pharmacy leadership team perspective on covid-19 …critical care pharmacy transitioning from bcu to...
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Nebraska MedicinePharmacy Leadership Team Perspective on COVID-19 Preparedness
Presentation PanelLori Murante, PharmD, Director, Pharmaceutical & Nutrition Acute Care, The Nebraska Medical Center-Nebraska Medicine
Colleen Malashock, PharmD, BCPS, Clinical Pharmacy Manager, Acute Care & Remote Pharmacy Services, Pharmaceutical and Nutrition Care, Nebraska Medicine
Gregory J. Peitz, Pharm.D., BCCCP, FCCM, Pharmacy Coordinator - Adult Intensive Care, PGY2 Critical Care Residency Program Director, Clinical Associate Professor -Pharmacy Practice, University of Nebraska Medical Center - College of Pharmacy
Katharine Reisbig, PharmD, BCPS, Clinical Services Pharmacy Manager, CC/ER and Acute Care Specialty, Department of Pharmacy, Nebraska Medicine
Nick Crites, PharmD, Medication Safety Pharmacist, Department of Pharmacy, Nebraska Medicine
Bryan Alexander, PharmD, BCIDP, AAHIVP, ID/ASP Pharmacist and OPAT Pharmacy Coordinator, Nebraska Medicine
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Disaster PreparednessPharmacy Disaster Preparedness Team
• Operations Managers• Clinical Managers• Emergency Department Clinical Coordinator• Stewardship Program Coordinators• Staff Development Coordinator• Pharmacy Buyers
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Pharmacy Evacuation
2016
Computer Ransomware
Attack 2017
Pandemic Influenza
2018
Mass Casualty Hospital
Evacuation 2019
2020 Pandemic Response
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February • Pharmacy
Disaster Preparedness Team begins meeting
• Bed planning meeting for opening of BCU
March• Organization of
pharmacy team based on HICS command structure
• Preparation of anticipated resources
April• Implementation
of response plans
• Inpatient Pharmacy adaptation to COVID 2.0
Bed Planning: BCU & Beyond
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Negative Pressure Units
• Initial patients admitted to the Biocontainment Unit (BCU)
• 6 additional inpatient units transitioned to negative pressure rooms for Covid + patients
ER: Tent Extension
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Warm ZoneHot Zone
Cold
Zon
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Pharmacy Response StructurePreparedness Teams based on HICS Structure
Logistics
Operations
Communications
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Pharmacy Response StructureLogistics Team
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Logistics: Medication Availability
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Logistics: Treatment Guidance & Recommendations
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COVID-19 Pharmacotherapy Guidance
Pharmacy Response StructureOperations Team
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Operations: Workflow/Staffing
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Staff Surveys:
• Pharmacists & Technicians
• Areas Trained
• Ability to Work Remotely
• Circumstances that may limit working with Covid+ patients
Operations: Workflow/Staffing
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Central Operations
Safety
Dispensing
RP & Tech Training
Operations: Workflow/Staffing
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Conversion to 12 hour shift
staffing model
JITT resource creation
Cross-training
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Operations: Just in Time Training (JITT)
Operations: Staff Wellbeing
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Pharmacy Response StructureCommunications Team
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Communications: Ongoing Updates
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Communications: Call in Procedures
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Communications: Organizational Resources
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Pandemic Preparedness: Critical Care Pharmacy Valuable Teaching Tools• Previous Biomedical Containment Unit learnings
– Lessons from 2014 (Ebola)• Converting bed space to lab space• Enhancement of communication tools• More mobile emergency response kits vs.
traditional code cart supplied medications• Multi-disciplinary input and development of
rounding models
• National and international communication during CoVID-19
Pandemic Preparedness: Critical Care PharmacyTransitioning from BCU to COVID units
Biocontainment Unit
• Capacity 10 patients• Electronic interface with patients• Specifically trained staff and
protocols • Biocontainment Team with
associated conference room and designated multidisciplinary rounds
COVID Units
• Capacity up to 160 patients • Converted hospital rooms to
negative flow• Hospital wide staff with recent
training• Multiple COVID ICU teams
comprised of varying critical care disciplines
Pandemic Preparedness:Patient Transport
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COVID Pandemic Preparedness: Critical Care Pharmacy Challenges Identified• Emergency Response
• Bedside engagement• PPE use• Medication availability
• Inventory management• Multidisciplinary support• Staff safety
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Pandemic Preparedness: Critical Care Pharmacy
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Pharmacist Integration into COVID Medical Emergencies
Pandemic Preparedness: Critical Care Pharmacy
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Medical Emergency Response for NonCOVID Patients
Pandemic Preparedness: Critical Care Pharmacy
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Emergency Medication Availability
Pandemic Preparedness: Critical Care Pharmacy
Background Work (Supporting Documents and Workflows)• Infectious Disease Pharmacotherapy Support Document
• Cath-lab Work-flow revision for COVID patients
• Respiratory Medication Administration Policies
• Critical Medication utilization tools and house-wide conservation strategies
Pandemic Preparedness: Critical Care Pharmacy
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Creation of a Pharmacy Specific Tenecteplase Checklist
ACS Management Pathway Updates
Pandemic Preparedness: Critical Care Pharmacy
Respiratory Medication Guidelines
Pandemic Preparedness: Critical Care Pharmacy
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Critical Care Medication Surveillance Tools and Reports
Pandemic Preparedness: Critical Care PharmacyCommunication
– Pharmacy Department• Collated communication strategies
– ICU Pharmacy Team• Bi-weekly team huddles
– Multidisciplinary Communication
Pandemic Preparedness: Critical Care Pharmacy
• Desire to maintain our multidisciplinary model• Schedule alterations to accommodate 7 days a week
consistency• Developed an on-call strategy• Using non-ICU personnel to extend our capacity• Increased use of technology
Multidisciplinary Support and Pharmacy Scheduling
Pandemic Preparedness: Critical Care Pharmacy
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ICU Pharmacist Pandemic Staffing Plan
Pandemic Preparedness: Critical Care Pharmacy
ICU Pharmacist Pandemic Staffing Plan
Pandemic Preparedness: Critical CarePatient Care Observations• Relatively small number of patients compared to
locations who have experienced a surge• Similar patient care issues observed:
– High sedation requirements– Prolonged duration of mechanical ventilation– Presence of Coagulopathy– Robust insulin requirements
Just in Time FMEA to Predict Issues with Workflow and Safe Medication HandlingNick Crites, PharmDMedication Safety PharmacistDepartment of Pharmacy, Nebraska Medicine
Medication Safety Structure at Nebraska Medicine
Director of Pharmacy
Medication Safety Pharmacist Specialist
Safety Report Review and Root Cause AnalysisMedication workflow and process improvement
Medication policy oversightRegulatory compliance
Medication Management Committee, P&T, Core Event Review Team, etc.
Nursing Professional
Practice/Informatics Executive Director
Medication Safety Nurse Specialist
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Medication Safety & Pandemic Planning
Learnings from outside organizations has been crucial- Institute for Safe Medication Practice (ISMP)- American Society of Health-System Pharmacists (ASHP)- Medication Safety Officers Society (MSOS)- Visante- Vizient- Outside hospitals- Others
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Medication Safety & Pandemic Planning
- Pump placement outside patient rooms
- Dual nurse check medications and med station workflows
- Infusion pump shortage preparation and IV push medications
- Handling of medications that enter isolation patient rooms or units
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Medication Safety & Pandemic Planning- Infusion pump shortage preparation and IV push medications
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Medication Safety & Pandemic Planning- Handling of medications that enter isolation patient rooms or units
- Weighing the pros and cons of saving medications that enter isolation patient rooms
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Pros Cons
Staff time & resources
Contamination Risks
Drug shortages
Cost
Medication Safety & Pandemic Planning- Handling of medications that enter isolation patient rooms or units
- Weighing the pros and cons of saving medications that enter isolation patient rooms
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Pros Cons
Drug shortage
Drug shortages
Drug shortages
Cost
Staff time & resources
Contamination Risks
Failure Mode Effects Analysis (FMEA)- Proactive risk assessment
• Review each step in a high risk process to identify:- Potential failure modes (what errors could occur?)- Potential failure effects (what would happen if an error
occur?)• Score severity, occurrence and detectability to
calculate a Risk Priority Number (RPN)• Identify follow-up actions and owners• Rescore once action plan is developed
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Failure Mode Effects Analysis (FMEA)- Risk Priority Number (RPN)
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Failure Mode Effects Analysis (FMEA)- Just in time FMEA
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3/25/20• COVID unit walk through
3/26/20• Initial Pharmacy planning meeting• Summarize overall plan for negative airflow rooms versus negative airflow units
4/2/20• Review draft of FMEA process steps• Begin identifying failure modes/effects and RPN scoring
4/3/20• Discussion with Nursing on current workflows and possibility of removing
medications from isolation
4/6/20• Review FMEA and drafted process for Nurse and Pharmacy roles in removing
medications from isolation rooms, and process for Pharmacy cleaning
Failure Mode Effects Analysis (FMEA)- Portion of just in time FMEA
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Handling of Unused Medications that Enter Isolation Rooms (e.g. 7UT, 5UT, 7N, etc.)
Follow each step to ensure safety and infection prevention:
1. IMPORTANT: Is medication in a glass vial or sealed zip lock bag?a. If no, medication must be discarded prior to exiting
patient roomb. If yes, proceed with the below steps
2. Inside the room, near the entrance, RN wipes down outside of vial or ziplock bag with a low level disinfectant wipe
3. RN contacts a 2nd staff member and asks them to hold a hazardous bag open at the entrance outside the room (bags are located near Omniell in designated area on unit)
4. RN drops cleaned medication vial or ziplock bag in hazardous bag
5. Hazardous bag with medication within is placed in yellow return bin located next to Omnicell in designated area on unit
6. Pharmacy is contacted (additional instructions located on pharmacy return bin)
7. Pharmacy completes 2nd wipe down of medication per Pharmacy SOP and restocks after cleaning complete
Medication Safety & Pandemic Planning- Handling of medications that enter isolation patient
rooms or units, next steps• Complete surface sampling to validate cleaning
process effectiveness• Nursing and Pharmacy education• Monitoring compliance
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