Implementation of a Professional Practice Assessment within a nuclear pharmacy

In 2023, a new version of the French Good Preparation Practices (GPP) was issued, thus prompting our hospital to renovate the Radiopharmacy and reclassify the controlled atmosphere area (CAA) to C. This requalification resulted in adjustments to the hygiene and environmental control processes, followed by a presentation to the staff. The aim of this project is to set-up a Professional Practice Assessment (PPA) geared towards hygiene, for every employee operating in the CAA, separate from initial instructions.
An evaluation chart published by the French Radiopharmacy Society (SOFRA) was adapted to our local practices and validated by the Infection Control Team. A hygiene GPP refresher meeting was scheduled, followed by the planning of the PPA.
The assessments, led by the pharmacy resident, were conducted during routine work and consisted of an observation and a discussion. Simultaneously, agar samples (aero biocontamination and gloves prints) were collected in order to appropriately quantify the microbial load and to correlate our findings with observed practices.
4 distinct charts were created, each one corresponding to a workbench within the CAA : High Energy Enclosure (HEE), Low and Medium Energy Enclosure (LMEE), Microbiological Safety Cabinet (MSC) and dispensation automate (TRASIS). Each one was made up of 7 to 10 thematic index cards (entrance, controls, …) and included about 74 items, 17.5 of which didn’t appear on the SOFRA chart. Employees involved in the chart development were excluded from the evaluation.
In total, 7 employees, out of the 15 trained, were evaluated, (p=47%) : 3 on the LMEE (p=60%), 1 on the MSC (p=50%) and 3 on the TRASIS (p=37.5%). The mean noncompliance rate (NC) is 32.6% with anomalies most often encountered during retrieval and storage (100%), as well as hygiene and bio cleaning (48.53%). In contrast, the index cards with the lowest NC regarded syringe filling and syringe delivery (16.7%) along with the preparation of the radiopharmaceutical drugs (16.7%). Some microbial growths were observed on the agar collected on the LMEE on the 11/04 and are not correlated to the evaluation with the highest number of NC.
The limits identified for this project included an incomplete evaluation of the employees, the pre-emptive announcement that the evaluation would take place thus skewing the observations, and lastly the lack of scoring and the vast disparity within the number of items amongst the index cards complicating the interpretation of results.
This study helped identify discrepancies to the GPP, emphasizing the importance of continuing the PPA with the rest of the employees, as well as implementing a training course concerning the items with the most NC, and lastly to conduct another PPA, remote from the corrective measures.

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