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Extension of Intravenous Tubing and Pumps Outside Rooms for Safety and Efficiency

2021; American Association of Critical-Care Nurses; Volume: 41; Issue: 4 Linguagem: Inglês

10.4037/ccn2021107

1940-8250

Ellen Le, Ruben Lopez, C. Moreau, Sharon W. Foster, Evangeline Galera, Charity L. Shelton, Anita Catlin,

Intravenous Infusion Technology and Safety

Intensive care unit (ICU) nurses caring for patients with COVID-19 must be careful to protect themselves against contagion and prevent the spread of the virus to others. In our ICU, a patient with COVID-19 is housed in a single room and requires isolation precautions. A nurse may go into and out of the room multiple times during a single shift to manage and administer intravenous (IV) fluids and medications, change dosages, add or discontinue a medication, and manage pump alarms.In April 2020, as hospitalization of patients with COVID-19 was increasing, our nurses heard about a program that allowed IV pumps to be maintained outside patient rooms. The Institute for Safe Medication Practices (ISMP) has mentioned IV pumps in the hallway twice in its newsletters, in the context of concerns about COVID-19 spreading from patient to patient or from patients to staff and of having an adequate supply of personal protective equipment (PPE). Our staff nurses approached their unit manager, who took the suggestion to senior management. Nurses and intensivists provided justification to senior leadership, who then approved a trial project evaluating the use of extended tubing.Among a population of ICU nurses caring for patients with COVID-19, will placing Alaris IV pumps outside of the isolation rooms and connecting them to patients by using extended tubing decrease nurses' exposure to COVID-19, save time, and be fiscally efficient—all while ensuring safe IV infusion for the patient during a 24-hour period?Scant available literature discussed the use of extended IV tubing. A search of the CINAHL and PubMed databases revealed no published literature about using extended tubing to administer IV fluids. We found 2 short practice alerts: one from the ECRI Institute1 and one published by the ISMP.2 The ECRI Institute is an independent, nonprofit organization whose goal is to improve safety and quality in health care, test technologies and assess cost-effectiveness. On April 1, 2020, the ECRI Institute published guidelines (the only set we found) that described the problem of, supply chain requirements for, engineering tasks in, and nursing management of the use of extended IV tubing outside of a patient's room in an ICU to prevent exposure to COVID-19.The ISMP is a nonprofit organization that educates the health care community and consumers about safe medication practices. In April 2020, the ISMP described IV pumps used outside of a patient's room.3 The ISMP reported both positive and negative findings related to the innovation and considerations for practice, such as how barcode scanning should be done; the need for continual, independent double checks of high-alert medications; and issues with infusion timing and alarms. Considerable literature describes the adherence of medications to, or the precipitation of medications in, IV tubing; the effect of absorption of di-(2-ethylhexyl) phthalate (DHEP) into IV solutions; and the development of tubing free of DHEP.4–6Our stakeholders included nurses who provided direct care to patients, the physicians who developed patients' medical treatment plans, the pharmacists who worked with us to address medication precipitation, the engineering staff who developed the attachments through which tubing could be passed, and hospital administration who provided resources for developing safe processes.Engineering staff met with nursing staff to understand the envisioned outcome. Engineering staff were responsive to our requests and worked with us to create of a bar with eyelets that could be attached to the sliding doors on patient rooms. The eyelets were sanded to avoid rough edges that could compromise the integrity of the tubing. The infection prevention officer and engineering staff assessed whether the bar attachment would allow air to flow out of the rooms; they determined that there was no risk that air would leave the room through the eyelets. As the project developed, the eyelets were cut smaller, limited to 4, and placed centrally on the bar (Figure 1).We used only tubing that did not contain DHEP, and we chose not to administer amiodarone, insulin, or lorazepam through extended tubing.7–9 The extension tubing is 30 to 35 inches long, and up to 3 sets can be used. Pharmacists worked with us to ensure the amount of medication-infused fluid used to prime the tubing would not affect volume, as we wanted to be certain that the patient would not receive too much medication or fluid (Table 1). Nurses collaborated with pharmacists to time medication administration so that IV bolus medications would be clustered with other medications that had to be delivered inside the room.When providing and monitoring IV fluids and medications for a patient with COVID-19, nurses must wash their hands then don complete PPE, including a gown, gloves, a mask, and a face shield. The nurse scans barcodes; quiets an alarm; adds a new fluid or medication; sets pump instructions; and removes completed bags, bottles, or cylinders. A patient may have up to 14 medications and tubes. The nurse must remove all PPE before leaving the room, and then exit the room and sanitize their hands. We timed this process: 5 minutes were required to don or doff PPE. One set of isolation garb costs $7.46.We developed a procedure for using the pump outside the patient room, which all stakeholders agreed to: The protocol also included additional factors for consideration: We conducted a prospective, nonexperimental, descriptive quality improvement project. This project was deemed not research on human subjects by the regional institutional review board. This report includes data collected from September 11, 2020, to February 3, 2021.Nurses collected data on IV events among patients who met inclusion during the study period. Patients were included in the study if they (1) were positive for COVID-19 and being isolated; (2) were located in a room with a special bar on the door that allowed extension tubing to be run into the room; (3) had a central catheter; (4) had an IV pump running normal-length IV tubing inside of the room; (5) had a pump outside the room, with additional extended-length tubing connected to it (Figure 3).Nurses recorded data on an event sheet that was hung next to the external pump. Each time a nurse approached the pump outside the room and did not enter the room, they marked it as 1 event. Nurses recorded the type and number of actions taken at the external pump every hour. The events recorded were hanging a new medication or infusion, hanging a new bag or opening a new bottle of existing medication, titrating or changing the rate of an infusion, changing the extended tubing, attending to an alarm, and exchanging information with another nurse. Nurses collected data for each patient throughout a 24-hour period.Data were collected for 58 patients for 24 hours. Nurses recorded a total of 1186 events; a mean of 20 events occurred outside a room each day. Table 2 presents the numbers of events that were recorded.Donning and doffing PPE took 5 minutes each, requiring nurses to spend 10 minutes per room entrance/exit. In our ICU, 10 minutes of a nurse's time is equivalent to $14.66 (not including benefits). The total cost savings across the 1186 times nurses did not enter patient rooms and thus avoided donning and doffing new PPE equaled $17 387. Across the mean of 20 events per 24 hours, this process saved 200 minutes (3.3 hours) of nursing time per patient day, equating to $293.The actual cost of each PPE set is $7.46. Avoiding use of PPE across all 1186 events provided $8848 in total savings; saving 20 sets of PPE daily saved $149 per day.Nurses were protected from exposure to COVID-19–positive patients 20 times per 24 hours. Had nurses entered the room for these events, they would have risked transmission and contracting COVID-19. When a nurse becomes positive for COVID-19, they must quarantine at home for 14 days, and they are paid for that time. Using the mean hourly rate for nurses in our ICU, we estimated the potential cost of one 14-day home quarantine in Northern California to be $7040.The initial results of our project showed that exposure to COVID-19 was reduced among nurses, that we saved time because nurses donned and doffed PPE less often, and that we were able to safely administer IV fluids and medications from outside patient rooms. A second search of PubMed and CINAHL also returned no articles about extended tubing. However, we found 1 mention of extended tubing in an article on COVID-19 initiatives.10 Unlike our specially constructed bars that allow tubing to be threaded through, Stifter et al10 described placing extended tubing on top of disposable underpads set on the floor. In addition, The Joint Commission recently responded to a question about allowing machinery and tubing in hallways (Sylvia Garcia-Houchins, Director, Infection Prevention and Control, Division of Healthcare Improvement, The Joint Commission, email communication, March 15, 2021): No incidents of harm occurred during our use of extended tubing; we found only benefits. Its use limited exposure to COVID-19 for both nurses and patients. Running extended tubing outside the rooms of other patients such as those infected with Clostridium difficile might also avoid nurse exposure and save PPE-related costs. Our interdisciplinary initiative shows what a group of committed colleagues can do when they work together to improve quality and safety for both patients and staff.