American Society of Health System Pharmacists. ASHP guidelines on compounding sterile preparations

Parenteral nutrition compatibility and stability: Practical considerations

Parenteral nutrition (PN) is a complex preparation that contains multiple component products with the associated risk for incompatibilities and diminished stabilities when combined together as an admixture. Significant patient harm can result from prescribing, preparing, and administering PN without confirming compatibility and stability. Incompatibility or instability is rarely obvious to the unaided eye, so safe PN admixture relies on incorporating physicochemical properties of the included components into compatibility and stability decisions. Practices include applying active ingredient concentration limits to reduce risk for incompatibilities and instabilities. The purpose of the current article is to distill the wide-ranging information on PN compatibility and stability into a feasible blueprint that individual healthcare organizations can then use to design and implement practical initiatives. Compatibility and stability considerations can be incorporated into the routine tasks of PN prescribing, order reviewing, preparing, and administering. The focus of this review is on identifying potential physicochemical interactions that can be addressed at each step in the PN use process. Organizations should incorporate compatibility and stability considerations into the routine procedures and practices of all clinicians involved with PN therapy. Those clinicians in healthcare organizations and caregivers in the home should then be in a position to safely provide the appropriate PN admixtures in terms of compatibility and stability.

Benefits and Risks of Preprepared Parenteral Nutrition for Early Amino Acid Administration in Premature Infants with Very Low Birth Weight

Purpose

Administering early parenteral amino acids to very low birth weight (VLBW) premature infants (birth body weight [BBW]<1,500 g) is challenging due to factors such as holidays, cost, and access to sterile compounding facilities. Using advance-prepared parenteral nutrition (PN) may address this issue and should be evaluated for its safety and potential benefits.

Methods

We extracted data from medical records collected between July 2015 and August 2019. VLBW infants received PN for at least seven days and were split into two groups: the traditional group (n=30), which initially received a glucose solution and then PN on workdays, and the pre-preparation group (n=16), which received advance-prepared PN immediately upon admission to the neonatal intensive care unit.

Results

The median BBWs of the traditional and pre-preparation groups were 1,180.0 vs. 1,210.0 g. In the initial two days, the pre-preparation group had a significantly higher amino acid intake (2.23 and 2.24 g/kg/d) than the traditional group (0 and 1.78 g/kg/d). The pre-preparation group exhibited greater head circumference growth ratio relative to birth (7th day: 1.21% vs. -3.57%, p=0.014; 21st day: 7.71% vs. 3.31%, p=0.017). No significant differences in metabolic tolerance were observed.

Conclusion

Advanced preparation of PN can be safely implemented in VLBW preterm infants, offering advantages such as early, higher amino acid intake and improved head circumference growth within the first 21 days post-birth. This strategy may serve as a viable alternative in settings where immediate provision of sterile compounding facilities is challenging.

Development and Implementation of an Ultraviolet-Dye-Based Qualification Procedure for Hand Washing and Disinfection to Improve Quality Assurance of Pharmacy Preparations and Compounding, Especially in Cleanrooms: A Pilot Study

Even though, nowadays, most medicines are manufactured industrially, patients may have medical needs that can only be met by a tailor-made approach. This requires the availability of pharmacy preparations made under Good Manufacturing Practice (GMP) conditions. An efficient hand hygiene practice is essential herewith, especially if sterile products that are prepared in a cleanroom are concerned. The effectiveness of hand washing and hand disinfection procedures greatly relies on adequate training. We carried out an observational cross-sectional pilot study aimed at optimizing hand hygiene training with objective and measurable quality assessments using an ultraviolet (UV) dye. Practical acceptance criteria for qualifying personnel through this method were set and evaluated. In total, 25 GMP-qualified cleanroom operators washed and disinfected their hands with UV dye hand wash lotion and UV dye hand alcohol, respectively. To obtain a proof-of-concept, the results were judged based on adherence to the WHO six-step protocol and associated acceptance criteria. Commonly missed areas were brought to light, and the influence of procedure duration was investigated. UV-dye-based assessments appeared to be more valuable in hand disinfection than in hand washing. In both procedures, the back of the hands and the thumbs were frequently missed. This underpins the need for enhanced and repeated education on hand washing and disinfection. Additionally, a dry skin gave rise to extra cleaning challenges. From this pharmacy practice pilot study with a focus on pharmaceutical product care, it may be concluded that the application of UV-dye-based assessments offers valuable insights for pharmacists to optimize hand hygiene, thereby increasing the safety of tailor-made medicines and on-site preparations.

Intelligent supervision of PIVAS drug dispensing based on image recognition technology

Pharmacy Intravenous Admixture Services (PIVAS) are places dedicated to the centralized dispensing of intravenous drugs, usually managed and operated by professional pharmacists and pharmacy technicians, and are an integral part of modern healthcare. However, the workflow of PIVAS has some problems, such as low efficiency and error-prone. This study aims to improve the efficiency of drug dispensing, reduce the rate of manual misjudgment, and minimize drug errors by conducting an in-depth study of the entire workflow of PIVAS and applying image recognition technology to the drug checking and dispensing process. Firstly, through experimental comparison, a target detection model suitable for drug category recognition is selected in the drug-checking process of PIVAS, and it is improved to improve the recognition accuracy and speed of intravenous drug categories. Secondly, a corner detection model for drug dosage recognition was studied in the drug dispensing stage to further increase drug dispensing accuracy. Then the PIVAS drug category recognition system and PIVAS drug dosage recognition system were designed and implemented.

Quality assurance standards and their use in the preparation of parenteral systemic anticancer therapy products in healthcare establishments: a scoping review

OBJECTIVES

The use of parenteral systemic anticancer therapy (SACT) has led to improved cancer survival. A quality assurance (QA) system of the aseptic compounding process is necessary to ensure safe and consistent production of parenteral SACT. This scoping review identifies international evidence and practice relating to QA standards in the preparation of parenteral SACT in healthcare establishments.

METHODS

Standards relating to aseptic compounding in hospital pharmacies and literature exploring the aseptic compounding of parenteral SACT were included. Literature relating to the non-aseptic compounding of medicines and records specific to sterile manufacturing in industrial settings were excluded. A search of several electronic databases, trial registries, the grey literature and websites of key European hospital pharmacy groups and accreditation bodies was conducted on 16 March 2022. A narrative discussion was performed by country, and content analysis of articles was conducted.

RESULTS

Thirty-seven records were included. Standards reviewed covered the work environment, the preparation process and the safety of the workers who are potentially exposed to hazardous chemicals. It was a common practice to include frequent audits to ensure adherence to standards. Some standards also recommended external inspections to allow for further learnings. Periodic reviews are encouraged to ensure standards maintain relevance. National standards of the countries reviewed were based on international standards, with minor adaptations for local conditions.

CONCLUSIONS

The main limitation of this review is that it is limited to countries with a high human development index. The review shows that the use of an internationally recognised standard as a basis for national standards is best practice, and will allow for relevance into the future.

Drug compatibility with various closed intravenous infusion containers

Objective: The aim was to systematically compare the drug compatibility with various closed intravenous (i.v.) infusion containers, to provide a reference for selecting a relatively superior infusion container and improve the medication safety for patients in clinical practice. Methods: The compatibility of four commonly used clinical injections (ceftazidime, pantoprazole sodium, ambroxol hydrochloride, edaravone) with three representative closed i. v. infusion containers (non-PVC infusion bags, upright polypropylene infusion bags, inner sealed polypropylene infusion bags) prefilled with infusion fluids (0.9% sodium chloride or 5% dextrose) in the Chinese market were investigated in this study. The particle counts of both infusion fluids and diluted chemical injections by infusion fluids in various infusion containers were determined by the light obscuration method. At 0, 2 and 6 h after four injections following dilution with infusion fluids in each container, the pH of the solutions was detected, and the physical properties were examined by visual inspection. Meanwhile, the drug concentrations were assessed by high performance liquid chromatography (HPLC). Results: As for either infusion fluids or diluted injections by infusion fluids, the particle counts in non-PVC infusion bags were significantly greater than those in the other two bags under some circumstances. The particle counts in diluted injections by infusion fluids increased dramatically compared with those in infusion fluids in all infusion containers, especially for the small-size particles. But pH, physical properties and drug concentrations of diluted infusion solutions in all infusion containers remained nearly unchanged over the test period. Conclusion: Closed i. v. infusion containers included in this study are all well-compatible with four injections. Moreover, the closed infusion containers produced by Chinese manufacturers have met the international quality standard. Particularly, the intravenous admixture preparation process needs to be optimized to reduce the overall particulate contaminants.

Glass particulate adulterated in single dose ampoules: A patient safety concern

AIMS AND OBJECTIVES

To determine the amount, size and characteristics of glass particulate contamination inside single-dose ampoules.

BACKGROUND

Glass particulate contamination in an ampoule when opened can cause adverse effects on critically ill patients.

DESIGN

Crossectional descriptive study.

METHODS

Eight hundred 10-ml sterile water ampoules were inspected for glass particulate contamination upon opening. Ampoules were opened by nurses following their usual practices. Glass particulates were inspected by stereomicroscope. Further examination was conducted using a scanning electron microscope (SEM) to determine the size and amount of the particulates in the 20 positive and 20 negative samples from stereomicroscope inspection. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for preparing this manuscript.

RESULTS

Seven hundred and ninety-eight ampoules were inspected, as 2 ampoules were broken. Glass particulates were detected in 65% of the ampoules (519/798). The size of glass particulates from 20 positive and 20 negative samples, ranged from 8 to 172 microns and 8 to 102 microns, respectively. The glass particulates were detected most at sized ≤ 50 microns in both positive and negative samples with the mean number of 47.8 ± 20.4 and 27.8 ± 21.8 particulates, respectively.

CONCLUSION

Glass particulate contamination occurred while opening medication in glass ampoules. A safety tool is needed to prevent glass particulates from contaminating injection treatments.

RELEVANCE TO CLINICAL PRACTICE

Many critically ill patients and neonates need intravenous injections for treatment. Almost all medication solutions are stored in glass ampoules. Nursing personnel should be aware while drawing medication solutions from glass ampoules. Using filtered needles and leaning the ampoules can help reduce the number of glass particulates that pass into the solutions being drawn into the syringes.

Evaluation of subvisible particles in human immunoglobulin and lipid nanoparticles repackaged from a multi-dose vial using plastic syringes

The multi-dose vial (MDV) is widely used for most biopharmaceuticals that are repackaged in plastic syringes before use. However, subvisible particle formation with the use of plastic syringes containing silicone oil (SO syringes) for handling therapeutic proteins can be problematic. This study aimed to evaluate the extent of and trends in microparticle (>1 μm) formation and accumulation in repackaged syringes from MDVs containing human immunoglobulin (IgG) and lipid nanoparticles (LNPs). Light obscuration (LO) and flow imaging (FI) were used to analyze the microparticles. The number of microparticles observed with the use SO syringes was greater than that with SO-free syringes, and the number of microparticles continuously increased as did the number of times of repackaging in syringes for both drugs. However, a large variation was observed across different brands of SO syringes. In contrast, using a different technique of drug withdrawal from the vial significantly reduced the number of microparticles. Furthermore, the use of filter-integrated needles or the inclusion of stabilizers such as acetyl-arginine and Tween 20 into the formulation also helped reduce particle formation.

Leakage Dynamics of Glass Bottles on Container Closure Integrity Testing: Influence of Different Laser-Drilled Microhole Geometries

Container closure integrity testing (CCIT) is a critical step in ensuring package integrity and providing feedback on package designs. In practical applications, CCIT methods, namely physical and probabilistic methods, must be appropriately selected and validated to ensure their suitability for the intended use. However, the industry still lacks practical recommendations regarding the choice of CCIT methods and artificial leaks to set the acceptance criteria. The main reason is the lack of correlation between testing methods. Artificially introduced leak microholes are the only way to determine the sensitivity of a CCIT method and to implement the method correlation. However, the type of artificial leakage is a key factor because in most studies, leakage is described and valued using a single parameter, such as size. This can significantly affect the credibility of the relevant test results, especially in the case of microbial invasion, where the difference in test conditions and samples will severely affect the probability of microbial invasion. Therefore, it is vital to conduct a systematic study on the influence of leakage conditions on CCIT methods. In this study, the influence of the shapes of artificial leaks on the two kinds of testing methods was systematically studied based on a laser-drilled microhole-a highly potential and non-exogenous artificial leak manufacturing method that can fabricate different leakage geometries. The reason for the influence of the shape of an artificial leak on the CCIT is that the deterministic method takes defects as an idealized model and ignores the influence of the leak shape, wall thickness, and other factors on leakage and pollution risks. However, these factors seriously affect the dynamic process of leakage and microbial invasion. The pressure decay method is used to test the leakage flow rate of conical and straight holes. Microbial challenge tests are then used to verify the impact of leakage shapes on the pollution risk. The results of the tests indicated that the probability of microbial invasion in the conical holes is much higher than that in straight holes with the same flow test results and that the wall thickness can also affect microbial invasion. Thus, it can be proven that the risk of leakage and invasion or the sensitivity of different methods cannot only be compared through the leak diameter. Numerous influencing factors, including leakage geometry (e.g., shape and thickness), must be considered in practical applications.

Application of information-intelligence technologies in pharmacy intravenous admixture services in a Chinese third-class a hospital

Background

Pharmacy intravenous admixture service (PIVAS) center has emerged as an important department of hospital as it can improve occupational protection and ensure the safety and effectiveness of intravenous infusions. However, medication errors were considered to be a significant challenge in PIVAS, so information-intelligence technologies were introduced to optimize the management of PIVAS. Our article summarized the application of information-intelligence technologies in PIVAS of a large third-class A hospital in China, and provided an example for PIVAS in other hospitals at home and abroad.

Methods

Prescription-reviewing rules containing intravenous medications and infusion solution guideline were recorded in the database of prescription-cheking system. Drugs information were recorded in the PIVAS management system with special identification and warning labels to reduce intravenous infusion errors. Automatic labeling device was used to label the infusion bags, and the quality control program database of intelligent compounding robot for cytotoxic drugs was established ingeniously. Automatic sorting devices were applied for the third batch of finished infusion admixtures, and intelligent logistics robots were used to transport the infusion to the ward.

Results

After establishing and implementing of prescription-reviewing rules in the prescription-cheking system database, the number of prescriptions checked by pharmacists increased from 18 to 43 per minute. The success rate of intervention with irrational medical orders increased from 85.89% to 99.06% (P < 0.05). By introducing various intelligent devices, automatic labeling significantly enhanced work efficiency and reduced the error rate (P < 0.001). Furthermore, the use of intelligent intravenous compounding robots significantly reduced the risk of errors (P < 0.001).

Conclusions

The application of information-intelligence technologies in PIVAS can improve work efficiency and reduce error risk. However, some intelligent devices have failed to achieve the expected effect in practical use, and further improvements are needed to meet the demands of PIVAS in the future.

A quality by design approach for the qualification of automating compounding device for parenteral nutrition

Automated compounding device (ACD) are increasingly used for parenteral nutrition (PN) bag production, and their acquisition must be sufficiently thought. The law requires the qualification of these ACD, but did not specify the tests to be performed. The quality by design (QbD) risk based approach allowed to define the quality target product profile in order to acquire the best ACD for each unit, and thanks a risk analysis permitted to define the critical quality attributes (CQA). These CQA will allowed to define tests performed during qualification. The ACD qualified was a 12 pump volumetric system. The CQA for PN bags consisted in sterile, precisely and accurately production with enough stability. During operational qualification volumetric accuracy test was performed, and during the performance qualification: flush volume, media fill, microbiological integrity of environment, sterility of control bag and production test were performed. At the end, all tests were conclusive (excepted for some results mostly due to analytical bias) and the ACD was considered to produce sterile bags in a control environment, precisely (relative standard deviation < 4%) and accurately (mean bias < 1% for weight and < 7% for other controls) with a sufficient stability. The QbD risk based approach allowed to acquire the best ACD for our need, and qualify relevant elements regarding the production process.

Stability of extemporaneously prepared preservative-free methylphenidate 5 mg/mL intravenous solution

DISCLAIMER

In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To advance the implementation of consciousness-promoting therapies in patients with acute disorders of consciousness, the availability of potential therapeutic agents in formulations suitable for administration in hospitalized patients in the presence of complex comorbid conditions is paramount. The purpose of this study is to evaluate the long-term stability of extemporaneously prepared preservative-free methylphenidate hydrochloride (HCl) 5 mg/mL intravenous solution for experimental use.

METHODS

A methylphenidate 5 mg/mL solution was prepared under proper aseptic techniques with Methylphenidate Hydrochloride, USP, powder mixed in sterile water for solution. Methylphenidate HCl 5 mg/mL solution was sterilized by filtration technique under USP <797>-compliant conditions. Samples were stored refrigerated (2-8°C) and analyzed at approximately days 1, 30, 60, 90, 180, and 365. At each time point, chemical and physical stability were evaluated by visual inspection, pH measurement, membrane filtration procedure, turbidometric or photometric technique, and high-performance liquid chromatography analysis.

RESULTS

Over the 1-year study period, the samples retained 96.76% to 102.04% of the initial methylphenidate concentration. There was no significant change in the visual appearance, pH level, or particulate matter during the study period. The sterility of samples was maintained and endotoxin levels were undetectable throughout the 1-year stability period.

CONCLUSION

Extemporaneously prepared preservative-free methylphenidate 5 mg/mL intravenous solution was physically and chemically stable at 32, 61, 95, 186, and 365 days when stored in amber glass vials at refrigerated temperatures (2-8°C).

The suitability of a glovebox and of a covered still air box design for semi-sterile applications in environmental monitoring

Laminar flow cabinets (LFCs) ensure a safe working space within which product manipulation can be carried out safely excluding contaminations of the product with the environmental microorganisms. However, for environmental monitoring applications mobile laboratories are required and these prefer the lighter gloveboxes (GB; restricted arm movement) or still air boxes (SAB; free arm movement) over the heavier, more expensive LFCs, which need to be regularly maintained. Nevertheless, the efficiency of simple GBs/SABs (no HEPA filter), in providing semi-sterile working conditions has yet to be clearly defined. Consequently, our aim was to assess the suitability of GBs/SABs for semi-sterile applications by using passive and active bioaerosol sample collection procedures within the interior spaces of these boxes. Prior to sample collection the boxes were pre-treated with different spraying preparations (70% ethanol, 2% detergent or sterile water). For a greater restriction of bioaerosol entry, SABs were constructed with covered arm ports and these were classified as partially covered (SAB_PC) and completely covered SABs (SAB_CC). Results showed that ethanol sprayed GB and SAB_CC exhibited microbial aerosol colony counts of zero after one hour of passive sample collection, and active sample collection revealed counts ranging between 1.9 (for GB) - 2.3 Log₁₀CFU/m³ (for SAB_CC). However, ethanol sprayed SAB and SAB_PC were ineffective having colony counts of 6.9 and 6.5 Log₁₀CFU/m³, respectively. Other spraying regimes resulted in even higher colony counts (up to 7.3 Log₁₀CFU/m³). Therefore, the ethanol sprayed GB and SAB_CC could effectively be used for semi-sterile applications, with the SAB_CC allowing for an unrestricted arm movement within it.

Parenteral Nutrition Process Management for Newborn and Preterm Infants - A Preliminary Risk Analysis

BACKGROUND

There are variable practices in the management of the parenteral nutrition (PN) process in hospitals having a neonatal intensive care unit (NICU). In our hospital, PN is prepared partially on the neonatal ward by nurses but also at the central pharmacy by trained pharmacy technicians. A previous study showed a concentration non-conformity of 34% of on-ward PN preparations potentially resulting in under- or overfeeding of the patients.

OBJECTIVE

The objectives were to perform preliminary risk analyses (PRA) in preparation for our hospital's transition to universal central pharmacy PN compounding.

METHODS

A working group including pharmacists, neonatologists, nurses, and pharmacy technicians performed two PRA. The risks of 9 management steps of the PN process were identified, evaluated, and quoted. A comparison of the number of risks and their criticality index (CI) was conducted.

RESULTS

A total of 36 and 39 risks were identified for PN preparation in the NICU and the pharmacy, respectively. For the NICU, ten risks (28%) had an "acceptable" CI, 15 risks (42%) were "under control" and eleven (31%) were defined as "non-acceptable". For the pharmacy, 14 risks (36%) had an "acceptable" CI, 19 risks (49%) were "under control" and six (15%) were defined as "non-acceptable". Risks directly related to the preparation process, including the steps preparation hood, PN preparation and analytical quality control, represented a cumulated CI of 145 for eleven NICU-risks vs 108 for twelve pharmacy risks (-26%). The implementation of immediate improvement measures, eg, an electronic prescription form, reduces the total CI by 5.7% and 2.2% for the NICU and the pharmacy, respectively.

CONCLUSION

This PRA highlighted the safety differences between PN preparation in the NICU vs the pharmacy at our institution, and facilitated our moving forward with a process change that should improve the care of our neonatal patients. Nevertheless, long-term improvement measures have to be implemented to further reduce risks related to the PN management process.

The impact of pharmacist oriented mode on risk control in a Chinese centralized intravenous admixture service centre

Centralized intravenous admixture service (CIVAS) centres, which are pharmaceutical departments found in Chinese hospitals, provide high-quality intravenous fluids and pharmaceutical services for patients, and errors in their working procedures can lead to adverse consequences. Pharmacists, the primary CIVAS centre personnel, play a role in risk control; however, to date, the effect of pharmacists' participation in risk management has not been reported. The main aim of this study was to evaluate the pharmacist's role in risk control and evaluate its impact. A retrospective observational study was designed to assess the principal working process in the CIVAS centre of a provincial healthcare setting. Errors in the main working process were identified, and intervention measures were formulated. The pharmacist intervention effect was evaluated by assessing the identification rate of improper prescriptions; the incidence rate of drug preparation, compounding, packaging and delivery process errors; and expenditures on wasteful drugs. There was a higher identification rate for improper prescriptions after the intervention (P < 0.05), while the incidence of drug preparation (P < 0.05), admixture (P < 0.05), and packaging and delivery errors (P < 0.01) was significantly lower; the total wasteful medication expenditure was also dramatically reduced. The potential creativity of pharmacists in error control can provide dependable intravenous drugs for patients and reduce the running expenditures for CIVAS.

Sterile Compounding Knowledge, Skills, and Confidence Among Graduating Doctor of Pharmacy Students

Objective. To determine whether the exposure to sterile compounding in the pharmacy curriculum produces Doctor of Pharmacy graduates who are both competent and confident in the area of sterile compounding, and to identify additional variables that may predict student performance.Methods. Participants were recruited from the fourth-year pharmacy class of 2018 at one university. The students were asked to complete a questionnaire assessing the following domains: demographics, confidence in compounding performance, prior experience, and theoretical knowledge. A written assessment was followed by a faculty-evaluated practicum in which the students were required to prepare two sterile products using a standardized rubric. Results were analyzed with a Student t test and linear regression to determine differences in performance based upon prior experience, confidence, and theoretical knowledge.Results. Overall, the 158 students performed well on the knowledge and skill examination, achieving an average total score of 89.8%. Of the 158 total participants, the 122 survey respondents had an overall mean confidence score of 2.9 on a four-point Likert scale, with 40.2% of students scoring in the confident or very confident range of the survey. In our analysis, we found that neither prior compounding experience or self-rated confidence were predictive of students' total score.Conclusion. The results of this study suggest that the inclusion of sterile compounding education and training in all four years of the pharmacy curriculum produces PharmD graduates who are competent, with varying levels of confidence in the area of sterile compounding.

Designing a microbiological monitoring program for compounding facilities

PURPOSE

We describe the evolution of a large multicenter health system's microbiological monitoring program to improve standardization of viable sample collection practices; results review, interpretation, and response; and record keeping. We also describe lessons learned and considerations for other organizations considering microbiological monitoring program enhancements.

SUMMARY

Developing a robust microbiological monitoring program requires policy and procedure development; training and education of staff involved in viable sample collection, results interpretation, and investigations; establishing a robust sampling plan; reviewing trend data; reviewing systems data; and conducting investigations. Well-defined policies and procedures ensure consistent response to "out of level" (ie, violative) sampling results. Staff education ensures staff involved in microbiological monitoring are educated on adequate sampling techniques and microbial contamination sources and mitigation strategies. Thorough record keeping is essential for microbiological monitoring sampling activities and ongoing systems monitoring. The records should include results, investigations, assessments, recommendations, and records of completed follow-up actions.

CONCLUSION

Facilities management requires a comprehensive microbiological monitoring and systems monitoring plan. In health systems with multiple sites, a centralized oversight and management program may be beneficial to standardize records, response planning, and overall control of controlled compounding environments.

Prediction of the permeability of antineoplastic agents through nitrile medical gloves by zone classification based on their physicochemical properties

BACKGROUND

Permeability of antineoplastic agents through medical gloves is an important factor that must be considered for the appropriate selection of gloves. However, predicting the permeability of antineoplastic agents through medical gloves based on their physicochemical properties remains difficult. Thus, this study aimed to elucidate the relationship between the physicochemical properties and permeability of antineoplastic agents through medical gloves. Additionally, we tried to predict the risk of permeation of antineoplastic agents through medical gloves based on physicochemical parameters.

METHODS

Ten antineoplastic agents (carboplatin, carmustine, cisplatin, cyclophosphamide, doxorubicin, etoposide, fluorouracil, ifosfamide, oxaliplatin, and paclitaxel) with varying physicochemical properties were investigated, and their permeation rates (PRs) through nitrile medical gloves of varying thicknesses (0.05, 0.07, and 0.1 mm) were measured using a continuous flow in-line cell device. We also determined the apparent permeation clearance (CL_P,app) values of the antineoplastic agents based on their PRs at 240 min (PR₂₄₀) and assessed the relationship between CL_P,app and physicochemical parameters [molecular weight (MW) and logarithm of octanol-water partition coefficient (LogP)].

RESULTS

The CL_P,app values of the 10 antineoplastic agents through nitrile medical gloves (0.05 mm thickness) were significantly correlated with their MWs, but not their LogP values (P = 0.026 and 0.39, respectively; Spearman's rank correlation). This finding indicated that the rates of diffusion of the antineoplastic agents in the glove material showed greater effects on CL_P,app than the rates of absorption into the glove surfaces within 240 min of exposure. We then classified the 10 antineoplastic agents into 3 zones (Zone A, high LogP/low MW drugs; Zone B, high LogP/high MW drugs; and Zone C, low LogP) and found that Zones A, B, and C corresponded to high (PR₂₄₀ > 10 ng/min/cm²), moderate (PR₂₄₀ < 10 ng/min/cm²), and low (no detectable permeation) permeation risk, respectively.

CONCLUSIONS

The permeation risk of antineoplastic agents through nitrile medical gloves within the actual continuous wearing time in clinical settings could be predicted using MW and LogP values. We believe that the proposed zone classification of antineoplastic agents will be a useful tool for predicting the permeation risk of antineoplastic agents through medical gloves.

Assessment and Optimization of the Pediatric Parenteral Nutrition Preparation Process in a Hospital Pharmacy

BACKGROUND

Parenteral nutrition (PN) is associated with risks that could threaten the clinical condition of premature neonates hospitalized in the neonatal intensive care unit. In this work, risk-analysis methodology was implemented to contain the risks associated with the PN production process and improve PN safety.

METHODS

The Failure Modes, Effects, and Criticality Analysis was performed by a multidisciplinary team. All potential failure modes of the PN preparation process were recorded, and associated risks were scored based on their severity, occurrence, and detectability, with a risk priority number (RPN). All identified failure scenarios and the respective work stages were ranked in descending order of criticality. Corrective actions were proposed to address critical points, and the safety of the process was reassessed by the same method in a prospective manner.

RESULTS

The highest RPN scores were obtained with the PN composition calculation performed manually (RPN: 530) or electronically (RPN: 478), completion of the PN medical order form (RPN: 354), manual compounding of PN admixtures (RPN: 258), and the structure/organization/maintenance of the PN preparation unit (RPN: 133). The quality and safety of PN admixtures could be compromised by many critical factors, such as the increased particle-microbial load in the unit and the inadequate training/experience of the involved health professionals and their incompliance with the given instructions. The implementation of the proposed corrective measures is expected to reduce the risks of the overall PN production process by 67.5%.

CONCLUSIONS

Improvement of the PN production process through risk-analysis methodologies enhances safety for premature neonates.

Construction situation, costs and charges associated with pharmacy intravenous admixture services: multi-center cross-sectional survey based on 137 medical institutions in mainland China

Background

To investigate the construction situation, costs and charges associated with pharmacy intravenous admixture services (PIVAS) to provide references for the construction and development of PIVAS in mainland China.

Methods

A multi-center cross-sectional survey was conducted via a WeChat Group targeting PIVAS leaders in hospitals to investigate the basic situation of PIVAS, including opening time, area, number of PIVAS, equipment, management mode, PIVAS costs and charges, as well as numbers of beds, open wards, and staff, and analyze differences in PIVAS construction at different provincial and hospital levels.

Results

137 questionnaires were collected from 29 provinces, representing a response rate of 99.3%. Most participants (88.4%) were from Level III Hospitals. The number of years of operations of PIVAS ranged from 1 to 22 (median: 6). PIVAS site area ranged between 100 and 1973 m²; daily average infusion volume was concentrated in the ranges 0–1000 bags (29.9%, 41/137) and 1001–2000 bags (26.3%, 36/137). In terms of PIVAS management mode, the vast majority used separate pharmacy management (65.0%, 89/137). Only 52.6% (72/137) of PIVAS have standardized charges, and 70.1% (96/137) operate at a loss. The median costs of mixed tumor chemotherapy drugs, total parenteral nutrition, general medicine, antibiotics were 20, 35, 4 and 5 RMB, respectively. With the exception of a few features, PIVAS construction does not obviously differ among different regions and hospital levels.

Conclusions

In recent years, PIVAS in China has developed rapidly and become relatively large. The main problems are that most provinces lack standards for charges and PIVAS construction differs among hospitals. Therefore, standards for PIVAS construction and charges should be developed to provide a reference for the future development of PIVAS.

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.

Development and Implementation of a Standardized Sterile Compounding Training Program

Purpose: The purpose of the study is to develop and implement a standardized sterile compounding training program in a multihospital system that incorporates sterile compounding best practice recommendations and ensures compliance with United States Pharmacopeia (USP) Chapters 797 and 800 standards. Methods: Baseline sterile compounding training data were collected and reviewed for sterile compounding facilities across a multihospital health system, which included 37 distinct sterile compounding operations. Current sterile compounding personnel across the system completed preintervention assessments consisting of a written, knowledge-based exam; media-fill challenge test; and an observed assessment of aseptic technique. The personnel then completed refresher training of sterile compounding concepts by completing online and in-person courses. A postintervention assessment was then conducted to evaluate training methods and topics. Based on the intervention data, a training program for new sterile compounding personnel was developed and implemented. A program to provide annual, ongoing training to existing sterile compounding personnel was also developed and implemented. Results: There was a statistically significant improvement in sterile compounding written exam scores (P < .0001) and aseptic technique observation scores (P < .0001) after implementation of refresher training. The validated training program was then included in the development and implementation of standardized training for all new and existing sterile compounding personnel across a multihospital health system. Conclusion: A standardized and consistent, sterile compounding training program was developed for all new and existing sterile compounding personnel incorporating a live, in-person training course, as well as online and hands-on training.

Chinese centralised intravenous admixture service (CIVAS), an emerging pharmaceutical industry: survey of the recent advances of CIVAS in China

Purpose

To present the results of a survey involving 97 centralised intravenous admixture service (CIVAS) centres in China to review the recent advances of Chinese CIVAS.

Methods

103 CIVAS centres in first- or second-class Chinese hospital settings were surveyed by email questionnaire.

Results

Ninety-seven centres responded(response rate 94%). With regard to scale and output issues, large CIVAS centres with a daily output of more than 10 000 bags accounted for 10% while the per workbench and per square metre output varied dramatically among different centres. For personnel structure, 80% of CIVAS centres chose the combination model of pharmacy and nursing. For the CIVAS operation model, more than 80% of centres adopted the drug centralised compounding model.

Conclusion

CIVAS centres are playing an important role in Chinese hospital pharmacy and have developed into an emerging pharmaceutical industry. The development of Chinese CIVAS centres is very variable. With regard to the personnel structure, the pharmacy-nursing combination model is recommended, while the operation model should be selected according to specific hospitals. Universal guidelines for CIVAS operation and personnel training are urgently needed.

A Collaborative Initiative for Reducing Operating Room Waste of Unused Refrigerated Medication

BACKGROUND

Inappropriate management of anesthetic medications requiring refrigeration creates waste and increases costs of intraoperative care. At Tampa General Hospital, pharmacy personnel refill medications in cardiovascular operating rooms (CVOR) nightly and noticed large amounts of unattended medications at room temperature for unknown periods of time. Per protocol, these medications were disposed.

OBJECTIVE

To effectively decrease pharmaceutical waste in the CVOR.

METHODS

A pharmacy-led anesthesia committee identified the most used intraoperative medications requiring refrigeration and implemented changes to decrease waste. As a result, norepinephrine intravenous piggyback (IVPB), norepinephrine vials, nitroglycerin vials, and epinephrine IVPB were physically relocated into preexisting mini-refrigerators inside each CVOR. Vasopressin vials and phenylephrine syringes/vials were relocated into automated anesthesia cabinets. Amounts and cost of wasted medication were analyzed before and after protocol implementation.

RESULTS

Average weekly cost of wasted medication was significantly reduced (preintervention: US$1188.59 vs postintervention: US$322.96; P < .001), despite a consistent caseload.

CONCLUSION

Recorded weekly savings of US$865.63 (∼annual savings of >US$45 000) reflect only the explicit cost of waste. True savings are higher when including opportunity costs such as salary of pharmacy personnel and supplies needed to replace wasted medications. We demonstrate the benefits of a collaborative approach to improving inefficiencies in health care.

Cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures

PURPOSE

A cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures was evaluated.

SUMMARY

A medication-use evaluation at a 454-bed tertiary medical center revealed that the cardiac catheterization laboratory was the highest user of isoproterenol. Isoproterenol was removed from all AcuDose-Rx machines Omnicell, Mountain View, CA, and compounding was performed by pharmacy personnel. It was initially provided to the cardiac catheterization laboratory as an 8-µg/mL concentration in 20-mL 0.9% sodium chloride injection syringes with a 24-hour beyond-use date. This resulted in an initial cost savings but with an unacceptably high rate of wastage. Isoproterenol was then compounded as a 4-µg/mL concentration in 30 mL 5% dextrose in water syringes with a 9-day beyond-use date after a thorough literature search supported longer stability with this admixture. After 12 months of our current process, isoproterenol use during radio frequency catheter ablations (RFCAs) in the cardiac catheterization laboratory was reduced by 85%, decreasing the number of ampules used from 11.15 to 1.66 per week.

CONCLUSION

A pharmacy-initiated process to mitigate an extraordinary increase in isoproterenol acquisition cost resulted in a reduction in usage in a tertiary care community hospital. Isoproterenol usage was reduced 85% after two different interventions were implemented, which is estimated to save $1,839 per procedure.

A systematic review of epinephrine stability and sterility with storage in a syringe

Background

Epinephrine is a lifesaving medication in the treatment of anaphylaxis. Epinephrine auto-injectors are the preferred method of epinephrine administration, but are not universally available or affordable. Little is known about the effects on epinephrine when it is drawn up in advance and stored as prefilled syringes.

Objective

To study the stability and sterility of epinephrine when stored in syringes.

Methods

We searched Embase, Medline, and Web of Science in June 2016 for all studies of epinephrine stored in syringes in concentrations between 0.1 and 1 mg/mL that measured epinephrine stability and/or sterility over time, regardless of date published or language.

Results

Three studies were included, one testing two concentrations of epinephrine. Only one study tested epinephrine 1 mg/mL, the concentration clinically relevant for intramuscular use during anaphylaxis. Neither this study nor the one study testing 0.7 mg/mL epinephrine found significant degradation after 56 and 90 days, respectively. One of the two studies testing epinephrine at a concentration of 0.1 mg/mL found significant degradation by 14 days; the other found no degradation up to 168 days. Two studies tested for bacterial growth, with none detected after 28 and 90 days, respectively. One study tested for fungal growth, with none detected after 90 days.

Conclusions

Limited evidence suggests that syringes filled with 1 mg/mL epinephrine are stable and sterile for 90 days. More research is needed testing the duration of stability and sterility of prefilled syringes with the 1 mg/mL concentration most commonly used in anaphylaxis, testing more extensively in different storage conditions and across a wider range of marketed syringe brands.

Guidelines for safe handling of hazardous drugs: A systematic review

Objective

To review the scientific literature related to the safe handling of hazardous drugs (HDs).

Method

Critical analysis of works retrieved from MEDLINE, the Cochrane Library, Scopus, CINHAL, Web of Science and LILACS using the terms "Hazardous Substances", "Antineoplastic Agents" and "Cytostatic Agents", applying "Humans" and "Guidelines" as filters. Date of search: January 2017.

Results

In total, 1100 references were retrieved, and from those, 61 documents were selected based on the inclusion and exclusion criteria: 24 (39.3%) documents related to recommendations about HDs; 27 (44.3%) about antineoplastic agents, and 10 (33.3%) about other types of substances (monoclonal antibodies, gene medicine and other chemical and biological agents). In 14 (23.3%) guides, all the stages in the manipulation process involving a risk due to exposure were considered. Only one guide addressed all stages of the handling process of HDs (including stages with and without the risk of exposure). The most described stages were drug preparation (41 guides, 67.2%), staff training and/or patient education (38 guides, 62.3%), and administration (37 guides, 60.7%). No standardized informatics system was found that ensured quality management, traceability and minimization of the risks associated with these drugs.

Conclusions

Most of the analysed guidelines limit their recommendations to the manipulation of antineoplastics. The most frequently described activities were preparation, training, and administration. It would be convenient to apply ICTs (Information and Communications Technologies) to manage processes involving HDs in a more complete and simpler fashion.

Epinephrine, auto-injectors, and anaphylaxis: Challenges of dose, depth, and device

OBJECTIVE

This review was undertaken to review epinephrine dosing, site and route of administration, focusing on special populations (patients weighing less than 15 kg, and obese patients); and to discuss storage and delivery of epinephrine in prehospital and hospital settings.

DATA SOURCES

Review of published literature.

STUDY SELECTION

Relevance.

RESULTS

The recommended 0.01-mg/kg (maximum 0.3-0.5 mg) epinephrine dose in anaphylaxis is based on limited pharmacokinetic data in healthy volunteers. No pharmacokinetic or pharmacodynamics studies involving patients in anaphylaxis have been published. When epinephrine auto-injectors (EAIs) are used in infants, the dose increasingly exceeds the recommended dose as weight decreases, although the clinical significance of this is unclear. Limited data indicate that the intramuscular route and lateral thigh site are superior. Ultrasound studies suggest that 0.15 EAI needles may be too long for many patients weighing less than 15 kg, and 0.3 mg EAI needles may be too short for obese patients weighing more than 30 kg. A newly available 0.1 mg EAI has a lower dose and shorter needle better suited to patients weighing 7.5 to 15 kg. In some medical settings, vials and syringes may provide a safe, efficient alternative with substantial cost savings over EAIs.

CONCLUSION

EAIs should be available in the community with doses and needle depths that meet the needs of all patients. More research on epinephrine pharmacodynamics are needed in children and adults in anaphylaxis, to better delineate what optimal doses should be. Optimizing epinephrine dose and delivery has the potential to improve anaphylaxis outcomes and prevent adverse events.

Effectiveness of a shielded ultraviolet C air disinfection system in an inpatient pharmacy of a tertiary care children's hospital

Viable air particles pose a risk in areas where sterile preparations are compounded. This study investigated the efficacy of an innovative air purification technology that uses a shielded ultraviolet C light lamp to continuously purify the air in an inpatient pharmacy. Mean airborne fungal and bacterial colony forming units were obtained preinstallation and again in 6 months. A statistically significant decrease of 78% and 62% was observed for fungal and bacterial particles, respectively. This study demonstrates a potential role for this novel technology in decreasing the spread of airborne pathogens.

Acquisition and Retention of Sterile Compounding Accuracy Skills

Objective. To determine the accuracy of dose of pharmacy students' parenteral sterile preparation skills and to measure pharmacy students' skill retention 1.5 years later. Methods. An exercise was designed to assess each student's accuracy in compounding a sterile preparation with the correct potency during a second and then third year course. Results. Initially, the mean (standard deviation) of 141 students' compounded preparation dose was not significantly different than the desired dose. Additionally, 91.5% of products were within 10% of the desired dose. In the follow-up activity the next academic year, the mean dose was not significantly different than the original compounded dose. Similarly 92.9% were within 10% of the desired dose. Conclusion. Students' overall accuracy of sterile compounding was good initially and well-retained more than a year later, with more than 90% of students being within 10% of the desired dose in both courses.

Intravenous medicine preparation technique training programme for nurses in clinical areas

Objective

The key objective of this study was to highlight the weak points in the medicine use process.

Method

We collected 15 videos from eight neonatal intensive care units where staff nurses showed how medicine preparation was performed. Recorded medicines were: vancomycin (6), gentamicin (5), caffeine citrate (2) and phenobarbital (2).

Results

We did not review any video without errors. In 8/15 (53.3%) videos, the same syringe was used to measure the medicine and the diluent. In 8/15 (53.3%) videos, the syringes used were not the correct size for the volume being measured. In 4/15 (26.6%) videos, the volume measured into the syringes was not checked after it was measured from vials or ampoules. In just one vancomycin preparation could the reconstitution process be described as a correct process; in the other five videos, mixing after diluent addition to the vancomycin vial was almost non-existent (less than 10 s). Mixing after the medicine and diluent were in the same syringe was also non-existent in all of the videos.

Conclusions

Hospitals should provide training programmes outlining the correct preparation technique.

Evaluation of the permeation of antineoplastic agents through medical gloves of varying materials and thickness and with varying surface treatments

BACKGROUND

Medical gloves are an important piece of personal protective equipment that prevents exposure to antineoplastic agents. The permeability of medical gloves to antineoplastic agents is a crucial factor in the appropriate selection of gloves. However, the relationship between glove permeability and material type, thickness, and surface treatment is poorly understood.

METHODS

A continuous flow in-line cell device was used for the evaluation of the permeation of five antineoplastic agents (etoposide, cyclophosphamide, doxorubicin hydrochloride, paclitaxel, and fluorouracil) through medical gloves. Medical gloves made of three types of materials (chlorinated latex, non-chlorinated latex, and nitrile) were subjected to a permeability test. The antineoplastic agents in test solutions were tested at the highest concentrations employed in general clinical practice. Then, the relationship between glove thickness and permeability was assessed using chlorinated latex gloves with thicknesses of 0.1, 0.15, 0.2, and 0.1 mm × 2 (to represent the practice of "double gloving").

RESULTS

Only cyclophosphamide and fluorouracil showed detectable permeation through the tested latex gloves. The permeability of chlorinated latex was lower than that of non-chlorinated latex. Nitrile gloves showed no detectable permeability to any of the five antineoplastic agents tested. The permeability of chlorinated latex gloves depended on the thickness of the gloves; 0.1 mm × 2 (double gloving) exhibited the highest resistance to permeation by antineoplastic agents.

CONCLUSIONS

The permeability of medical gloves was dependent on the type of material and the surface treatment and decreased as the thickness of the glove increased. The double glove was shown to prevent antineoplastic agent permeation more efficiently than did a single glove of the same total thickness. These results provided important information that will guide the appropriate selection of medical gloves.

Intrathecal Amphotericin B: A 60-Year Experience in Treating Coccidioidal Meningitis

Coccidioidal meningitis (CM) is a devastating complication of coccidioidomycosis. Since the late 1950s, intrathecal (IT) amphotericin B deoxycholate (AmBd) has been successfully used to treat and often cure this disease, reducing mortality rates from 100% to approximately 30%. The introduction of azoles further revolutionized the treatment of coccidioidal infections. However, IT AmBd remains the only known curative option in the management of CM. While the use of IT AmBd is well described in many articles, few discuss the actual methods behind preparation, titration, and dosing strategies utilized. The practitioners at Kern Medical (Bakersfield, California) have >60 years of experience in the utilization of IT AmBd and the treatment of CM. This article describes the practice experience in the treatment of CM, preparation of IT AmBd, and the different dosing strategies used in regard to route of administration (ie, cisternal, lumbar, ventricular).

Outbreak of Pantoea agglomerans Bloodstream Infections at an Oncology Clinic-Illinois, 2012-2013

OBJECTIVE To determine the source of a healthcare-associated outbreak of Pantoea agglomerans bloodstream infections. DESIGN Epidemiologic investigation of the outbreak. SETTING Oncology clinic (clinic A). METHODS Cases were defined as Pantoea isolation from blood or catheter tip cultures of clinic A patients during July 2012-May 2013. Clinic A medical charts and laboratory records were reviewed; infection prevention practices and the facility's water system were evaluated. Environmental samples were collected for culture. Clinical and environmental P. agglomerans isolates were compared using pulsed-field gel electrophoresis. RESULTS Twelve cases were identified; median (range) age was 65 (41-78) years. All patients had malignant tumors and had received infusions at clinic A. Deficiencies in parenteral medication preparation and handling were identified (eg, placing infusates near sinks with potential for splash-back contamination). Facility inspection revealed substantial dead-end water piping and inadequate chlorine residual in tap water from multiple sinks, including the pharmacy clean room sink. P. agglomerans was isolated from composite surface swabs of 7 sinks and an ice machine; the pharmacy clean room sink isolate was indistinguishable by pulsed-field gel electrophoresis from 7 of 9 available patient isolates. CONCLUSIONS Exposure of locally prepared infusates to a contaminated pharmacy sink caused the outbreak. Improvements in parenteral medication preparation, including moving chemotherapy preparation offsite, along with terminal sink cleaning and water system remediation ended the outbreak. Greater awareness of recommended medication preparation and handling practices as well as further efforts to better define the contribution of contaminated sinks and plumbing deficiencies to healthcare-associated infections are needed. Infect Control Hosp Epidemiol 2017;38:314-319.

Stability of sildenafil in combination with heparin and dopamine

PURPOSE

The stability of sildenafil in combination with heparin and dopamine was evaluated.

METHODS

A stability-indicating high-performance liquid chromatography method with ultraviolet detection was developed for sildenafil citrate and validated. The method was applied to the investigation of sildenafil alone, sildenafil with heparin, sildenafil with dopamine, and sildenafil with heparin and with dopamine, all in 5% dextrose injection at room temperature and under refrigeration for 30 days. Samples of 100 μL were pulled from each storage bottle on each sampling day, diluted in mobile phase, and assayed in duplicate. Samples were tested on days 0, 1, 2, 3, 4, 5, 7, 9, 12, 14, 21, and 30. Each preparation was visually inspected for precipitation and color change. The percent recovery in each study sample was determined by comparing the peak area of sildenafil in the sample with the peak area of sildenafil from a freshly prepared 100-μg/mL standard in mobile phase.

RESULTS

The sildenafil alone, sildenafil with heparin, and sildenafil with dopamine remained within 90-110% of the expected sildenafil potency for at least 30 days at both temperatures. The preparation of sildenafil with both heparin and dopamine fell below 90% potency after 3 days at room temperature and 21 days in the refrigerator.

CONCLUSION

Sildenafil prepared in 5% dextrose injection alone, with heparin, and with dopamine retained over 90% potency after 30 days of storage at room temperature and under refrigeration. Sildenafil prepared with both heparin and dopamine had a potency of <90% after 3 days of storage at room temperature and 21 days of storage under refrigeration.

Water Soluble Vitamins Enhance the Growth of Microorganisms in Peripheral Parenteral Nutrition Solutions

Peripheral parenteral nutrition (PPN) solutions contain amino acids, glucose, and electrolytes, with or without some water soluble vitamins. Peripheral venous catheters are one of the causes of catheter related blood stream infection (CRBSI), which requires infection control. In Japan, PPN solutions have rarely been prepared under aseptic conditions. However, in recent years, the necessity of adding vitamins to infusions has been reported. Therefore, we investigated the effects of water soluble vitamins on growth of microorganisms in PPN solutions. AMINOFLUID^® (AF), BFLUID^® (BF), PARESAFE^® (PS) and PAREPLUS^® (PP) PPN solutions were used. Water soluble vitamins contained in PP were also used. Causative microorganisms of CRBSI were used. Staphylococcus epidermidis decreased after 24 hours or 48 hours in all solutions. On the other hand, Escherichia coli, Serratia marcescens, Pseudomonas aeruginosa, Staphylococcus aureus and Candida albicans increased, especially in PP. When each water soluble vitamin was added to BF and PS, growth of S. aureus was greater in solutions that contained nicotinamide than in solutions that contained other vitamins. As for C. albicans, they grew in all test solutions. C. albicans grew especially well in solutions that contained biotin. When commercial amino acids and glucose solutions with electrolytes are administered, in particular those containing multivitamins or water soluble vitamins, efforts to control infection must be taken to prevent proliferation of microorganisms.

Design Considerations of a Compounded Sterile Preparations Course

OBJECTIVE

To design a comprehensive learning and assessment environment for the practical application of compounded sterile preparations using a constructivist approach.

DESIGN

Compounded Sterile Preparations Laboratory is a required 1-credit course that builds upon the themes of training aseptic technique typically used in health system settings and threads application of concepts from other courses in the curriculum. Students used critical-thinking skills to devise appropriate strategies to compound sterile preparations.

ASSESSMENT

Aseptic technique skills were assessed with objective, structured, checklist-based rubrics. Most students successfully completed practical assessments using appropriate technique (mean assessment grade=83.2%). Almost all students passed the practical media fill (98%) and gloved fingertip sampling (86%) tests on the first attempt; all passed on the second attempt.

CONCLUSION

Employing a constructivist scaffold approach to teaching proper hygiene and aseptic technique prepared students to pass media fill and gloved fingertip tests and to perform well on practical compounding assessments.

DrugCam®-An intelligent video camera system to make safe cytotoxic drug preparations

DrugCam(®) is a new approach to control the chemotherapy preparations with an intelligent video system that enables automatic verification during the critical stages of preparations combined with an a posteriori control with partial or total visualization of the video recording of preparations. The assessment was about the recognizing of anticancer drug vials (qualitative analysis) and syringe volumes (quantitative analysis). The qualitative analysis was conducted for a total of 120 vials with sensitivity of 100% for 84.2% of the vials and at least 97% for all the vials tested. Accuracy was at least 98.5% for all vials. The quantitative analysis was assessed by detecting 10 measures of each graduation for syringes. The identification error rate was 2.1% (244/11,640) i.e. almost 94% to the next graduation. Only 3% (35/1164) of the graduations tested, i.e. 23/35 for volume <0.13 ml of 1 ml syringes, presented a volume error outside the admissible limit of ± 5% of a confidence band constructed for the estimated linear regression line for each syringe. In addition to the vial detection model, barcodes can also read when they are present on vials. DrugCam(®) offers an innovative approach for controlling chemotherapy preparations and constitutes an optimized application of telepharmacy.

Eliminating the use of intravenous glass bottles using a FOCUS-PDCA model and providing a practical stability reference guide

OBJECTIVES

To identify the intravenous (IV) medications that are prepared in glass bottles at the institution and establish which of these medications can be prepared in flexible IV bags such as polyvinyl chloride (PVC) or non-PVC instead of glass bottles. The cost implication of switching from glass bottles to flexible IV bags was calculated.

METHODS

A study using FOCUS-PDCA model to identify IV medications prepared in glass bottles and establish which of these medications could be prepared in IV bags (PVC or non-PVC). The cost impact of switching from glass bottles to IV plastic bags (including PVC or non-PVC) was calculated. The stability data obtained were used as a reference for updating pharmacy internal IV preparation charts.

KEY FINDINGS

A total of 17 IV medications were found to be prepared in IV glass bottles. Of these 17 medications, only 8 (47%) were prepared in IV glass bottles due to incompatibility with PVC bags. For 7 (41%) of the medications, of which 6 were monoclonal antibodies (MABs), the reason for preparation in glass bottles was unclear as these medications are compatible with either PVC or non-PVC or both. The potential cost savings associated with switching all of the identified medications to IV plastic bags (either non-PVC or PVC) exceeded $200 000.

CONCLUSIONS

The elimination of glass bottles within the institution resulted in a significant cost saving. The use of FOCUS-PDCA model can help healthcare institution achieve significant improvements in process and realize significant cost savings.

The effect of different methods of intravenous injection on glass particle contamination from ampules

There have been many studies on glass particle contamination from glass ampules during the injection of glass ampules, but only the contamination from direct IV bolus injection has been measured. This research aimed to study the difference in glass particle contamination from ampules with different intravenous administration methods commonly used in clinical practice. Four methods were studied: IV bolus injection directly after immediate aspiration, IV bolus injection directly after 2 min’ delayed aspiration, IV bolus injection directly after aspiration with a filter needle, and side shooting to an infusion set with an in-line filter. 45 ampules per method for a total of 180 ampules were used. The number and length of glass particles were measured using a slide scanner. Aspiration was performed without specifically using a slow aspiration method. The longest glass particle was observed in the immediate aspiration group. The side shooting group showed the lowest maximum number of glass particles per ampule. The side shooting group also showed the smallest number of glass particles, but it was statistically insignificant. Using a filter needle syringe and 2 min’ delayed aspiration, which are frequently recommended to minimize contamination, may not be as effective as commonly believed, unless combined with a slow and low pressure aspiration method. Using a side shooting to an infusion set with an in-line filter may minimize glass particle contamination from ampules even without a slow and low pressure aspiration method, but more evidence from a larger study is needed.