Aseptic simulation test challenged with microorganisms for validation of pharmacy operators

A retrospective hospital benefit and cost analysis of the management of human tissues for orthopaedic allografts

OBJECTIVES

The transplantation of human tissues is a greatly expanding field of medicine with unquestionable benefits that raise questions about safety, quality and ethics. Since 1 October 2019, the Fondazione Banca dei Tessuti del Veneto (FBTV) stopped sending thawed and ready to be transplanted cadaveric human tissues to hospitals. A retrospective analysis of the period 2016-2019 found a significant number of unused tissues. For this reason, the hospital pharmacy has developed a new centralised service characterised by thawing and washing human tissues for orthopaedic allografts. This study aims to analyse the hospital cost and benefit derived from this new service.

METHODS

Aggregate data relating to tissue flows were obtained retrospectively for the period 2016-2022 through the hospital data warehouse. All tissues arriving from FBTV for each year were analysed, dividing them according to the outcome (if used or wasted). The percentage of wasted tissues as well as the economic loss due to wasted allografts were analysed per year and trimester.

RESULTS

We identified 2484 allografts requested for the period 2016-2022. In the last 3 years of the analysis, characterised by the new tissue management of the pharmacy department, we found a statistically significant reduction in wasted tissues (p<0.0001) from 16.33% (216/1323) with a cost to the hospital of 176 866€ during the period 2016-2019 to 6.72% (78/1161) with a cost to the hospital of 79 423€ during the period 2020-2022.

CONCLUSION

This study shows how the centralised processing of human tissues in the hospital pharmacy makes the procedure safer and more efficient, demonstrating how the synergy between different hospital departments, high professional skills and ethics can lead to a clinical advantage for patients and a better economic impact for the hospital.

Validation of orthopedic allograft preparation process: a new application of media fill test

Musculoskeletal allografts represent an important practice in orthopedic surgeries and the demand for them has been growing. For this reason, in order to reduce clinical risk and to more efficiently manage the increase of allograft usage and also to optimize timing of the surgeries, the thawing and washing processes with aseptic technique were centralized in the department of Hospital Pharmacy. This study describe the design and execution of an adapted Media Fill Test (MFT) to demonstrate aseptic thawing and washing of allografts. For this specific and innovative setting, to better simulate the actual processing steps, a surrogate system was developed to simulate the tendon allograft. The aseptic technique of four operators was assessed and an initial performance validation and the first revalidation were described. All MFT were completed successfully, with no observation of turbidity. The readapted MFT shown in this study can provide insight into this innovative and growing field to other health professionals who want to implement this service.

Accuracy of pharmacy student self-assessment of a single sterile compounding technique following didactic training

INTRODUCTION

The primary objective was to determine pharmacy students' ability to self-assess sterile compounding technique in a single evaluation three semesters after training in the curriculum.

METHODS

School of pharmacy (SOP) students were trained and assessed on sterile compounding technique during their second year of school, with no additional formal assessments provided later in the curriculum. From 2016 to 2018, 262 students were asked to compound a simulated sterile product in their third year of pharmacy school and self-evaluate their technique, which was compared to an instructor evaluation with both people using the same rubric.

RESULTS

Two thresholds were used to define successful assessment: strict (ability to detect ideal technique) and lenient (ability to detect harmful technique). The average match rate was 70.2% and 87.6% in the strict and lenient analyses, respectively, with outcomes varying between categories. In the product preparation and inspecting product categories, students who disagreed with assessors tended to misidentify their incorrect technique as correct.

CONCLUSIONS

Pharmacy students who assessed themselves on sterile compounding technique three semesters after formal sterile compounding training were able to accurately self-assess in most cases, but when disagreeing with an assessor, commonly identified their incorrect technique as correct. Most students demonstrated the ability to self-assess sterile compounding technique and are prepared to assess their own sterile compounding in practice. SOPs could consider whether sterile compounding training coupled with self-assessment throughout the curriculum would be beneficial to further improve students' sterile compounding ability and accuracy of self-assessment.

Use of simulation for education in hospital pharmaceutical technologies: a systematic review

OBJECTIVES

Because of the inherent risks facing pharmacy technicians, and consequently also patients, initial and continuing education on hospital pharmaceutical technologies is essential. Simulation is a pedagogical tool now widely used in healthcare education. This study's objectives are to provide an overview of simulation's current place in the field of hospital pharmaceutical technology education, to classify these uses, and to discuss how simulation technologies could be better used in the future.

DATA SOURCES

Two pharmacists independently searched PubMed, Embase, and Web of Science on 21 July 2020 and included studies in English or French that used simulation as an educational tool in the field of hospital pharmaceutical technologies, whether in academic teaching or professional practice.

DATA SUMMARY

Our search criteria resulted in 6248 articles, of which 24 were assessed for eligibility and 13 included in the qualitative synthesis. Simulation in hospital pharmaceutical technology education is used in three different ways: first, as a playful pedagogical tool, with error-based simulations (cleanrooms and preparation sheets with errors), or game-based simulations (escape games, role-plays, and board games); second, as an electronic tool with virtual reality (virtual cleanrooms and serious games), or augmented reality (3D glasses); finally, to evaluate chemical contamination (fluorescein and quinine tests) and microbiological contamination (media-fill tests) during compounding to periodically requalify pharmacy technicians.

CONCLUSION

Further studies, including non-technical skills evaluations, are needed to confirm the usefulness of this innovative technique in training as efficiently as possible actual and future pharmacy professionals.

Implementation and validation of an in-house combined fluorescein/media-fill test to qualify radiopharmacy operators

Background

The purpose of this work was to design, validate and implement a media-fill test combined with fluorescein (MFT-F) for the specific qualification and training of radiopharmacy operators, in accordance with United States Pharmacopeia General Chapter 797 and European Good Manufacturing Practices. MFT-F was embedded in the quality management system of our radiopharmacy unit. Its validation involved fluorescein concentration choice, media growth promotion test and evaluation protocol controls (with or without intentional aseptic mistakes). Each operator was evaluated following a three-part evaluation form. Evaluation criteria related to garbing and hygiene, fluorescent contamination and bacteriological contamination (pre- and post-evaluation environment controls and MFT-F samples). Combined MFT-F allowed the assessment of aseptic compounding skills and non-contamination of the working area through a single evaluation. It was also designed to fit the constraints of radiopharmacy common practice related to radiation protection equipment and to the small volumes handled.

Results

A 0.01% fluorescein concentration was chosen to prepare MFT-F. Addition of fluorescein in the culture medium did not jeopardize its growth properties according to growth promotion test. Eleven operators were evaluated and carried out 3 MFT-F over 3 successive days. Pre- and post-evaluation bacteriological controls of every session showed no CFU of microbiological contaminant above 5. All operators validated the garbing and hygiene evaluation, with an average score of 92.7%. All operators validated the fluorescent contamination evaluation, with an average score of 29.4 out of 30. None of the MFT-F samples showed any visible bacterial growth after incubation.

Conclusions

Combined MFT-F, as a part of a comprehensive sterile compounding training program, appeared as a convenient and promising tool to increase both the sterile compounding safety and awareness of radioactive contamination in radiopharmacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41181-020-00117-6.

Microbiological stability tests with simulated broth preparations and integrity testing for sterile standard cytotoxic preparations

Objectives

The objectives were to assess the microbiological stability and the physical enclosure integrity of the overwrapping for batch production of standard cytotoxic injectable solutions.

Methods

Broth culture media were used in place of cytotoxic drugs to assess the worst case in term of microbiological contamination risk. Iterative sterility tests on batches were performed for 60 days using rapid microbiological method. Validation of microbiological growth of culture media was assessed by direct inoculation of <100 CFU/mL of six microbiological strains recommended by European Pharmacopeia. Validation of the ability of growth of microorganisms in 11 cytotoxic solutions and one monoclonal antibody was assessed using eight strains. In addition, the physical integrity of the seal of the overwrapping containing cytotoxic preparations was assessed by dynamometric method and dye penetration test.

Results

No microbiological contamination was observed on all units of batches for 60 days of investigation. The ability to detect microbiological growth in cytotoxic solutions was validated for the eight challenge microorganisms after 1/10 dilution for cytotoxic investigated, except for 5 Fluorouracil, gemcitabine and cisplatin. In addition, physical integrity testing of the seal of overwrapping pointed out the need of specific validation of heatsealer and operator education.

Conclusions

Besides physico-chemical testing, microbiological stability testing combined to physical integrity testing is the additional part of the development method for batch production of sterile drugs in hospital.

Reducing the risk of non-sterility of aseptic handling in hospital pharmacies, part A: risk assessment

Objectives

To determine prospectively the sources of risk of non-sterility during aseptic handling and to quantify the risks of each of these sources.

Methods

A risk assessment (RA) of non-sterility according to Failure Mode and Effect Analysis was executed by a multidisciplinary team of (hospital) pharmacists and technicians, a consultant experienced in aseptic processing and an independent facilitator. The team determined the sources of risk of non-sterility, a 5 point scale for severity, occurrence and detection, and risk acceptance levels. Input about general applied risk reduction was collected by audits in 10 hospital pharmacies. The results of these audits were used for determining the remaining risks. The results, as well as scientific information and the experience of the team members, was used to determine scores for severity, occurrence and detection.

Results

Multiplying the scores for severity, occurrence and detection results in the risk prioritisation number (RPN) which is a relative value of the remaining risks of non-sterility for each source. Incorrect disinfection techniques of non-sterile materials and the chances of touching critical spots were estimated as the greatest risks. The risk of non-sterility via the airborne route was low. RPN values were helpful in prioritising measures for additional risk reduction (this will be described in an accompanying article).

Conclusion

The RA, described here, was a systematic survey related to all sources of risk of non-sterility during aseptic handling. The determined RPN values were helpful in prioritising measures for additional risk reduction.

Simulation program of a cytotoxic compounding robot for monoclonal antibodies and anti-infectious sterile drug preparation

The aim of this study was to develop a specific simulation program for the validation of a cytotoxic compounding robot, KIRO® Oncology, for the preparation of sterile monoclonal antibodies and anti-infectious drugs. The impact of excipient formulations was clearly measured using simulation accuracy tests with worst case excipient (i.e. viscous, foaming) and allowed to correct the robotic settings prior to real production. Corrections brought accuracies within the acceptable range of ±5%. KIRO® Oncology robot has also the capacity of self-cleaning and a simulation combining media fill test, and environmental monitoring was able to validate the aseptic process including simulation of worst case conditions and highlighting the areas not accessible to self-cleaning to be corrected by additional manual cleaning measures. The risk of chemical contamination was simulated by using fluorescent dye of the process with high-risk excipient formulation and overpressure vials. Quality control reliability was simulated by using a model drug, and final concentration was determined by high-performance liquid chromatography-ultraviolet detection. Finally, productivity was simulated using different models of production showing the impact of the type of drug, the number of vials and the poor standardization of the process.

Incorrect aseptic techniques in medicine preparation and recommendations for safer practices: a systematic review

Objective

Many patient deaths have been reported because of administration of contaminated intravenous medicines due to incorrect aseptic techniques. Our aim was to review the literature for (1) incorrect practices in aseptic drug preparation and administration and (2) recommendations for safer practices in hospitals.

Methods

A systematic literature search was conducted in PubMed covering 2007-2015. Studies were included if they concerned aseptic medicine preparation and administration in hospitals by different healthcare professionals, assessed incorrect practices and made recommendations for safer aseptic preparation and administration.

Results

26 studies were included of which 19 were original articles. 12 of the studies concerned description of incorrect practices that led to contamination. The studies reported 11 incorrect practices that increased the risk of contamination of parenteral medicines. The most reported incorrect practices were multiple use of phials and syringes (2/12 studies) and lack of overall disinfection during the aseptic preparation and administration (3/12 studies). 22 practices were recommended to avoid contamination, which were classified into six categories: equipment and medicines (7); disinfection (6); working environment (3); storing (3); catheter care (2) and quality of prepared medicines (1). The results indicate that pharmacists prepared syringes with less contamination than nurses because of the pharmacist's aseptic skills and environmental aspects in pharmacy units.

Conclusions

The review discusses many appropriate and enhanced practices in aseptic drug preparation and administration. As the change for the better in contamination rates of administered medicines seems to be challenging to achieve in hospitals, better and possibly international procedures for safe parenteral practices need to be developed.

Evaluating the Sensitivity of a Media-Fill Challenge Test Under Various Situations as a Reliable Method for Recommended Aseptic Technique Competency Assessment

Background: Microbial contamination of compounded medications is a serious concern within hospital pharmacies as it can lead to severe patient injury. The United States Pharmacopeia <797> mandates that pharmacy personnel responsible for preparing compounded sterile preparations must annually demonstrate competency in aseptic technique by performing a media-fill challenge test. Objective: The purpose of this study is to evaluate the sensitivity of a commonly used media-fill test through proper and improper compounding techniques. Methods: Two aseptically trained pharmacy technicians performed media-fill challenge testing by carrying out 5 separate manipulations 5 times each for a total of 25 trials. Sterile vials, syringes, and intravenous bags were prepared. The first manipulation followed best-practice aseptic technique and sterile compounding procedures. Each of the following 4 manipulations removed one aspect of best-practice aseptic technique. The prepared products were incubated at 20°C to 25°C. A positive result for microbial contamination is indicated by visible turbidity within the vials, syringes, and intravenous bags at the following check points: 24 hours, 72 hours, 7 days, 14 days, 21 days, and >30 days. Results: Twenty-five trials, each containing 10 distinct admixtures, resulted in a total of 250 compounded preparations. No single preparation showed signs of turbidity, sedimentation, or visible microbial growth at any of the 6 checkpoints yielding a 0% contamination rate. However, the positive controls inoculated with bacteria did have positive microbial growth results. Conclusion: A more sensitive test needs to be developed to provide assurances that all poor aseptic practices are detected in compounding personnel.

[Staff accreditation in parenteral nutrition production in hospital pharmacy]

OBJECTIVES

This work aims to provide staff accreditation methodology to harmonize and secure practices for parenteral nutrition bags preparation.

METHODS

The methodology used in the present study is inspired from project management and quality approach. Existing training supports were used to produce accreditation procedure and evaluation supports.

RESULTS AND DISCUSSION

We first defined abilities levels, from level 1, corresponding to accredited learning agent to level 3, corresponding to expert accredited agent. Elements assessed for accreditation are: clothing assessment either by practices audit or by microbiologic test, test bags preparation and handling assessment, bag production to assess aseptic filling for both manual or automatized method, practices audit, number of days of production, and non-conformity following. At Angers Hospital, in 2014, production staff is composed of 12 agents. Staff accreditation reveals that 2 agents achieve level 3, 8 agents achieve level 2 and 2 agents are level 1. We noted that non-conformity decreased as accreditation took place from 81 in 2009 to 0 in 2014.

CONCLUSION

To date, there is no incident due to parenteral bag produced by Angers hospital for neonatal resuscitation children. Such a consistent study is essential to insure a secured nutrition parenteral production. This also provides a satisfying quality care for patients.

Comparison of lateral shuffle and side-step cutting in young recreational athletes

This study compared three-dimensional (3-D) hip and knee kinematics and kinetics between lateral shuffle and side-step cutting movements to determine whether the simpler lateral shuffle movement can be used in place of cutting to assess knee injury risk. A total of 78 patients (52 female) and 34 controls (16 female) aged 8-19 years performed lateral shuffle and 45° side-step cutting movements. Hip and knee kinematics and kinetics between initial contact and peak knee flexion were calculated using the Plug-in-Gait model and compared between activities using Pearson's correlation and paired t-tests. Peak knee valgus angle correlated strongly (r=0.86, p<0.0001), while minimum (r=0.25, p=0.0001) and peak hip abduction (r=0.24, p=0.0003), and peak hip internal rotation (r=0.33, p<0.0001) correlated only weakly between the two activities. Peak external knee valgus moment (r=0.32, p<0.0001) and average external knee (r=0.42, p<0.0001) and hip (r=0.37, p<0.0001) flexion moments correlated weakly to moderately between activities. Subjects were more internally rotated (3.6°, p<0.0001) and less abducted (16.7° and 17.3° for minimum and maximum, p<0.0001) at the hip during cutting, with higher hip (0.12, p<0.0001) and lower knee (-0.02, p=0.0001) non-dimensional flexion moments. These results suggest that the lateral shuffle movement may be useful for evaluating knee valgus, particularly during initial visual assessment. However, the lateral shuffle may not be challenging enough to reveal poor neuromuscular control over hip ab/adduction and rotation, necessitating follow-up assessment of cutting, ideally using 3-D motion analysis.

Comparison of Aseptic Compounding Errors Before and After Modified Laboratory and Introductory Pharmacy Practice Experiences

OBJECTIVE

To determine whether aseptic compounding errors were reduced at the end of the third professional year after modifying pharmacy practice laboratories and implementing an institutional introductory pharmacy practice experience (IPPE).

DESIGN

An aseptic compounding laboratory, previously occurring during the third-year spring semester, was added to the second-year spring semester. An 80-hour institutional IPPE was also added in the summer between the second and third years. Instructors recorded aseptic compounding errors using a grading checklist for second-year and third-year student assessments. Third-year student aseptic compounding errors were assessed prior to the curricular changes and for 2 subsequent years for students on the Oklahoma City and Tulsa campuses of the University of Oklahoma.

ASSESSMENT

Both third-year cohorts committed fewer aseptic technique errors than they did during their second years, and the probability was significantly lower for students on the Oklahoma City campus. The probability of committing major aseptic technique errors was significantly lower for 2 consecutive third-year cohorts after the curricular changes.

CONCLUSION

The addition of second-year aseptic compounding laboratory experiences and third-year institutional IPPE content reduced instructor-assessed errors at the end of the third year.

Media-fill simulation tests in manual and robotic aseptic preparation of injection solutions in syringes

OBJECTIVE

The purpose of this study was to evaluate the contamination rate of media-fill products either prepared automated with a robotic system (APOTECAchemo™) or prepared manually at cytotoxic workbenches in the same cleanroom environment and by experienced operators. Media fills were completed by microbiological environmental control in the critical zones and used to validate the cleaning and disinfection procedures of the robotic system.

METHODS

The aseptic preparation of patient individual ready-to-use injection solutions was simulated by using double concentrated tryptic soy broth as growth medium, water for injection and plastic syringes as primary packaging materials. Media fills were either prepared automated (500 units) in the robot or manually (500 units) in cytotoxic workbenches in the same cleanroom over a period of 18 working days. The test solutions were incubated at room temperature (22℃) over 4 weeks. Products were visually inspected for turbidity after a 2-week and 4-week period. Following incubation, growth promotion tests were performed with Staphylococcus epidermidis. During the media-fill procedures, passive air monitoring was performed with settle plates and surface monitoring with contact plates on predefined locations as well as fingerprints. The plates got incubated for 5-7 days at room temperature, followed by 2-3 days at 30-35℃ and the colony forming units (cfu) counted after both periods. The robot was cleaned and disinfected according to the established standard operating procedure on two working days prior to the media-fill session, while on six other working days only six critical components were sanitized at the end of the media-fill sessions. Every day UV irradiation was operated for 4 h after finishing work.

RESULTS

None of the 1000 media-fill products prepared in the two different settings showed turbidity after the incubation period thereby indicating no contamination with microorganisms. All products remained uniform, clear, and light-amber solutions. In addition, the reliability of the nutrient medium and the process was demonstrated by positive growth promotion tests with S. epidermidis. During automated preparation the recommended limits < 1 cfu per settle/contact plate set for cleanroom Grade A zones were not succeeded in the carousel and working area, but in the loading area of the robot. During manual preparation, the number of cfus detected on settle/contact plates inside the workbenches lay far below the limits. The number of cfus detected on fingertips succeeded several times the limit during manual preparation but not during automated preparation. There was no difference in the microbial contamination rate depending on the extent of cleaning and disinfection of the robot.

CONCLUSION

Extensive media-fill tests simulating manual and automated preparation of ready-to-use cytotoxic injection solutions revealed the same level of sterility for both procedures. The results of supplemental environmental controls confirmed that the aseptic procedures are well controlled. As there was no difference in the microbial contamination rates of the media preparations depending on the extent of cleaning and disinfection of the robot, the results were used to adapt the respective standard operating procedures.

Aseptic simulation test for cytotoxic drug production in isolators

PURPOSE

The results of a media-fill test (MFT) study to validate processes for cytotoxic drug preparation inside and outside aseptic compounding isolators are presented.

METHODS

Using an MFT protocol adapted to institution-specific production conditions, the pharmacy team at a hospital in France performed a series of tests to verify the efficacy of decontamination and sterile compounding procedures, as required by French compendial standards, while assessing the performance of its team of 12 isolator operators; all operators were tested on three occasions, producing 10 MFT samples per test for a total of 30 samples per operator. The team also tested alternative compounding systems (i.e., two closed-system transfer devices and a classic spike system) for use during power outages or other emergencies precluding drug preparation within isolators. MFTs were performed using a standard tryptone soy broth-based test kit under worst-case conditions.

RESULTS

The hospital's facilities for cytotoxic drug preparation were found to be in conformance with applicable sterility standards. Bacterial growth was not detected in any of the MFT samples produced by isolator operators during the study (total n = 360). In one instance, an MFT sample prepared using a closed-system transfer device was found to be contaminated due to improper cleaning of the medication vial, highlighting the importance of strict adherence to proper decontamination procedures.

CONCLUSION

A hospital's practices for preparation of sterile products according to applicable good manufacturing guidelines, as well as emergency procedures for cytotoxic drug preparation outside isolators, were validated by the results of an MFT study.