Among community oncology practices, the US Pharmacopeia (USP) Convention’s General Chapter <800> draft guidelines have already raised the bar for hazardous drug (HD) management and imposed costs for compliance.
The impact of these changes will be significant. Prior to the publication of USP <800>, most community oncology practices used a biosafety cabinet (BSC) and personal protective equipment for handling HDs. Although these offered some protection, formal education about HD management was all but nonexistent, and the lack of detailed policy and procedures made enforcement and optimal use of HD equipment a significant challenge. USP <800> brought this issue to the forefront by providing a clear explanation of the spectrum of safeguards needed to protect employees.
In the community practice setting, readiness for enforcement of USP <800> varies from full compliance (rare) to no compliance decision having been made (also rare). Although not all are in conformance, most community oncology practices intend to comply.
USP <800> was intended to be enforceable starting on July 1, 2018. However, the final document release has been postponed to coordinate with the scheduled December 1, 2019, publication of the USP <797> revision. These guidelines cover pharmaceutical compounding and sterile preparations. The intent is to provide a unified approach to compounding practices that is safe for both patients and employees. USP <797> describes responsibilities of drug compounding personnel, training, facilities, environmental monitoring, and storage and testing of finished preparations. USP <800> describes requirements for HDs; facility and engineering controls; procedures for deactivating, decontaminating and cleaning; spill control; and documentation.
Preparing for USP <800>
Many oncology practices have been preparing for USP <800> for a long time and are well on their way to compliance. However, for those just getting started, the following steps may make the process more manageable:Assign a project lead.
Although USP <800> clearly states it is the responsibility of all practice employees who handle HDs to understand the chapter’s requirements, for ideal stewardship, each practice should designate a person to oversee implementation of USP <800> procedures and compliance.Identify hazardous drugs in the practice.
The practice must identify the HDs it currently handles to ensure proper management in the future. Practices should closely read the National Institute for Occupational Safety and Health’s 2016 list of HDs to see which are classified as hazardous.Assess how HDs traverse the practice.
Obviously, practice administrators and managers need to thoroughly understand USP <800> requirements. Once comfortable with these requirements, practice members should focus on how HDs traverse the practice from the point of receipt to inventory, storage, compounding, administration, and, finally, disposal. This will identify trouble spots where compliance is lacking.
USP <800> is specific about design and engineering controls, so evaluate the compounding area and BSC ventilation.
Prior to the date that USP <800> becomes enforceable, a drug compounding hood that vents to room air is acceptable. After December 1, 2019, USP <800> requires that all BSC hoods be vented to the outside environment.
Next, a practice should examine the compounding room design, as there are minimum requirements that must be met. In addition to the requirement for BSC hoods that vent to the outside, all quantities of HDs must now be compounded in a segregated, negative-pressure room that is properly ventilated.
One of the standards for this room is that it must be constructed of a specific type of material. This represents the greatest challenge to general compliance because most community practices do not yet conform to this requirement.
If facility and engineering changes are needed, it is important to understand these may require 12 to 18 months to complete. If possible, it may be helpful to delay this aspect of compliance until the publication of the second-draft revision (late 2018) of USP <797>. Although unfinished, this draft should provide greater clarity about facility requirements.Evaluate processes for personal protective equipment (PPE), and determine the current level of compliance.
Understanding the degree to which staff members embrace PPE is critical and necessary to developing improvement initiatives. Once management has a good understanding of their staff’s current compliance level, they can identify improvements and begin drafting policies and procedures. Many templated products are available that make this job a bit easier. Training processes that include competency exams should be established, and strategies should be developed to ensure that the consistent use of PPE becomes part of the practice culture.