Creating ICU Environments, COVID-19 Units in Health Systems

As the number of patients hospitalized with coronavirus disease 2019 (COVID-19) has surged, hospitals have been faced with the challenge of converting various spaces into intensive care units (ICU) and COVID-19 units. Although this is a major challenge to health care systems, a session at the American Society of Health-System Pharmacists 2020 Midyear Clinical Meeting and Exhibition offered pharmacists some best practices.

When creating an ICU space, hospital leaders must consider the need for negative pressure, anteroom and areas to don and doff personal protective equipment (PPE), placements for automated dispensing cabinets, and optimal pump placements either inside or outside of patient rooms. Presenter Jawad N. Saleh, PharmD, BS Pharm, BCCCP, BCPS, clinical manager of pharmacy services at the Hospital for Special Surgery in New York, walked attendees through the procedures implemented at his facility.

Negative pressure utilizes high-efficiency particular air exhaust fans, Saleh said, adding that engineering teams must be involved to help convert as many isolated inpatient rooms into negative pressure rooms. Operating rooms should be converted from positive to negative pressure as well to protect staff, and post-anesthesia care units or open area suites should be converted with a complete rebalancing of air, in which it is taking in less air than it is taking out.

Saleh said anteroom chambers should be strategically placed outside of negative pressure rooms if a specific doffing bay area is not feasible or if the entire unit was not converted to a negative pressure COVID-19 unit. Of course, he said, emphasizing proper PPE and hygiene is essential.

Placement of automated dispensing cabinets (ADCs) should be carefully considered as well, and they should be placed in clean areas, with the goal of less pharmacy staff exposure and fewer opportunities for medication contamination. Saleh also said 2 refrigerators per unit would be ideal, with 1 for patient-specific medications and 1 with bins for most common noncontrolled infusions. Staff should also have a strict plan for how to deliver non-ADC medications.

Saleh said some units may implement runners, or nurses operating in the clean area who can take medications from the ADC and pass it to the nurses in the unit. Runners help maintain a designated clean area which allows for a safer pharmacy refill and medication delivery process and minimizes both contamination and exposure.

Managing medication returns should also have a strict process, Saleh said. To reduce contamination, medications that have been potentially contaminated may be returned after proper steps are taken, including sanitizing the containers with alcohol wipes, placing them in a paper bag, labeling it with the incident date, and also sanitizing the exterior of the bag. Saleh said that the virus is more visible on plastics and steels than on copper and cardboard but noted that the times can vary depending on a number of factors, including temperature, humidity, ventilation, and the amount of the virus deposited.

Pump shortages may also be a concern as hospitals experience an influx of patients, because Saleh said the COVID-19 patient population often requires multiple infusions and may utilize between 3 and 6 pumps each. First Saleh recommended searching for unused pumps in less-busy areas of the hospital, such as interventional radiology, perioperative areas, and outpatient settings. He also recommended utilizing gravity flow infusions for medications that can be safely managed, and maximizing oral formulations where possible.

Finally, Saleh said caring for the health and wellbeing of staff is vital, including mental health and motivation. At the Hospital for Special Surgery, he said they have implemented a daily livestream to enhance transparency and decrease anxiety, which includes motivational video snippets sent by former patients and celebrities. Wellness emails with coping method tips are also sent on a regular basis, with tips including meditation, stretching, and more. Finally, Saleh said hospital administrators round through the COVID-19 units frequently to encourage staff and discuss any issues.

REFERENCE

Saleh J. COVID-19 Survival Tips: Curb the Surge. Presented at: 2020 ASHP Midyear Clinical Meeting and Exhibition; virtual: December 8, 2020.