The task we set ourselves for our Round Table discussion at this year’s Arab Health Critical Care Focus Day was to review how technology can help to improve outcomes of COVID-19 patients in ICU.
Critical care nursing staff are highly trained, in short supply, and are our most valuable asset. They are essential to good patient outcomes. It is logical, therefore, to apply technology to protecting them and to reducing their risk of exposure. We have heard so much about ‘intermediate technology’ in the form of PPE in the last year, but high-level technology also has a part to play here.
IV medication administration commonly requires a two-nurse check. With highly infectious isolation patients this can potentially expose two nurses to the risk of infection during patient identification. In highly developed IV infusion medication safety systems the second nurse can be replaced by barcode medication administration (BCMA) during which the smart pump, via a bidirectional wireless communication with the patient’s electronic medication administration record (EMAR), undertakes the bedside checks of right patient, right medication, and right timing, auto-populates the pump with the correct starting rate and dose, and automatically documents administration in the patient’s EMAR. This also significantly reduces the risk of making an IV medication error for staff who may be working outside of their normal working environment, and under tremendous pressure. Given the hemodynamic effects of COVID-19 related sepsis we would expect also to see a significant amount of titration of vasoactive medications. Smart pumps with Dose Error Reduction Systems (DERS) reduce the risk of inadvertent toxic or untherapeutic dosing with the application of hard limits for dose/rate, and concentration of continuous infusions.
Updating DERS libraries on pumps with alternate drugs due to international shortages of opiates and sedatives has been a major challenge during the COVID-19 emergency. One hospital reported Propofol requirements for ventilated patients increasing by over 1,900 per cent over the course of a few days during the first wave of the pandemic. Being able to substitute 1 per cent Propofol with 2 per cent Propofol (rarely used outside of anaesthesia) was a partial solution for this facility but updating DERS libraries rapidly and safely to match such changes in the central formulary can only really be achieved when there is the capability to deploy the new library to connected pumps via extensive wired or wireless networks. This, of course, also allows facilities to respond to emergent changes in treatment protocols such as the new protocol for Dexamethasone use in COVID-disease. Wirelessly integrated infusion devices enable the deployment of updated DERS libraries to react to practice and formulary changes, even in Field Hospitals. Being able to add new medication regimes to our frontline medical devices so they can be safely used by clinicians is fundamental to good ICU patient outcomes.
The maintenance of continuous critical short half-life infusions (CSHLI) such as noradrenaline is vital, as with critically ill COVID-disease patients in the ICU any prolonged interruption of CSHLI infusion delivery could be fatal. Monitoring of these infusions is crucial for isolated ICU patients, as nursing staff must respond promptly to any infusion alarm, and certainly within the short plasma half-life of these medications if serious cardiovascular events are to be avoided.
During the Arab Health ICU Focus Day, we were also able to discuss studies such as a three-year retrospective study in The University Hospital of Antwerp, Belgium that identified how centralised monitoring of isolated neonates in an NICU with 60 single rooms reduced nurse reaction times to CSHLI alarms by 31 per cent and reduced the total number of alarms that nurses are exposed to by 56.25 per cent. We, therefore, recommend central monitoring of all infusions delivered to isolated COVID-19 ICU patients. This has an extension beyond the pandemic to immunocompromised critical-care patients who require protective isolation. The use of wireless pumps in single rooms that can transmit their infusion data and any alarms to a centrally based monitor is extremely valuable in this respect.
We have learnt a lot about managing COVID-19 disease in the ICU over the last year. With novel drug treatments and with the protocolising of treatments becoming more common a large capacity DERS library with multiple profiles can allow for a specific library for critically ill COVID-disease patients, giving rapid and easy access to specific medications used to care for these patients along with specialist concentrations for those patients with COVID-related kidney dysfunction and pulmonary oedema.
Impact on hospital pharmacy
The pressures in the ICU during the pandemic have also impacted on the hospital pharmacy. To reduce the pressure on already overstretched nursing staff there has been a move to increased production and compounding of IV medications via Central Intravenous Additive Services (CIVAS) in central or satellite pharmacies. This can give rise to an issue of the storage of bulky and high-volume CIVAS infusions requiring refrigeration with issues of track and control as, commonly, the refrigerators used in facilities are not connected to the pharmacy system. Equally, manual reporting of continuous infusion rates and the patient census by ICU staff to calculate critical care medication requirements in the central pharmacy is a serviceable but not ideal workaround. Fuller integration of infusion pumps allows the central pharmacy to view dashboards of each ICU bed’s infusion rates (and therefore obtain exact medication consumption rates in each ICU) allowing for a rapid response to ‘supply-shocks’ and ensuring that Just In Time (JIT) delivery can be achieved. Aggregation of this data and integration with par-level reporting data from Automated Dispensing Cabinets (ADC) and integrated medication fridges also allows for more accurate forecasting going forward as the current emergency evolves and can be used as real-world data to forecast for future crises. Good critical care COVID-19 patient outcomes are dependent on the consistent and uninterrupted supply of maintenance medications and of antibiotics for the treatment of secondary infections. Full information flow and the ability to locate a compounded or pre-mixed medication at any point in the production-delivery-administration chain is key to ‘feeding’ the ICU’s needs and also allows for rapid data gathering from both in-house medication stock levels and consumption rates of critical medications. This can potentially improve how minimum and par levels of medications are set for each care unit and provides incredibly useful information for the setting up of ADCs supplying ‘pop-up’ ICUs to manage surge during biological disasters such as the COVID-19 pandemic. This data can also theoretically feed directly into regional and national systems, many of which currently rely on individual facilities regularly reporting stock-levels. These are currently often calculated from weighted averages, and projected needs based on historical order volumes and extra ‘daily-loads’ reported by the ICUs. National or regional coordination needs a more dynamic real-time data-feed to allow for centralised ordering and distribution and inter-facility ‘lending’ arrangements for critical need. We are truly all in this together and sharing of scarce medications during crises has been a central part of the strategy to increase survival rates across healthcare systems.
Assessing the impact of our ICU interventions is made easier by data-analytics. ‘Big data’ allows for rapid review of therapies and for guiding us to do ‘the right thing in the right way’.
A significant change in the management of controlled medications has been a noticeable feature of the challenge to ICUs of the COVID-19 emergency. In many countries their management was very much a paper-based exercise, with double signatures and wastage accounting through returns of empty ampoules to the pharmacy required for all transactions. As a positive result of the COVID-19 emergency, many healthcare systems have now begun to adopt and accept electronic signature solutions and to use automation to both secure opiates and sedatives and to maintain account and wastage records that can be viewed centrally and on shared dashboards.
The response of critical care clinicians to the COVID-19 emergency has been magnificent and has commonly extended to mentoring and supporting staff working outside of their usual specialties as well as undertaking their ‘usual’ duties in these unusual times. Clinicians have stated that wholesale changes have been undertaken in facilities with the creation of numerous ICU beds so rapidly that it has often felt like working in ‘a brand-new organization.’ Facilities have had to quickly cross-train existing staff and recruit new staff to ease the burden, and clinical facilitators have been tasked with upskilling nurses who usually work in non-critical care areas to care for critically ill patients. ICUs can benefit here from partnerships with medical device vendors, providing educational resources and clinical training to ensure best practices. For example, infusion therapy during a pandemic is multi-faceted and challenging, engaging with pump vendors to seek expert advice, the application of technology, and creative strategies that build on, or adapt, existing safeguarding processes and strategies are the keys to keeping both critically ill patients, and the staff caring for them, safe.
With such intense activity inside facility ICUs, tracking of medications and the ability to reintroduce unused but highly valuable medications back into the system is a real challenge. Monitoring of ADC refills and discrepancies between items dispensed from central pharmacy and those that are acknowledged in the ADC network can help with reconciling open-shelf items that are difficult to track. Other suggestions on medication stock tracking include integration between pharmacy applications and ERP systems for ‘stock-in stock-out’ reconciliation. Connected inventories servicing high medication-turnover units in critical care could be further enhanced by the rollout of GS-1 and GTIN barcodes, with accounting for expiry dates, lot numbers, and real-time identification of available medication stock.
Integrating infusion pumps and automated dispensing cabinets allows for more accurate forecasting of ICU medication needs as infusion rates can be viewed in real-time and overall medication consumption can be assessed and shared across facilities.
Of course, as organisations and as a community of ICUs we also need to answer one key question: Have we improved outcomes of our COVID-19 patients in critical care?
We can only show that our work, strategies, and techniques have made a difference through the assessment of data. ICU medication usage data integrated into Electronic Medical Records (EMR) and made available as ‘big data’ has the potential to be a real asset for rapid review of therapies and for guiding us to do ‘the right thing in the right way’, data is the bedrock of Evidence Based Medicine. Therapy data tied to patient demographics helps us to create evidence of its effectiveness. This approach utilising specialist tracking technology has already shown an impact on the tracking of Antibiotic Microbial Resistance in ICUs, it is now being applied to help track and share COVID-19 insights with hospitals across the United States and has shown in a recent publication that the work of dedicated and skilled ICU clinicians and the therapies they deploy have indeed made a huge difference to survival rates from severe COVID-19 disease.
In summary, the pandemic has challenged ICUs and critical care services, driven change to working practices, and accelerated the application and integration of technology solutions. To effectively meet future crises, there can be no return to ‘traditional’ ICU models of work.
References available on request
This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.