Clinical Experiences Keeping Infusion Pumps Outside the Room for COVID-19 Patients
Quite a few hospitals are using extension sets to position infusion pumps outside of COVID-19 patients’ rooms (Figure 1) to conserve personal protective equipment (PPE) and reduce the frequency of exposure that nurses would ordinarily experience by going into patients’ rooms to manage infusions. ISMP spoke to an intensive care unit (ICU) nurse at one hospital, and a pharmacist at another hospital, to learn more about their experiences with this practice. Both hospitals have been using this measure without major issues for about 2 weeks. A description of their experiences follows.
One hospital’s experience
Vascular access. All patients with pumps in the hallway have a central line; midline or peripherally inserted central catheters are not being used. The nurse noted that peripheral intravenous (IV) lines may not work well due to flow rate issues.
Pump set-up. “Small bore” extension tubing is attached to the pump’s primary administration set and run under the door. The hospital investigated using regular (macrobore) extension sets with a larger inner diameter since the increased volume in the tubing may allow infusions to flow better. However, the macrobore tubing did not fit as well under the door. Also, with the “small bore” extension tubing, there is less volume in the tubing between the infusion and patient. Thus, the solution from small-volume infusions appears to reach the patient more quickly, although resistance to flow is possible with very high infusion rates. (See the ECRI publication mentioned below for more information about tubing of different lengths and inner diameters.)
Three “small bore” extension sets totaling about 15 feet in length are added to the primary pump tubing to reach from the pump in the hallway to the patient. In some hospitals, a triport connector is attached to tubing for patients with more than one medication infusion. At this hospital, Y-site connectors are used, much as they would be with secondary infusions, and all are covered with port protectors. Compatible medications can be run together, and up to three may be administered via the same line, including neuromuscular blocking agents, vasopressors, sedatives, and antibiotics. To prevent the risk of tripping on the tubing or potentially dislodging it, nurses secure disposable Chux pads over the tubing on the floor and at each connection, which serves as a visual reminder and protects the tubing. There are no Y-site connectors on the floor. Infusions are managed the same way in both positive- and negative-pressure patient rooms.
Site assessments and independent double checks. Each patient’s IV site is checked every 2 hours when a nurse enters the room to reposition a patient. Nurses are still conducting parts of an independent double check for certain high-alert medications, requiring a second practitioner to verify the medication/solution, concentration/ dose, and pump settings. While nurses still scan the barcode on a medication or solution for verification against the patient’s medication administration record (MAR) on a workstation on wheels (WOW) outside the room, they are unable to scan the barcode on the patient’s identification band. To work around this, a patient barcode is located outside the room for scanning. While recognizing this is not ideal, the hospital has carefully weighed the risk versus benefit and decided that this workaround is necessary at this time.
Responding to pump alarms. One unexpected result of locating pumps in the hallway is that pump alarm issues have been reduced. Nurses can easily hear and see when pumps are alarming in the hallway, making it easier to respond quickly and without entering the patient’s room. In some hospitals with negative airflow units, white noise may make it difficult for nurses to hear pump alarms inside patient rooms, requiring high-volume settings. Having pumps in the hallway does not require such an adjustment.
Another hospital’s experience
At another hospital, the process of positioning infusion pumps in the hallway is similar, but the doors and front walls of patient rooms are glass, and nurses perform a dual verification of the patient’s barcoded identification band during initial set-up of the pump in the hallway. An isolation nurse inside the room scans the patient’s identification band, which is verified through the glass wall by a nurse outside of the room. This nurse then prints a second barcoded identification band, verifies the band again with the isolation nurse in the room, and then attaches the second identification band securely around the IV pole for subsequent scanning outside of the room. Some hospitals also require the patient’s name and date of birth on the pump to reduce the risk of making changes to the wrong pump or administering medications or solutions to the wrong patient.
Weighing the pros and cons
Many hospitals have considered using extension sets to locate pumps in the hallway to conserve PPE and reduce staff exposure, but have decided against it for various reasons.
Shortage of extension sets. As expected, the use of extension sets has skyrocketed. Product vendors could not have known that pumps would be moved to hallways and that 3 or more extension sets would be needed to do this. We spoke with some vendors who told us that extension sets were either on backorder or allocated for previous customers. They have stepped up manufacturing to meet the demand, though, and some vendors are producing longer extension sets (e.g., 12 feet). Check with your pump vendor about availability.
If a decision is made to locate pumps in the hallway, ECRI notes that any brand of luer-lock extension tubing can be attached to a pump manufacturer’s proprietary primary administration set. Also, manufacturers may offer long primary administration sets suitable for use. Check with the pump manufacturer for any additional pump-specific considerations, and conduct a small pilot test of the process before widescale use.
Other considerations. Examples of other issues to consider when deciding whether to locate pumps in the hallway include the following:
Barcode scanning at the bedside may not be possible.
Fewer trips into the patient’s room will result in fewer opportunities to directly monitor and interact with the patient.
Certain components of independent double checks will become more difficult or impossible in some situations.
The length and inner diameter of long extension tubing can impact flow rates and the time medications and solutions take to reach a patient without flushing.
Occlusion alarms may be delayed at low flow rates and become excessive at high flow rates.
Inadvertent bolus doses may be administered when the tubing is flushed.
Electrical cords and extension tubing can become a tripping hazard. (Some hospitals extend the tubing above or through the side of the door to keep it off the floor. One hospital made an airtight hole in the wall, with engineering staff oversight, to put tubing and equipment wires through to reduce the risk of tripping, disconnection, and power issues.)
There may not be adequate outlets in the hallway to keep pumps charged.
Pumps in the hallway should not be used for two patients in a single room.
Healthcare providers are experiencing an unprecedented time, where nearly every decision presents challenges and potential risks, from reusing PPE to administering some solutions and medications via gravity. And it’s certainly not an easy decision regarding whether to position infusion pumps in the hallway. At the same time, this measure is working at some hospitals that have decided that the risk is worth the benefit. If you identify other strategies or risks associated with this measure, please send them to us so we can evaluate and circulate updated information and guidance.