Whitepaper: Considerations on Facility and Engineering Controls in the Wake of USP 800

New white paper explores the facilities challenges of USP 800 compliance and provides considerations to overcome them

Simplex Isolation Systems has announced a new white paper that explores the challenges imposed by USP 800 Section 5: Facilities and Engineering Controls. The white paper was developed to help healthcare institutions understand the necessary upgrades and modifications required of their facilities to achieve USP 800 compliance. Additionally, the white paper provides these organizations ways in which they can leverage their current facility layout and infrastructure to keep modifications within budget.

The US Pharmacopeial Convention (USP), a non-profit organization that sets health care activity standards enforceable by the Food and Drug Administration (FDA), adopted the USP General Chapter 800 regulation in February 2016 to address concerns over the handling of hazardous drugs. The regulation identifies the requirements for the receipt, storage, compounding, dispensing and administration of hazardous drugs to protect the patient, healthcare personnel and environment. It includes both non-sterile and sterile products and preparations and the standard applies to all personnel who compound these drug preparations and all places where they are prepared, stored, transported and administered.

This white paper provides an overview of USP 800 Section 5: Facilities and Engineering Controls.

Key topics that are discussed include:

• USP 800-compliant space configurations for receipt, unpacking, storage and compounding of hazardous drugs.

• Optimal space layouts for non-sterile and sterile hazardous drug compounding rooms.

• Modular versus traditional stick-built secondary engineering control rooms.

• Typical facility infrastructure challenges and potential solutions recommended for compliance.

“Since the publishing of USP General Chapter 800 in 2016, we have seen a trend in the configuration, building and infrastructure challenges that our customers have been faced with,” stated Darren McKinnon, Critical Environment Specialist at Simplex and key contributor to the white paper. “Our goal for the whitepaper was to define all potential difficulties from a building design standpoint in one educational piece that healthcare institutions can reference when planning for USP 800 compliance.

Learn about US Pharmacopeial Convention (USP) regulation, USP 800, which addresses concerns over the handling of hazardous drugs in the healthcare setting.

USP 800 is an important step in protecting healthcare workers and the environment, but what does it mean for cleanroom design and functionality

Recently, Subzero Engineering attended the PCCA International Seminar in Houston, TX. Not surprisingly, the hot topic of the event was the recently adopted US Pharmacopeial Convention (USP) regulation, USP 800, which addresses concerns over the handling of hazardous drugs in healthcare settings. As an update to current compounding standards, this regulation incorporates information contained in USP 795 and 797 and adds the element of containment of Hazardous Drugs.

The regulation seeks to “identify the requirements for receipt, storage, compounding, dispensing, and administration of hazardous drugs (HDs) to protect the patient, healthcare personnel and environment.” Overall, the philosophy is that there is no acceptable level of exposure to hazardous drugs and that exposure should be limited to the lowest possible level by using engineering controls and personal protective equipment. The latest revision of USP 800 can be found here.

While it’s clear that USP 800 is an important step in protecting healthcare workers and the environment, it is also clear that there is some confusion on what USP 800 actually means for cleanroom design and functionality. During the PCCA International Seminar, our Critical Environmental Specialists were asked many questions about the modifications needed to make current cleanrooms USP 800 compliant before the July 2018 implementation date. Others asked what USP 800 means for their future cleanroom designs.

With the abundance of questions being asked, we wanted to take the opportunity to answer the most frequently asked questions to clear up some of the confusion.

The 5 Most Asked Questions About Cleanroom Design in the Wake of USP 800:

1. Regarding the requirements for C-PECs (Containment Primary Engineering Controls) and negative pressure rooms, what are the key differences between USP 797 and USP 800?

A lot of the regulations are congruent because USP 800 is meant to work conjointly with USP 797. There are a few exceptions, however, and USP 797 is expected to be updated with these new changes in the future.

In regards to USP 800, the regulation states that the negative pressure room has to be between 0.01 and 0.03 inches of water column more negative than the surrounding areas. USP 797, on the other hand, does not have an upper limit.

It is also a requirement of USP 800 for C-PECs to be located within a negative pressure room for all hazardous drug work. This does not have to be a CACI (compounding aseptic containment isolator).

The last difference is that all hazardous drug work needs to be done in a C-PEC.

2. Is a positive pressure ante-room required in a non-sterile hazardous compounding cleanroom per USP 800 regulations?

No. Non-sterile hazardous drug C-SECs do not require a positive pressure ante-room. It is a requirement, however, that they be physically separated from other areas, with negative pressure of 0.01-0.03 inches of water column relative to surrounding areas, as well as 12 ACPH. Refer to Figure 1 below.

3. Do C-SECs (Containment Secondary Engineering Controls) have to have HEPA (high-efficiency particulate air) filtered external exhaust?

The original draft of USP 800 did require that C-SEC rooms be externally vented through HEPA filtration. However, Section 5.3 FACILITIES AND ENGINEERING CONTROLS, Compounding has since been revised to indicate that C-SECs used for sterile and nonsterile compounding must be externally vented, but do NOT need to be vented through HEPA filtration. The official announcement of the change to USP 800 can be found on the USP website here.

4. Can the negative pressure be greater than 0.03” of water column?

No. USP 800 states that the C-SEC, or room in which the BSC (biosafety cabinet) is located for hazardous drug preparation, must be between 0.01 and 0.03 inches of water column more negative than the surrounding areas.

5. Can the hazardous drug C-SEC, or room, be accessed through an ISO Class 7 clean room where non-hazardous drug sterile compounding occurs under positive pressure?

Yes. While the non-hazardous drug room is under positive pressure, the hazardous drug room needs to be 0.01-0.03 inches of water column more negative than the non-hazardous drug room, as illustrated in Figure 2. Both rooms need to be ISO Class 7 and have 30 ACPH. Note that this configuration has a restriction on the BUD (beyond-use date) which is outlined in USP 797. USP 800, Appendix 2, denotes this to be typically used in oncology clinic settings.

Have more questions about USP 800 and your cleanroom design?

As a leader in USP 800 cleanroom technology, Subzero Engineering has the expertise required to design, engineer and construct your USP 800 cleanroom. Simplex products are distributed in the U.S. and Canada through a nationwide dealer network. Contact a Subzero Engineering Environmental Specialist today.

From our article in Refrigerated Transporter, the industry information source for transportation and distribution of refrigerated products.

Food warehouse saves big with strip curtains

The Southern California facility of Chef’s Warehouse, located in the City of Industry, made some modifications that resulted in significant operational efficiencies. It placed strip doors on both ends of the facility’s almost 1,500-square-foot freezer compartment, and on the doors to its 38,000 square feet of temperature-controlled storage space… Within a few days of installation of the ArmorBond strip doors, the average temperature in the meat freezer dropped from 29.4° to 26.7°F, with no change in the set temperature on the thermostat. A similar temperature drop occurred in the temperature-controlled storage area.

ArmorBond doors are designed and manufactured by Subzero Engineering. “That’s a huge savings in energy for Chef’s Warehouse,” said Vince Iulianello, executive general manager of the company’s City of Industry facility.

Iulianello points to additional savings on the front end. He originally contemplated installing automatic freezer doors on both ends of the freezer room at a cost of $15,000. The entire package of ArmorBond strip doors, two strip doors on either end, came in for a price tag of $4,000.

Several weeks after installation, an auditor from Southern California Edison, the local electrical utility, came through the warehouse and spotted the strip doors. After a few calculations, the auditor told Iulianello that the installation qualified for a rebate equal to more than 25% of the cost of the strip doors.

“That was an added bonus,” said Iulianello.

Another benefit is the saved traffic time through the strip doors.

“The Subzero Engineering Simplex ArmorBond Strip Doors are designed to allow easy two-way access from not only pedestrians, but from heavy pallet jack and forklift traffic,” said Iulianello.

Read the full article at Refrigerated Transporter