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COVID-19 Collaboration: Tripping on extension tubing

A COVID-19 patient was being treated in an intensive care unit (ICU) in a negative pressure room. An ICU nurse had seen a post on social media about another facility placing smart infusion pumps outside of patient rooms to help minimize the use of personal protective equipment (PPE). She decided to implement this workflow. She moved the infusion pump to an anteroom outside the patient’s negative pressure room, and used extension sets to run the tubing under the door and to the patient. The patient was receiving intravenous (IV) norepinephrine via the infusion pump to treat hypotension. The extension tubing was on the floor and not secured to prevent a tripping hazard. At some point, staff tripped on the extension tubing, which caused the tubing to become disconnected from the patient for an unknown period. Fortunately, no adverse outcomes were reported in the patient.

Until this event happened, nursing and pharmacy leadership had not planned for this workflow change and did not know that the ICU staff had moved this one infusion pump to the anteroom. However, the event gave the hospital an opportunity to review their processes and the information provided by ISMP in our April 3, 2020 newsletter (Clinical experiences keeping infusion pumps outside the room for COVID-19 patients), as well as explore the experiences of other facilities. Based on that assessment, the hospital determined that, at this time, the risks outweigh the benefits and decided not to position infusion pumps outside of patient rooms.

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