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March 30, 2020

Establishing Policies and Guidelines

Betsy Early
Director of Pharmacy Services (Western Region), 
Sentara Healthcare

Hospital-wide policies focus on screening, visitor policies and PPE. Pharmacy guidelines range from patient therapies and medication delivery to inventory management and cleaning techniques.

Hospital Specific

The visitation policy was changed and applies to our hospital, and also our Outpatient Centers and Medical Office Buildings. All routine visiting is being suspended until the transmission of COVID-19 is no longer a threat to our patients, staff and community.

  • Approved visitors (one birthing partner, end of life...) are directed through the ED entrance for screening (see below)
  • Visitors age 12 and under are prohibited

Tents are set up outside of the Emergency Department. The tents are serving as a screening site for all ambulatory patients coming to the ER.

  • Patients are greeted by a team member at the ED entrance
  • Screening questions asked
  • If the answers are consistent with potential coronavirus, patients are directed to the tent where a second team member in full protective equipment asks more detailed questions to determine if the patient should be tested for coronavirus

Public areas have been modified to ensure we are taking the necessary steps to prevent the spread of COVID-19. Just a FEW of these steps include:

  • The staff cafeteria will be full service only (no self-service) 
    • Removing the salad bar and all self-service options from the cafeteria
    • No fountain drink station
  • Removing all magazines and newspapers from public spaces
  • Positioning staff at each of the public elevators to push the buttons (while wearing gloves)
  • Self-serve coffee stations have been removed from each of the unit waiting areas
  • Tables in the cafeteria and sitting areas are reconfigured to create social distancing

Personal Protective Equipment:

  • Strict and consistent guidelines are being developed and enforced
  • PPE is being locked up to control the limited supply
  • Community donations are being screened and accepted if the equipment meets guidelines. A central phone line established to manage the donations

General Operations

  • IT requests limited to pandemic issues only
  • Strict and consistent guidelines for hospital scrubs
  • Evaluate options for pump operations from outside of the room
  • COVID patient care (including medications) centralized and communicated to providers

Pharmacy Specific

  • Pharmacy PPE is being inventoried several times per week
  • Alternate cleaning options for IV rooms are being evaluated
  • COVID-related critical medications are being maintained as controlled substances
    • Inventoried daily
    • Outpatient requests for COVID-related medications must have approved indication (evidence based), the patient-physician relationship must be validated, and supply may be limited to a 2 week supply
  • COVID patient care therapies are assessed to limit staff exposure to COVID patients
  • Common IT sites are being created to house communications and documents
    • Consistent and reputable sites are reinforced with staff
    • Daily information sent to staff at a consistent time and format
    • Check in with staff that have been off for a few days to check their fitness to work and update them on latest information
  • Home order verification is being evaluated
    • Proactive staff assessment of home IT capabilities
  • Team A/Team B staffing is being evaluated
  • Code cart and intubation tray processes are being modified in isolation areas
  • Reinforce self-care and self-assessment of staff
    • Childcare issues identified
    • Eldercare issues identified
    • Family issues
  • Ensure pharmacy automation system recognizes surge beds
  • Cleaning guidelines for pharmacy automation need to be distributed


The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s). These views are always subject to change, revision, and rethinking at any time and may not be held in perpetuity.