3. Pharmacy can provide rigid plastic containers for medications

1. If individual bags are used, wipe the outside of the bag with alcohol, contents of bag (if the bag was not opened in the room) can be transferred into a new clean bag after being removed from the room
2. Carts and trays
   1. DO NOT MOVE THE CART UNTIL YOU RECEIVE APPROVAL FROM INFECTION CONTROL AND CENTRAL SUPPLY
   2. DO NOT BRING ANY POTENTIALLY CONTAMINATED TRAYS OR CARTS TO THE PHARMACY DEPARTMENT

• Options for handling contaminated carts include
  1. After either method outlined below, inform central sterile department that the cart is potentially contaminated and how it will be handled PRIOR to bringing it down – this allows central sterile to prepare to receive the cart
  2. Method 1– adequate time to air-out
     1. Leave the cart in the room for the duration of the air-out (minimum 1 hour, dependent upon number of air exchanges per hour)
     2. Clean exterior of cart and as much of the interior as possible
     3. Label with a biohazard symbol
     4. Move cart to central sterile department for complete decontamination
  3. Method 2– inadequate time to allow complete air-out (less than 1 hour)
     1. Person inside room wipes down exterior of cart and as much of interior as possible
     2. Cart is pushed outside room to a second individual (wearing appropriate PPE)
     3. Second individual applies equipment cover, places biohazard symbol, removes PPE and performs hand hygiene
     4. Cart can then be transported to central sterile department for complete decontamination
  4. Restocking
     1. Dedicated code cart (remains in COVID-19 treatment area and all patients receiving treatment in that area are suspected or confirmed cases)
        1. Code carts should not be moved from the unit
        2. Carts should be maintained outside of the patient rooms (similar to above workflows)
        3. There must still be a local process in place for cleaning used carts kept on floors and restocking medications and supplies along with maintaining logs
           1. May utilize similar workflows to Method 1 and Method 2 listed above
        4. Non-dedicated cart (cart is routinely moved or transported for processing, cleaning, and replenishment by central supply and/or pharmacy)
           1. Modified restocking workflow
              1. Pharmacy to prepare medication trays with medications individually bagged
              2. Pharmacy to bring medication trays to central supply for insertion into cleaned carts
           2. Alternative stocking and dispensing modalities
              1. Dedicated kits/boxes that can be cleaned and locked
• RSI Kits
  1. RSI kits should be handled similarly to code carts – it is best to keep the kit outside of the room until absolutely necessary in order to avoid waste
  2. Consider the creation of RSI kits specific for COVID-19 units with limited supply including, but not limited to:
     1. Etomidate
     2. Succinylcholine
• All other medications can be kept separately in ADS cabinets

1. In the event of an RSI kit exposure
   1. Medications may be wiped down with alcohol and kept sequestered in a container
   2. Label container "To be sequestered for 10 days beginning on incident date and ending 10 days from incident" total of 240 hours
      1. If patient confirmed to be negative then medications and supplies can be put back into normal stock
      2. The individual site must determine appropriate storage area for sequestered medications

Medication Handling Considerations

• Gloves should be used in areas with high exposure possibility and discarded when leaving that unit, helping to prevent spread throughout the hospital.
• When delivering, keep alcohol wipes and new plastic bags in the delivery cart for decontamination and sequestration.
• For COVID-19 confirmed/suspected units:
  • Bulk items will be kept in the patient room after initial use
  • Medications that have entered the patients room may be cleaned with alcohol, placed into a storage container and sequestered for 10 days
• 
  
  • Label container "To be sequestered for 10 days beginning on incident date and ending 10 days from incident" total of 240 hours
• Unused medications in the medication room can be returned to the pharmacy
  • If contamination is suspected, follow steps above for cleaning and sequestration

Patient's Own Medication Considerations

• Precautionary measures may be taken when handling patient's own medications
• Attempt to minimize the use and storage of all patient own medications at this time
  • Patient own formulary medications - if a patient brings in home medications that are stocked in the pharmacy department, make every effort to have them brought back home and dispense the pharmacy's supply
  • Patient own non-formulary medications – place the medications in individual bags and wipe down before bringing to pharmacy for identification; once identified, the medications may be kept and dispensed from a secure location determined by the site

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David Silverman PharmD, BCPS, BCCCP
VP of Pharmacy, Prime Healthcare"