I. All pharmacy personnel who work in patient care areas (hospital,
clinics, Emergency Department [ED]) will be trained in the use of
personal protective equipment (PPE) as described for All Barrier
Precautions (ABP). (See Policy 3.2 Isolation of Patients with an
Emerging Infectious Disease [EID] or a Possible EID).
A. N-95 mask
B. Goggles
C. Gown
D. Gloves
II. Use of PPE by pharmacy personnel
A. Pharmacy personnel will not enter the room of an EID patient.
B. No PPE is needed for pharmacy personnel as long as all EID patients are in negative pressure rooms.
C. When the number of EID patients exceeds the number of negative pressure isolation rooms, all Pharmacy personnel who enter a unit where EID patients are hospitalized will wear ABP barrier equipment.
D. Pharmacy personnel may enter the negative pressure isolation unit on 9D without PPE since they will not enter patient rooms.
E. Pharmacy personnel must don an N-95 mask to enter the negative pressure zone in the ED.
F. Pharmacy personnel do not need PPE in clinics since all possible EID patients will be screened out during clinic registration.
III. Protection of pharmacy personnel in special areas
A. The Operating Room pharmacists and technicians will not need
PPE since they will not have patient contact.
B. Pharmacy personnel on the third floor of the TDCJ hospital will not
need PPE, since they will have no contact with patients.
C. Pharmacists in the locked pharmacy in the TDCJ hospital will not
need PPE, since they will have no patient contact.
IV. Doctors of Pharmacy (PharmDs)
A. PharmDs will not be permitted to enter any patient care areas where patients with an EID or possible EID are hospitalized unless all EID patients are in negative pressure rooms.
B. When the number of EID patients exceeds the number of negative pressure isolation rooms, consultations between PharmDs and physicians will be by telephone or email.
V. Transfer of medications between the Shrine Burn Hospital and
UTMB Pharmacies
A. When an EID is present in the community, no one except physicians will be permitted to cross the bridge between UTMB and the Shrine Burn Hospital.
B. When medications are needed from the UTMB Pharmacy for patients in the Shrine Burn Hospital, the medications will be placed on a table on the bridge outside of the UTMB doors for pickup by staff from the Shrine Burn Hospital.
VI. Pharmacy personnel who fill prescriptions for outpatients
A. Clinic Pharmacy
1. Personnel who work at the windows will wear full ABP PPE.
a. N-95 mask
b. Goggles
c. Gown
d. Gloves
2. Personnel who work at a distance of > 3 feet from the window and who do not have contact with any article touched by a patient need to wear only a fit-tested N-95 mask.
B. Inpatient Pharmacy
1. Pharmacy personnel filling prescriptions at the window need wear only a fit-tested N-95 mask and gloves.
2. The door to the pharmacy must be kept closed at all times when one or more patients are at the window.
C. Removal of PPE
1. When full ABP PPE are worn, they must be removed in sequence (gloves, goggles, gowns) and, after washing hands with an antimicrobial soap or applying an alcohol hand rub, the mask. All PPE items should be removed taking care to avoid self contamination.
2. When only a mask and gloves are worn, the gloves should be removed first, hands washed with an antimicrobial soap or an alcohol hand rub applied and then the mask removed taking care to avoid self contamination. After the mask is discarded, hands should again be washed with an antimicrobial soap or an alcohol hand rub applied to the hands.
3. When only a mask is worn, first wash hands with an antimicrobial soap or apply an alcohol hand rub. Then remove the mask taking care to avoid self contamination. Then discard the mask and again wash hands with an antimicrobial soap or apply an alcohol hand rub.
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