Professionals who oversee infection control programs and contamination control in the hospital pharmacy are making do despite ever-tightening budgets
By Chris Anderson
It's a given that in today's healthcare climate, virtually any conversation about specific areas of operation begins—and often ends—with a discussion about money. Hospitals, especially, are under the gun. Some patients are rushed home to avoid the higher costs of a hospital stay, while others who do arrive for extended stays are arriving sicker than in years past.
“We have such sick patients in hospitals now,” says Luci Power, pharmacy manager for the University of California San Francisco Medical center and owner of consulting firm Power Associates. “Whether it is the HMO concept that they don't hospitalize you until you are absolutely dying or the major advances in the last 20 years in drug therapies that allow people to say at home longer—when the drug therapies are no longer effective, the patients who come to us are very sick.”
In this environment, you'd expect that infection and contamination control would make solid areas for investment. After all, these are both areas that protect the health of patients and workers alike. Unfortunately, professionals who oversee both infection control programs and contamination control in the hospital pharmacy have to make do with their ever-tightening budgets—just like anyone else in the hospital.
“Infection control professionals can use their epidemiological skills in investigating the best way to address issues in their facility,” says Loretta Fauerbach, director, infection control of Shands Hospital at the University of Florida. “But at times, programs are affected by reduced staff due to budgetary constraints.”
Infection control
Infection control in the hospital has a large and complicated task: to prevent nosocomial infection—infections patients get while hospitalized for another condition.
While this year's outbreak of Severe Acute Respiratory Syndrome (SARS) in Asia and Toronto may have captured plenty of media attention, it was also a testament to the ability of hospitals to effectively thwart the spread of infection.
“SARS was addressed and contained by using strict adherence to proven infection prevention of transmission strategies,” says Fauerbach, who also serves as the practice guidance team leader for the Association for Professionals in Infection Control and Epidemiology Inc. (APIC).
“It was important for healthcare workers to wear appropriate protective garb, such as N95 masks, gowns, gloves and eye protection,” Fauerbach adds. “Because it was not clearly known if it [SARS] was spread through the airborne route, patients were also placed in airborne isolation rooms, which had negative air pressure.”
Yet, for a couple of reasons, people shouldn't expect the SARS outbreak to affect how infection control is practiced here in the United States. First, SARS was halted using already proven techniques and second, it was not a widespread outbreak.
“This was not like Hepatitis C, Hepatitis B and HIV, which are almost endemic in the population,” says Dr. Robert W. Powitz, principal of R. W. Powitz & Associates, Old Saybrook, Conn. “We have these in all 50 states and that is why we've have the blood-borne infection procedures since the late '80s. SARS was a point outbreak and it is not in all 50 states.”
While the quelling of SARS is certainly a victory for practitioners of infection control, the programs are only as good as workers' adherence to proper procedures. Facing chronic shortages of qualified workers, many health care providers are taxed to near the breaking point. “Healthcare workers try as hard as they can,” says John Farris, CIH, president and managing principal of SafeBridge Consultants Inc., a Mountain View, Calif.-based health and safety firm. “But they are just spread too thin and it really impinges on their time. From a safety standpoint, time and proper procedure are the most important things for doing it right.”
The primary source of passing infection within the hospital is via the hands of healthcare workers. “We still haven't gotten people to wash their hands as often as they should,” says Powitz. “If we could write this into religion, we would be far better off, but we haven't done that.”
But incremental improvements in this area have been achieved recently, notes Fauerbach. She points to the introduction of new alcohol-based hand cleansing agents that decrease the amount of time it takes workers to perform their cleansing routine. “These products can be used when hands are not visibly soiled and are also gentler on the healthcare workers' skin, which decreases irritation,” she says. “The use of these hand hygiene agents has increased compliance with hand decontamination.”
A typical hospital pharmacy has technicians preparing everything from sterile IV solutions to highly toxic chemotherapy drugs and everything in between. That means both safe handling of the substances and traditional contamination control procedures are in effect.
But unlike infection control, where the primary focus is on preventing spread of infection to patients, pharmacy contamination control is intended primarily to protect the lab technicians from contamination by the substances they handle.
In the pharmacy
A typical pharmacy may consist of a couple of laminar flow hoods with horizontal airflow used for IV preparation or the mixing of relatively safe drug compounds, as well as one or more biological safety cabinets with a vertical airflow for chemotherapy compounds.
According to Hank Rahe, director of technology for Containment Technologies Group (Indianapolis), this set-up has remained virtually the same for the past 15 or 20 years. “But we do see many more hospitals switching to isolators, mostly for their people preparing chemotherapy,” he says. “I think they need this closed system instead of just having a little air blowing on the work surface to prevent contamination.”
That makes sense to Luci Power at UCSF, who would like nothing more than to convert her chemo room—with its two biological safety cabinets—to isolators. As always, the problem is money.
“The reality is remodeling money is very hard to come by,” she says. “So, we will probably need to get through with the equipment we now have until the equipment either decides to die or somebody leaves us a fortune.”
Since that hero on a white horse isn't likely to drop money at her door, Power makes the best of her older equipment and simply realizes she is no different than most other hospital pharmacy directors. At the same time, she understands the limitations of biological safety cabinets.
“Almost every one of the studies I've looked at shows that there is contamination on the floor directly in front of the biological safety cabinet,” Power says. “Now, no one has shown how that happens, but if you look at the mechanism of a tech working that particular cabinet, it has got to be that the contamination is coming out from around their arms, or when they are moving the stuff back and forth into he cabinet itself.”
Once on the floor, technicians can easily step in the contaminated area and track it throughout the room and beyond.
This kind of contamination may soon get a fresher look from hospital pharmacies across the country. The National Institute of Occupational Safety and Health (NIOSH) is readying the release of a hazardous drug alert about the potential effects to workers exposed to certain chemotherapy compounds. While the letter serves only as a warning, with recommended safe practices (it carries no regulatory weight), it will likely be sent to all hospitals, health organizations and compounding pharmacies.
“When this hazard alert hits the street and is distributed, it is going to raise the level of awareness and hospitals will need to take a look at what they are doing, how they are doing it and where they can improve,” says Farris.
One thing Farris hopes for is a greater sharing of information between the pharmaceutical manufacturers and the hospitals that dispense and mix their products. “There is a real disconnect between what professionals in the pharmaceutical industry know and what the health professionals, nurses and pharmacists inside private healthcare settings know,” he says. His hope is that the hospitals will have better access to best practices and safe procedures used by pharmaceutical companies.
A lot of times in the hospitals, those drugs that are classified as hazardous get swept up into the same category when, in fact, there is an entire spectrum,” Farris notes. He cites one hormone-based drug where, while not lethal, a level of 1 nanogram per cubic meter of air is the safe threshold.
The body of work linking health problems (such as decreased fertility and the increased chance of miscarriage) to chemotherapy drugs was enough reason for Power to take other measures. For these more toxic drugs, she has adopted the use of a disposable product called PhaSeal, which lets technicians compound the drugs in a completely isolated environment.
But the cost is significant, even when used with just a few of the drugs routinely compounded by Power's techs. Power estimates that she spends roughly $100,000 per year on these disposable items, and knows of another healthcare provider who has more widely adopted the product and reportedly spends $1 million on the disposable units each year. “That's a lot of money in today's health care environment,” she says.
While the lure of isolators remains, Power reinforces training and technique to her pharmacy workers. “We do a certification once a year using a kit that can show how effectively they can do a preparation. Then we check to see if they have had any spills,” she says. “But all we can check is if they know how to do it right, not whether they do it that way all the time. So, what we need to emphasize is that the biological safety cabinet is just a tool, and the only way it will work effectively is to use proper technique all the time.”
Because she can see spills in the hood of the biological safety cabinet, Power knows that these procedures aren't always followed. But she has little blame for the technicians. “They are under pressure every day and need to work quickly just to keep up,” Power says. “What's hard are these new drugs that have expirations of 6, 12 or 24 hours. So, we can't mix these in advance. These drugs are mixed essentially to-order every day.”
Even if Power would prefer having isolators in her pharmacy “because they don't allow the techs to cheat,” she simultaneously worries it will cause a drop in production. Plus, despite what she sees as a safer tool for her techs, Power doesn't see the isolator as the be-all, end-all to contamination problems.
“People call me all the time asking me to make a blanket recommendation for isolators, and that's hard because I see the large differences in quality between one cabinet and another,” Power adds. “I just know that a lot of people will make the decision to go with a certain isolator based on price. I wish I could say go with the isolator that is better than the one you are going to spend nothing on. But that is what we are faced with and it's hard.”
CHRIS ANDERSON, a special correspondent to CleanRooms magazine, lives in Portland, Maine. He can be contacted at: [email protected]
Hospital safety: 9-11 hits the ER
Not long after the September 11 attacks, hospitals across the country realized that if there were either a chemical or biological attack inside our borders, health care workers in the Emergency Room would be first responders to treat the affected people.
For some hospitals, it was a shocking reality. Others merely needed to broaden their scope of potential toxins, since they were already prepared for large scale chemical spills in their immediate area.
“To help with guidelines for how to respond to these emergencies, hospitals could turn to the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) in Washington, D.C.,” says Loretta Fauerbach, director, infection control of Shands Hospital at the University of Florida and practice guidance team leader for APIC.
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“APIC released a bio-terrorism draft plan for members to adapt to their practice site,” adds Fauerbach. “It provided educational opportunities to help bring the infection control community up-to-speed on the issues. Each hospital must then work with their local public health officials to develop a community-wide plan.”
This has also produced an opportunity for companies such as Bullard, a maker of personal protective gear and systems. The company's PA 20 powered air purifying respirator provides a hood and small HEPA filter system that would allow healthcare workers to breathe freely, even when treating contaminated individuals. “Compared with other products, like self-contained breathing apparatus, we think health care workers will like the relatively small size and weight of our unit,” says Brian Shockley, Bullard's product manager for respiratory and air quality products.
Other equipment needed by hospital workers includes chemical suits, boots and protective eyewear. The federal government, through the Health Resources Service Administration has a $498 million pot of money that it distributed to states for the purpose of funding the equipment and training needed by hospital staffers should they need to respond to an attack.
“Hospitals are looking to spend this money that is available as they prepare to protect their employees against the effects of bio-terror or other mass-casualty events,” says Shockley. —CA