Pharmacy Leadership Team Perspective on COVID-19 …Critical Care Pharmacy Transitioning from BCU to COVID units Biocontainment Unit •Capacity 10 patients •Electronic interface

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

https://www.nebraskamed.com/sites/default/files/documents/covid-19/antiviral-and-pharmacotherapy-information.pdf%3Fdate=04172020

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


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Central Operations

Safety

Dispensing

RP & Tech Training


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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


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Medical Emergency Response for NonCOVID Patients


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Emergency Medication Availability


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


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Creation of a Pharmacy Specific Tenecteplase Checklist

ACS Management Pathway Updates


Respiratory Medication Guidelines


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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


• 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


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ICU Pharmacist Pandemic Staffing Plan


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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