Safer Sterile Compounding: Choosing and Using Disinfectants for the Cleanroom.

Compounders worldwide are responsible for ensuring that the sterile preparations they dispense are pure, potent, and safe. To achieve that result, proper cleaning and disinfection of International Organization for Standardization controlled environments must occur. Because those tasks must be performed according to established standards, the compounding pharmacist must research regulatory requirements and appropriate products for use. In this report, we focus on U.S. regulations, guiding entities, and effective products that enable compliance with the increasingly stringent procedures required for pharmaceutical compounding. We also review cleaning and disinfecting processes, discuss the importance of correctly choosing and using disinfectants and/ or sporicidal disinfectants with surface claims in the cleanroom, and provide answers to questions frequently asked by staff who use those agents. In addition, we profile specific disinfectants that are compliant with United States Pharmacopeia Chapter <797> and current good manufacturing practice standards. Biological safety cabinets and compounding aseptic containment isolators must undergo an additional process that deactivates hazardous drug residues and removes them from the interior surfaces of those devices before they are cleaned and disinfected, but that discussion is beyond the scope of this article.

Sustaining capacity building and practical skills training during the COVID-19 pandemic: Lessons from India.

Background: The scale and duration of the COVID-19 pandemic posed a threat to provide the required support needed by emergency medicine (EM) trainees in India participating in the masters in EM program, a global partnership between the Ronald Reagan Institute for Emergency Medicine at the George Washington University and 14 institutions in India. While some of this support has been filled by remote education through thrice-weekly online video conferencing and webinars, the gap in procedural teaching posed a different challenge. Methods: We developed a two-part innovation to teach suture skills, a required procedure for EM trainees. The innovation consisted of a hands-on procedure lab with the opportunity for live feedback followed by an independent competitive skill demonstration. Trainees were notified in advance of materials needed for the procedure lab to encourage attendance and participation. Results: A total of 160 trainees attended the virtual suture skills lab; 74 trainees (46% of attendees) submitted feedback back of whom 94% were able to practice skills in real time. Written feedback was overwhelmingly positive and included requests to implement this method for other procedural skills. Twenty-one residents participated in the Innovative Suture Challenge, with the top three submissions receiving accolades in the following grand rounds-style session. Conclusions: The combination of virtual teaching with the opportunity for real-time feedback and an integrated project to independently showcase skills learned is a way to continue procedural skills teaching in a remote environment. The aim of this innovation was to test the feasibility, acceptability, and level of engagement of conducting virtual, live supervised suturing remotely across multiple geographical locations. Our next step would be to gather pre and post data to measure the impact. Additionally, we believe this provides a proof-of-concept model to further explore sustainable, cost-effective, and scalable models for remote procedure-based teaching.

Postgraduate Diploma in Emergency Medicine in India.

BACKGROUND: In India, and other low- and middle-income countries (LMICs), the majority of emergency care is provided by frontline providers without specialty training in emergency medicine. In order to fill this need, we developed the Indian Postgraduate Diploma in Emergency Medicine (PGDEM), a 1-year skills-focused course for practicing doctors. This article describes the curriculum development and implementation as well as the follow-up survey conducted to gauge the impact of the course. METHODS: Programme graduates were surveyed via e-mail. All participation was voluntary and survey data remained anonymous. RESULTS: A total of 98.1% of graduates reported that the skills and knowledge they gained during the programme were important to their current job; 94.7% reported using their training from the course on a regular basis. Graduates reported an improvement in confidence performing all procedures taught during the course. Respondents work in a variety of medical specialties, including emergency medicine (50.0%), cardiology (5.8%), internal medicine (11.5%) and family medicine (23.1%). DISCUSSION: PGDEM graduates overwhelmingly view the knowledge and skills they learned as essential training that they use on a regular basis and practice in a variety of medical specialties after completing the course. The PGDEM represents a unique model to provide training in emergency medicine and acute care to the frontline doctors who are frequently responsible for providing emergency care in LMICs. The PGDEM training model can be scaled up rapidly, with the potential to increase capacity in developing emergency care systems.

SAFER STERILE COMPOUNDING: Choosing and Using Disinfectants for the Cleanroom.

Compounders worldwide are responsible for ensuring that the sterile preparations they dispense are pure, potent, and safe. To achieve that result, proper cleaning and disinfection of International Organization for Standardization controlled environments must occur. Because those tasks must be performed according to established standards, the compounding pharmacist must research regulatory requirements and appropriate products for use. In this report, we focus on U.S. regulations, guiding entities, and effective products that enable compliance with the increasingly stringent procedures required for pharmaceutical compounding. We also review cleaning and disinfecting processes, discuss the importance of correctly choosing and using disinfectants and/ or sporicidal disinfectants with surface claims in the cleanroom, and provide answers to questions frequently asked by staff who use those agents. In addition, we profile specific disinfectants that are compliant with UnitedStates Pharmacopeia Chapter <797> and current good manufacturing practice standards. Biological safety cabinets and compounding aseptic containment isolators must undergo an additional process that deactivates hazardous drug residues and removes them from the interior surfaces of those devices before they are cleaned and disinfected, but that discussion is beyond the scope of this article.

A case of ocular cardiac reflex in a child with blunt ocular trauma.

An 11-year-old boy re-presented with refractory vomiting 18 h after blunt facial and head trauma. Initial CT of the brain performed at his first visit was normal. He was found to have a heart rate of 56 bpm (age appropriate 65-100 bpm) with a blood pressure 90/60 mm Hg. Physical examination revealed an injected sclera and limited vertical movement of the left eye. Neurological examination revealed no focal deficits, but a Glasgow Coma Scale of 14, with mild confusion, depressed mental status and diplopia on upward gaze. Performing upward gaze extra ocular movements exacerbated the patient's bradycardia and confirmed the presence of the oculocardiac reflex. High-resolution CT of orbits demonstrated a left orbital floor fracture with entrapment of the left inferior rectus muscle. Surgical correction resolved his bradycardia.

Global health and emergency care: a postgraduate medical education consensus-based research agenda.

Global emergency medicine (EM) is a rapidly growing field within EM, as evidenced by the increasing number of trainees and clinicians pursuing additional experiences in global health and emergency care. In particular, many trainees now desire opportunities at the postgraduate level by way of global EM fellowship programs. Despite this growing popularity, little is known of the effects of postgraduate training in global health and emergency care on learners and patients in the United States and abroad. During the 2013 Academic Emergency Medicine consensus conference on global health and emergency care, a group of leading educators at the postgraduate medical education level convened to generate a research agenda of pressing questions to be answered in this area. The consensus-based research agenda is presented in this article.

Guidelines for safety of trainees rotating abroad: consensus recommendations from the Global Emergency Medicine Academy of the Society for Academic Emergency Medicine, Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association.

The goal of a global health elective is for residents and medical students to have safe, structured, and highly educational experiences. In this article, the authors have laid out considerations for establishing a safe clinical site; ensuring a traveler's personal safety, health, and wellness; and mitigating risk during a global health rotation. Adequate oversight, appropriate mentorship, and a well-defined safety and security plan are all critical elements to a successful and safe experience.

Training and competency considerations for pharmacies providing compounded sterile preparations.

Quality is paramount to compounding and dispensing of compounded sterile preparations, and effective staff training is the single most important factor in ensuring quality outcomes. Successful training programs are based on four precursors, namely core knowledge; operational principles of the individual pharmacy; external requirements, such as those of state pharmacy boards and the United States Pharmacopeia; and pharmacy-specific policies and procedures. If properly detailed and customized to the specific pharmacy, policies and procedures can be used as a training tool. To be most effective, training for pharmacy personnel should be based on the principles of adult learning theory, which emphasize acquisition of practical knowldege and skills as the trainee needs to know them. Competency assessment should focus on both basic skills and developmental activities and can be accomplished by traditional checklists or by alternative techniques such as performance monitoring, mock audits, exemplars, and presentations to other staff.