From facility infrastructure to operating procedures with hazardous drugs (HDs), USP <800> will require organizations to make significant changes for the sake of HD safety.
HDs pose serious carcinogenic and teratogenic health risks. Even if your facility will not be required to be USP <800> compliant on December 1, 2019, regulations can always change, and there are ample moral and legal reasons to do so regardless of enforcement.
The following overview illustrates four major steps you will need to take for USP <800> compliance – and they are simply an introduction. As you will see, each step involves operational and infrastructural challenges that may require considerable research and resources to overcome.
Step 1: List The Hazardous Drugs at Your Facility
Compiling and maintaining a list of HDs at your facility is mandatory for compliance, and it can help form the basis of an introductory risk assessment. More than 264 drugs are classified as hazardous by the National Institute for Occupational Safety and Health (NIOSH).1 These drugs are grouped into three categories that may require different safe-handling procedures:2,3
Non-antineoplastic drugs that meet HD criteria
Drugs that pose reproductive risk
Each of these drugs has one or more of the following characteristics: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity, or new drugs that mimic existing HDs.
Pay close attention to the risk categories and the dosage forms of the HDs at your facility. High-risk HDs may require engineering controls under USP <800> that your facility does not possess. Certain tablets and capsules that are kept intact may not require the same stringent protocols as injectables, but they may need their own safety strategies.
With this information, compare your current practices for the HDs at your facility to the guidelines set forth in USP <800> for HD safe handling. Add new dosage forms and drugs to this list and review at least once every year. If you’re unsure of the HD status of a new drug, err on the side of caution and consider it to be an HD until you can definitively confirm otherwise.4
Step 2: Examine Receipt, Unpacking and Storage
This is the first area where facilities may need to make significant infrastructure upgrades. Antineoplastic HDs cannot be received and unpacked in a positive pressure environment, which would allow contamination to outside areas in the event of breakage or spills. Instead, a neutral or negative pressure environment must be used.5
Storage for most drug forms is affected as well. The majority of HDs, with the exception of some capsules and tablets, must be kept in a negative pressure room with a minimum of 12 air changes per hour (ACPH).6 HDs and non-hazardous drugs cannot share the same refrigerators, and refrigerators for HDs must also be kept in an externally ventilated negative pressure room with the same requirement of 12 ACPH.7
Step 3: Analyze Engineering Controls For HD Compounding
New engineering controls for HD compounding may be the most difficult and costly upgrades that facilities will have to make for USP <800> compliance. Note that guidelines for non-sterile compounding in USP <795> and sterile compounding in USP <797> must still be followed.8
Containment Primary Engineering Controls (C-PECs):
Under USP <800>, HD compounding requires highly controlled ventilation to protect against harmful byproducts such as aerosols and sprays. Containment primary engineering controls (C-PECs) provide the critical airflow for environmental and occupational protection when compounding HDs. As USP <800> offers general guidelines, facilities have a degree of choice in their controls.
Biological Safety Cabinets (BSCs):
USP <800> lists a range of BSCs that are appropriate for either non-sterile or sterile HD compounding. If your facility already possess BSCs that you would like to use for HD compounding, it is important to verify that they are an approved type for USP <800> compliance.9 If you need new BSCs, allow significant lead time as they require NSF International/American National Standard design verification and field testing.10
Compounding Aseptic Containment Isolators (CACIs):
CACIs come in a variety of configurations and have certain advantageous qualities. From a safety standpoint, they completely isolate the HD from the operator and the environment. From an operational standpoint, they do not require the same level of verification and field testing as BSCs, but rely on testing standards generated by the CACI manufacturer.11
Containment Secondary Engineering Controls for HD Compounding:
Containment secondary engineering controls (C-SECs) are the rooms in which C-PECs reside. C-SECs maintain negative pressure to capture airborne particles from HDs and are essential to C-PEC functionality. As with C-PECs, USP <800> offers a degree of choice in C-SECs for your facility.
An externally vented ISO Class 7 buffer room with an ISO Class 7 ante-room is arguably the most comprehensive solution. Negative pressure requirements between 0.01 and 0.03 inches of water column and 30 ACPH help ensure comprehensive contamination control.12 The two main drawbacks are cost and available facility space.
Containment Segregated Compounding Areas (C-SCAs):
An externally vented C-SCA with a minimum of 12 ACPH is a more economical and easier to implement option for many facilities. C-SCAs do not need to meet ISO standards or need to deliver ISO 7 quality air for medium and low-risk HDs. A drawback is that sterile product beyond use dating (BUD) is limited to 12 hours, which may be shorter than if the HD was prepared in a cleanroom.13,14
Containment Supplemental Engineering Controls:
These tools generally refer to closed system drug-transfer devices (CSTDs) that offer additional protection in compounding and administering HDs. USP <800> is careful to mention that there is currently not a “published universal performance standard for evaluation of CSTD containment” and cautions facilities to use independent, peer-reviewed studies to guide CSTD selection.15 Regardless of the CSTD you choose, it must be used in conjunction with proper C-PECs, not in place of them.
STEP 4: Devise a Comprehensive Training Program
Under USP <800>, all personnel involved with HDs must be comprehensively trained in safe handling practices that relate to their job function, from receipt through disposal. As outlined by USP <800>, training must include:16
• The facility’s list of HDs and corresponding risks
• Standard operating procedures (SOPs) for handling HDs
• Use of personal protective equipment (PPE)
• Use of equipment and devices (such as CSTDs)
• Response to HD exposure – known or suspected
• Managing spills
• HD and contaminated material disposal
Employees must prove competency in the above before independent HD handling. Their competency must be reviewed and reassessed every 12 months. Facilities should also designate a supervisor for HD practices and create a detailed quality assurance program.17
In practical terms, facilities can benefit from creating a standardized HD training program that ensures all SOPs are aligned with USP <800>. Special attention should be paid to training on personal protective equipment (PPE). According to OSHA, staff members who prepare HDs reportedly fail to wear basic protective equipment such as gowns up to 36% of the time.18
GET ON THE PATH TO HD SAFETY
This brief overview was meant to provide motivation and guidance for becoming USP <800> compliant as expediently as possible, regardless of initial enforcement by your state pharmacy board.
Due to the complexity of challenges posed for many facilities, having as much lead time as possible for USP <800> compliance will be critical to avoiding disruption to operations.
If you are conducting a gap analysis, determining cleaning protocols for new engineering controls, or investigating sampling and quality control programs, contact FG Clean Wipes. With more than 50 years in critical environment contamination control, we have experience with numerous facilities that meet USP <800> standards. We can help you get up to speed.