In late 2019 the novel coronavirus disease 2019 (COVID-19) emerged in China, causing severe respiratory illness with persistent person-to-person transmission.1–3 The first diagnosed case in the United States was reported in late January, sparking an initial US public health response that included restricted travel, traveler screening, and required quarantine.1 Because of the growing number of cases, the World Health Organization (WHO) declared a global health emergency on January 30, 2020; on March 11, 2020, the WHO issued a pandemic declaration.4,5 With the disease showing a high transmission rate, atypical symptoms, high rates of mortality, and documented transmission from patient to health care worker, fear grew as countries hurried to prepare.3
When a previously unknown pathogen causes an epidemic rate of infection, the success of national health systems relies on reserves of health care supplies and their appropriate allocation.4 Effective distribution, training, and use of personal protective equipment (PPE) is key to preventing spread between patients and health care workers.4 In the setting of COVID-19, PPE that was once taken for granted as a disposable commodity quickly became a treasured resource to maintain the personal health and safety of health care workers.4
Patients who contract COVID-19 experience a wide spectrum of symptom severity that requires care ranging from at-home symptom management to inpatient intensive care.6 The COVID-19 pandemic introduced a need to increase hospital intensive care capacity rapidly in order to be able to provide adequate care for the patients presenting with this disease.2 Although SARS-CoV-2, the virus that causes COVID-19, is primarily transmitted via droplets, aerosol-generating procedures can cause the virus to remain in the air for up to 3 hours and be infective through simple inhalation.7,8 Aerosol-generating procedures performed on patients positive for COVID-19 present an elevated infection risk for health care workers.5,8 Most studies suggest that aerosol-generating procedures include preintubation ventilation, intubation, tracheostomy, open-airway suctioning, cardiopulmonary resuscitation, and noninvasive ventilation.8
In order to provide the complex care required by critically ill patients infected with the highly contagious SARS-CoV-2, frontline clinicians have had to implement practice changes to address patient care needs while simultaneously conserving PPE and reducing personal exposure risk. One of the resultant practice changes was to move medical devices, most commonly intravenous (IV) infusion pumps, away from the bedside and into the anterooms or hallways outside of patient rooms. This article aims to provide nurses with the information needed to support clinical decision-making during IV infusion therapy when IV infusion devices are located away from the patient bedside.
Adversity drives people to change habits, adjust protocols, and innovate. In the case of COVID-19, the scarcity of PPE pushed health care workers to conserve and make do with what was available. As a result, health care workers were quickly required to balance unimaginable clinical demands for the sickest patients while also preserving personal safety.
In intensive care units (ICUs), where the most-critical patients go for care, aerosol-generating procedures are required frequently and, in some cases, continuously. To mitigate the risk of exposure and effectively manage the use and conservation of PPE, the doors to patient rooms must be kept closed, and nurses and other clinicians must limit contact frequency and time in COVID-19 isolation rooms. With the doors closed and PPE required to enter, nurses are unable to enter into patient rooms quickly or easily to manage the multiple lines and infusions required to care for critically ill patients. For very sick patients, even a brief pause in a life-sustaining infusion from an occlusion, air in the line, or the completion of a medication bag can have dire consequences. Because infusion pumps cannot be controlled without direct device interaction, the use of longer-than-usual extension tubing allows for placement and operation of the pumps outside of patient rooms. This practice has been rapidly adopted for care of critically ill patients with COVID-19 and is permitted by the US Food and Drug Administration (FDA) for the duration of this public health emergency under Emergency Use Authorization.9 One goal of this FDA policy is to “help foster technologies that maintain a safer physical distance between the health care provider and patient affected by COVID-19.”9 A modification that the FDA determines would not create undue risk is “remote monitoring and/or manual control of infusion pumps to manage the care of a patient without physically entering a patient’s room.”9
The complex care of critically ill patients often requires the simultaneous administration of multiple IV medications using large-volume IV smart pumps (IVSPs). Under normal circumstances, most IVSPs are located at the bedside only a few feet from the patient, where the nurse can see the patient and the pump when administering and adjusting medications. Frequent nursing intervention is necessary to manage concurrent IV medication administration, including infusion titrations, bolus/loading of medication doses, and intermittent medication dosing. Nursing intervention is also necessary to ensure that the correct volume of each individual infusion is completely delivered through the lengthy extension tubing. Managing IVSPs outside the rooms of patients with COVID-19 may also entail infusing multiple compatible medications together to reduce the use of extension tubing and the potential need to attend to frequent nuisance alarms or other tasks necessary to ensure continuous flow. Even when IVSPs are located at the bedside, IV infusion is associated with high rates of adverse drug events and medication errors, many of which can be life threatening.10 Remote IV infusion also makes it more difficult to verify patient identity during dual nurse medication checks. Operation of the IVSP in these circumstances is intricate, requires high levels of cognitive attention, and can be error prone.10,11 Nurses must recognize the potential for error associated with IV infusion under normal circumstances and keep in mind the added risk when moving the IVSPs farther from the patient, especially when both cannot be seen concurrently.
Moving IVSPs outside of patient rooms requires modifications to allow the IV tubing to reach the patient; the Figure includes images of real-world use and modifications. Various methods for increasing the length of IV tubing are now being used so patients can continue to receive their medications even while the IVSPs are placed outside the room at distances of 15 feet or more. Placing the pumps outside the rooms improves nursing workflow when managing patients with COVID-19 in isolation, allows for easier interaction with the IVSP, and helps reduce risk of exposure for the nurses. Although this practice can be effective in helping to manage competing patient care demands, it is important for nurses to understand the safety implications in order to ensure that medications are still being delivered as expected.
Flow Rate Accuracy: Peristaltic Versus Cassette-Based Technology
BD Alaris, Baxter Sigma, B. Braun Space Series, and ICU Medical Plum Series are the 4 most commonly used IVSPs in US acute care. The BD Alaris, Baxter Sigma, and B. Braun IVSPs use peristaltic pump technology to infuse fluid, whereas the ICU Medical Plum Series pumps use cassette-based volumetric technology. The Ivenix IVSP, which is not yet in clinical use but has recently received FDA approval, also uses cassette-based volumetric technology. A peristaltic pump uses rollers to propel fluid forward by pinching down on the length of tubing.12,13 Cassette-based pumps contain a flow regulator and a set of valves to administer fluids properly.13,14 Refer to the Table for additional definitions and technology features.
With peristaltic IVSPs, flow rate accuracy of the pumping segment is impacted by variations in system resistance in the form of intake and outlet pressures.14 When intake pressure decreases and/or outlet pressure increases during IV medication administration, decreases in both flow rate and flow rate accuracy will occur.14 Most troubling is that the IVSP will continue to display the intended flow rate, making these errors extremely difficult to detect. When volumetric delivery is provided by cassette-based systems (eg, ICU Medical Plum Series or Ivenix IVSPs) the IV infusion is delivered at the programmed rate regardless of system resistance.14
In addition to changes in system resistance, increasing the tubing length between the IVSP and patient presents additional challenges that must be considered. There is a significant increase in tubing dead volume, increased priming requirements, and elevated risk for air in line and medication adhering to the tubing because of increased tubing surface area. All of these factors can lead to portions of medication doses being left nonadministered or underinfused, which presents various safety concerns for the patient. Overinfusion may also be a concern in the setting of large amounts of medication left in the dead volume and then subsequently flushed into the patient at a higher-than-intended flow rate. A discussion of clinical implications, ways to mitigate effects, and dosing considerations is provided in the Table.
New practice norms will no doubt continue to develop to address the complex care requirements for patients with COVID-19. The remote use of IVSPs addresses many salient clinical and workflow issues. As the primary users of IVSPs, nurses must be aware of the impact of this practice on the accuracy of IV medication administration and the increased potential for error. The most important aspects of IV medication administration should be patient safety, delivery of medication dosing as intended, and achievement of the desired therapeutic effect and/or measurable patient outcome. Improved understanding of the impact of remote IVSP system set-up can help the health care team make more informed decisions for individual patients and situations. With education and continued vigilance regarding the implications these changes can have, nurses can take steps to decrease risk of flow inaccuracy and other complications to support the safest and most accurate remote IVSP medication administration practices.
The authors wish to thank Michelle Mandrack, MSN, RN, Director of Consulting Services for the Institute for Safe Medication Practices, for her generosity and expertise in providing a review of this brief report. Also thanks to to Robert Butterfield of RDB Consulting for his ongoing willingness to share his expertise.
Jeannine Blake declares no conflicts of interest. As a medical device development consultant and clinical outcomes researcher, Karen Giuliano has performed consulting services for numerous medical device companies, including Ivenix and ICU Medical.