Design Considerations of a Compounded Sterile Preparations Course

Compounding Education in US PharmD Curricula

OBJECTIVE

To determine the extent of compounding education (CE) offered in United States (US) doctor of pharmacy curricula.

METHODS

A 24-item survey instrument addressing various aspects of CE was developed and validated. An email containing the link to the survey instrument was shared with instructors of compounding at 122 of 141 accredited schools and colleges of pharmacy in the US.

RESULTS

Of these, 112 schools and colleges responded, rendering a survey response rate of 91.8%. Survey results indicate that CE is offered to a similar extent either as a required standalone course or as integrated instruction as part of a standard course. Whereas 70.8% of programs reported mostly hands-on training in CE in their curricula, there were about 11% programs that mostly offered didactic instruction in CE. Dispersed systems and semisolid formulations are the most prepared in nonsterile compounding, while proper hand washing, garbing, and gloving are the most taught techniques in sterile compounding. Compounding education is delivered principally by pharmaceutics faculty (62.3%) compared to practice faculty (32.1%).

CONCLUSION

The survey determined the extent to which CE is addressed across different schools and colleges of pharmacy in the US. Although some institutions lack minimal nonsterile or sterile compounding facilities, they may improve by modeling the established programs in the country. Leadership at pharmacy institutions may need to allocate funds for CE, and support faculty who instruct in compounding.

Economic Considerations and Cost-Saving Strategies for Sterile Compounding Education

OBJECTIVE

To determine economic considerations associated with the facilitation of sterile compounding education for students in schools and colleges of pharmacy across the United States.

METHODS

An online survey was sent to members of the American Association of Colleges of Pharmacy Pharmaceutics Section and Laboratory Instructor's Special Interest Group. Quantitative and qualitative data were collected on general information about the institution, student cohorts, compounding courses, types of compounds prepared, equipment, budgets, personnel, and cost-saving measures. Descriptive statistics were calculated using SPSS. Open-ended responses were used by respondents if the primary question could not adequately capture their institution-specific information. These answers were added to the study findings.

RESULTS

Of 555 surveys sent, 40 were completed. Reported annual sterile compounding budgets ranged from $500 to $95,500. Twenty-two percent of respondents reported collecting a lab fee from students to offset associated costs. Seventy percent of respondents specified cost-saving measures, including the use of expired drugs, reusing supplies or personal protective equipment, price comparisons, simulated drugs, and donations.

CONCLUSION

Findings from this study may assist pharmacy administrators and faculty in evaluating the costs associated with sterile compounding education and determining ways to reduce costs while maintaining the intent and quality of these courses.

Teaching and Assessing Pharmacy Students on Sterile Compounding Accuracy Checks

Objective. Accuracy checks are required by United States Pharmacopeia General Chapter <797> to ensure patient safety when dispensing compounded sterile preparations (CSP). Despite the importance of this task, reports of training pharmacy students to perform CSP accuracy checks are lacking. This study aimed to, first, report a method for teaching CSP accuracy checks to students and, second, determine whether increased time on this content and intentional focus on this skill would improve student performance in a simulated hospital environment.Methods. A laboratory teaching team identified the six most common types of errors in CSP accuracy checks. Student performance regarding these six errors and competency grades of final accuracy checks were compared between the fall 2019 and fall 2020 semesters.Results. Students had better overall performance on the competency assessment for accuracy checks in fall 2019 versus fall 2020, but students performed substantially better on the remediation in fall 2020 versus fall 2019. In each semester, students had different errors commonly missed during the first and second attempts.Conclusion. Despite enhanced teaching content and the incorporation of practice testing, students performed worse in fall 2020 than fall 2019. This effect could have been explained, in part, by the virtual environment required during the COVID-19 pandemic. To improve student performance, continued improvement in teaching methods and a restructured remediation process is needed.

Implementation and sequencing of a compounded sterile preparation validation testing protocol for second- and third-year pharmacy students

BACKGROUND AND PURPOSE

Incorporation of aseptic technique validation testing in a pharmacy curriculum consistent with United States Pharmacopeia Chapter 797 Standards is not well described. Validation testing is optimally placed prior to assignment to health-system introductory and advanced pharmacy practice experiences.

EDUCATIONAL ACTIVITY AND SETTING

Environmental and engineering controls consistent with a segregated compounding area were implemented. Medium risk media fill and gloved fingertip test (GFT) testing were incorporated to achieve initial and subsequent training in the second and third curricular years, respectively.

FINDINGS

For the graduating classes of 2018 through 2020, 234 students completed validation testing and knowledge assessment. Failure of the media fill test was uncommon. Failure of the initial GFT testing occurred in 16.1% to 22.1% of second-year students and 3.2% to 5.8% of third-year students. No significant differences were seen between three consecutive student classes.

SUMMARY

Incorporation of validation testing was successful, with consistent results. Procedures and results provide guidance with respect to student class size, available facility/equipment needs, implementation of validation protocols, and associated resources. Each student is provided with documentation of annual training and validation testing consistent with existing standards for health-system pharmacy practice.

"Practice makes perfect" strategy for teaching aseptic techniques improved observational scores but not preparation potency

INTRODUCTION

Student-compounded sterile preparations have been evaluated using observational scores, sterility testing, and potency determinations. Observational scores and potency determinations can be evaluated simultaneously, and three studies have been published using these assessment tools. One study found a significant number of students could not compound an acceptably potent preparation despite receiving very good observational scores. The previous study was judged to have an inferior instructional flaw, so a new teaching design, a "practice makes perfect" model, was utilized and was expected to increase the number of students compounding acceptably potent preparations.

METHODS

The "practice makes perfect" method provided students with more practice and one-on-one instruction time in aseptic techniques. First-year pharmacy students received both group practice sessions and individualized instruction on six occasions interspersed between three compounding assessments. Observational scores and potency results were compared between this study and the previously published study.

RESULTS

The "practice makes perfect" strategy improved students' observational scores but showed inconsistent results in the percentage of students who compounded an acceptably potent preparation and in the potency of preparations compounded by all students. There was no correlation between observational scores and potency values or between observational scores and the percentage of students compounding acceptably potent preparations at each individual observational score.

CONCLUSIONS

The study demonstrated that there was either a systematic error in the analytical potency protocol or that the observations made during student compounding were not adequate to identify problems that led to poor potency.

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.

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.

The Role of a Simulation-Based Activity on Student Perceptions of Parenteral Nutrition Education

Introduction: Parenteral nutrition (PN) education in pharmacy schools and postgraduate programs may not sufficiently prepare future pharmacists for clinical practice. Limited data exist regarding innovative teaching strategies in the area of PN. The purpose of this study was to identify students’ perceptions of a simulated PN activity in a pharmacotherapeutics course. Methods: Second-year Doctor of Pharmacy (PharmD) students from two cohorts (N = 84 for both cohorts) completed a PN assignment using simulated PN materials, which resembled those seen in clinical practice. Before and after the activity, students completed identical surveys about their perceived competence and interest in PN, which were analyzed using Wilcoxon signed-rank tests. Results: Following the simulation, the percentage of students affirming their perceived competence (selecting strongly agree or agree in the survey) in their ability to describe the process of combining ingredients to make a PN admixture (45.2% vs. 83.3%, p < 0.001) and calculate PN-related problems (58.3% vs. 83.3%, p < 0.001) improved. The proportion of students expressing interest in PN increased after the simulation (78.6% vs. 86.9%, p < 0.001). Conclusion: A simulated practicum experience in PN was viewed positively by PharmD students at this university, and may be a valuable active learning experience to incorporate in a PharmD curriculum.

Instructional and Assessment Redesign of a Sterile Compounding Course Using Immersive Simulation

Objective. To revise a traditional sterile compounding course to include content, competencies, and immersive simulations relevant to the current practice of sterile compounding pharmacy. Methods. Faculty and staff at the University of North Texas System College of Pharmacy made significant revisions to an existing sterile compounding course. Instruction was provided in didactic and laboratory sessions and delivered in three modules: fundamental skills, integration of skills and knowledge, and exceptions and specialty topics. Integration laboratory sessions consisted primarily of repetitive but increasingly difficult simulations that included both technician and pharmacist activities. Assessment methods included checkpoint assessments, a mock objective structured clinical examination (OSCE), a written examination, and a final comprehensive OSCE. Effectiveness of the course redesign was assessed by comparing student performance on assessments, overall course performance, and student perceptions extracted from the student course evaluation. Results. Of the 364 students enrolled in the sterile compounding course across four terms, 156 were in the pre-implementation cohort (cohort 1) and 208 were in the post-implementation cohort (cohort 2). Two hundred twenty-eight students completed the course evaluation. Course evaluations significantly demonstrated students' improved perceptions related to seven of 11 survey elements, most notably, critical thinking, integration of concepts, and students feeling challenged. Student performance on laboratory summative assessments also improved. However, written examination scores did not change. Conclusion. This novel sterile compounding course provided a practice-oriented blueprint for instruction and assessment of sterile compounding.

Potency Analyses Provide Insight Into Student Aseptic Compounding Technique Errors

Objective. To determine whether direct observational scores were predictive of the potency of pharmacy students' compounded sterile preparations (CSPs) and to identify any misunderstandings students had regarding individual aseptic technique steps. Methods. P1 students performed aseptic techniques during three observational encounters separated by two weeks. Students' performances were evaluated using an observation-based rubric and were subject to potency analysis. The encounters were transferring a drug solution from a vial, an ampule, and a reconstituted powder to intravenous (IV) bags. Results. The mean potency of the diphenhydramine (vial) and lidocaine (ampule) met the ±10% goal of expected potency. These results were significantly different from those of the ampicillin (reconstitution) encounter, which was outside the goal. The percentage of students meeting the potency goal was 59.3% for the diphenhydramine, 80.3% for the lidocaine, and 50.4% for the ampicillin encounters. The observation scores were significantly different between all three encounters. There were no correlations between the observational scores and the potency for any encounter regardless of whether or not the student met the goal potency. Although their observation scores were acceptable, up to 50% of students did not meet the potency goal for each of the three encounters. Conclusion. The potency data provided the critical insight that P1 students were not adequately trained to account for pressurization when manipulating vials using aseptic compounding processes. The results suggest that both observation scores and potency analysis should be part of an overall assessment of student ability to compound sterile preparations.

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.