Anaesthesia preparedness for COVID-19 pandemic readiness: a medication preservation strategy

Editor—The rapidly evolving global coronavirus disease 2019 (COVID-19) pandemic has highlighted the growing imbalance between supply and demand for medical resources as a result of limited global production capacity and changing demands. Information on pandemic-related pharmaceutical preparedness is particularly limited, and no Australian or international guidance is available thus far. Strategies to reduce, conserve, refine, replace, or substitute medications for sustainability during the current pandemic, and for the future, are a critical component to pandemic or disaster preparedness. A critical shortage of essential medications could severely limit access to best patient care and impact clinical outcomes. We highlight operational and strategic approaches taken by our Anaesthetic Department of The Royal Brisbane and Women's Hospital (RBWH), Brisbane, QLD, Australia, and provide a practical toolkit as a resource for other institutions undertaking pandemic preparation.

Hospital readiness and emergency response checklists have been described and published by international organisations such as the US Centers for Disease Control (CDC) and the WHO. In 2019, the Australian Government published the Australian Health Management Plan for pandemic influenza, providing a national approach to pandemic preparedness for the Australian healthcare sector.¹ Australian hospitals and specialist societies have provided their respective pandemic plans which are often accessible via their websites.2, 3, 4 The Faculty of Intensive Care Medicine in the UK published guidance on adaptations to standard UK critical care medication prescribing and administration during pandemic pressures. Highlighting medications potentially susceptible to short supply and high demand, the Faculty proposed alternatives to first-line drugs in an ICU setting.⁵ Relevant to usage of anaesthetic medications in a pandemic, the Royal College of Anaesthetists and the Association of Anaesthetists have provided guidance on some mitigation strategies.⁶

Aligning operational and policy action is paramount. However, translation of operational and clinical demand into day-to-day activity under a pandemic situation is extremely challenging. Anaesthetic departments have a major role within a hospital and provide essential and critical care to a variety of hospital services. Cooperation and collaboration between these service providers is crucial in a rapid response situation. The Royal Brisbane & Women's Hospital is a quaternary hospital with more than 1000 beds, and performs ∼ 37 500 procedures annually, including ∼10 000 emergency procedures, in 22 operating theatres and 11 procedural areas.

Despite a number of published hospital checklists, to our knowledge there is currently no published medication preparedness toolkit or checklist for pandemic readiness for hospitals in general, or for anaesthetic departments in particular. The described medication preservation toolkit is part of our Practical Anaesthetic Department Readiness Checklist developed in response to the COVID-19 pandemic (Ethics approval: LNR/2020/QRBW/64183). We have made considerable efforts to ensure that the information described is supported by current knowledge and recommendations. This toolkit (Supplementary Table 1) has been prepared to support anaesthetists and to provide some guidance. It is structured, highlighting four key components (Table 1 ): operational preparedness, communication, implementation, and audit, each with a list of proposed actions and their implementation status. We recommend that anaesthetic departments anticipating or experiencing an extreme demand for, or a shortage of essential medications (induction agents, sedatives, analgesics, muscle relaxants, reversal agents, and vasopressors), be prepared to implement each action effectively and as soon as it is required. In the case of a pandemic, implementation of this toolkit during the early phase of known imported cases is likely to be more effective than in the subsequent phase of community spread of the disease.

Table 1.

Components of the medication preservation toolkit.

1. Operational preparedness	Not started	In progress	Completed	N/A
Organisational planning	○	○	○	○
Collaboration with all stakeholders	○	○	○	○
Establish current local and state stock counts	○	○	○	○
Establish projected stock required	○	○	○	○
2. Communication	Not started	In progress	Completed	N/A
Assess demand in ICU	○	○	○	○
Assess demand in the Emergency Department	○	○	○	○
Communicate with staff regularly	○	○	○	○
3. Implementation	Not started	In progress	Completed	N/A
Reduce wastage, redistribute, refine anaesthetic techniques, substitute, adapt and prepare rapid access solutions	○	○	○	○
4. Audit	Not started	In progress	Completed	N/A
Audit clinical outcomes at different phases of the pandemic to help refine strategies	○	○	○	○

Since December 2019, the outbreak of a novel coronavirus has challenged health and hospital systems and clinicians alike. It is anticipated that this will continue. Pandemic and disaster preparation and response requires a coordinated, collaborative, and organised approach. We have summarised and conceptualised an anaesthetic department pandemic preparedness strategy to be used as a medication preservation toolkit. This toolkit was developed as part of our Practical Anaesthetic Department Readiness Checklist in response to the COVID-19 pandemic, but many of the recommendations described are generic in principle and anticipated to be applicable to any sized anaesthesia department. All actions undertaken should align with the hospital emergency or pandemic management plan and pharmacy policies, address interdepartmental implications, and undergo regular re-assessment of appropriateness and applicability.⁷ It is envisaged that this would be adaptable to future pandemics, outbreaks, natural disasters, and mass casualty events that will continue to challenge hospital resource management. Disaster preparation and response requires a coordinated, collaborative, and organised approach and this structured toolkit provides a pathway to this.

Declarations of interest

The authors declare that they have no conflicts of interest.

Disclaimer

The presentation of material in this publication only reflects the expression of personal opinions of members of the anaesthetic department at the RBWH based on knowledge and expertise at the time available. The published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader.

Appendix A. Supplementary data

The following is the Supplementary data to this article: