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This is derived from USP <797>, Compounding Sterile Preparations. This is a chapter that is mandatory for all to follow, although many do not realize this. It has preparations divided based on their risk, from immediate use, to low, mediam, and high risk. This statement about start infusion within one hour is a direct quote from this work of USP and APIC and CDC has also added it to their statements on safe injection practices. So I would not recommend any action to change it. This is the national standard of care and should remain asi it is. I compliment your hospital on this policy. Lynn

Here's a bit more...... www.apic.org/Content/NavigationMenu/PracticeGuidance/USP_Chapter_797_FAQ.doc

"The U.S. Pharmacopeia’s Revised General Chapter <797> Pharmaceutical Compounding - Sterile Preparations, which sets practice standards to help ensure that compounded sterile preparations are of high quality, became official on June 1, 2008. Since that time APIC has received many questions regarding this standard. APIC submitted the following questions to the USP<797> Sterile Compounding Expert Committee and prepared this FAQ to assist you in the  interpretation of the standard.

I.  Issue: Time for spiking IV bags (indirectly relates to 1 hour usage)

Question:  "I have a same day surgery department within my hospital for which I have infection control oversight. I have been asking them for the past year to not spike all their IV bags in the morning but have never been able to find any reference material or documentation to support my thoughts on this practice. Do you know of any resources that support this explicitly?"

USP Answer.  No.

Addendum: This question was also posed to the American Society for Healthcare Pharmacists (ASHP) and it was their judgment that good medication practice would not support this practice. The following ASHP Best Practice information and CSP Recommendations were offered:

A. ASHP Policy and ASHP Author Recommendation on Assembling Doses Hours Before Administration

ASHP guidelines on quality assurance for pharmacy prepared sterile products (Best Practices 2008 edition, p. 63) (Official ASHP policy):

RL 1.11: Handling of Sterile Products Outside the Pharmacy.

Pharmacists should participate in developing procedures for the safe use (e.g., stability, sterility) of sterile products once they are distributed outside the pharmacy. How the product is transported from the pharmacy, how it is stored outside the pharmacy, and methods for return, recycling, and disposal should be addressed in written policies and procedures. (15, 83) Sterile products should be transported so as to be protected from extremes of temperature outside their range of stability and from light if they are photosensitive. Storage containers and packaging verified as suitable for protection during transport should be specified. Transit time and conditions should also be specified and controlled. Delivery personnel should be instructed on special handling procedures. Once delivered to the end user, sterile products should be appropriately stored before use. Pharmacists should ascertain that the user has appropriate locations and equipment for storage (e.g., a refrigerator with a suitable thermometer). Special instructions for storage should be a part of the label or a separate information sheet (e.g., instructions for cleanliness, proper storage, interpretation of the expiration date and how to look for signs of product deterioration). The pharmacist should be notified if storage conditions do not remain suitable so that the pharmacist can give advice as to the disposition of the sterile products and remedies for storage problems. Pharmacists should participate in training end users on the proper care and storage of sterile products, either directly or through written instructional materials.

American Society of Health-System Pharmacists. ASHP Guidelines on Quality Assurance for Pharmacy-Prepared Sterile Products. Am J Health-Syst Pharm. 2000; 57:1150–69.

B. Compounding Sterile Preparations, 2nd ed, Buchanan and Schneider (p. 122) (Recommendation from authors in book published by ASHP):

Compounded sterile preparations should be issued in limited quantities and organized in the refrigerators so that nursing staff avoid the practice of assembling multiple doses for patient hours before scheduled medication administration"