059-17 Wyo. Code R. §§ 17-4 - Personal Hygiene and Garbing

(a) Pharmacy staff shall not handle CSPs if they have open sores, infected wounds, or an upper respiratory infection.

(b) When entering a cleanroom suite or SCA, compounding pharmacy staff shall remove any items that are not easily cleanable or that are not necessary for compounding. At a minimum pharmacy staff shall:

(i) Remove all cosmetics and personal outer garments including, but not limited to bandanas, coats, hats, jackets, sweaters, and vests. If worn, eyeglasses shall be wiped;

(ii) Remove all hand, wrist, and other exposed jewelry including but not limited to piercings that could interfere with the effectiveness of garbing or otherwise increase the risk of contamination of the CSP. Compounding pharmacy staff shall cover any jewelry that cannot be removed;

(iii) Not wear earbuds or headphones;

(iv) Not bring electronic devices that are not necessary for required tasks into the cleanroom suite or SCA; and

(v) Keep nails clean and neatly trimmed to minimize particle shedding and avoid glove punctures. Nail products, including, but not limited to polish, artificial nails, or extenders shall not be worn.

(c) Handwashing and garbing order shall be outlined in the facility's policies and procedures. Compounding pharmacy staff shall follow established hand hygiene and garbing procedures when entering the cleanroom suite or SCA and prior to handling CSPs.

(i) Compounding pharmacy staff shall wash hands and forearms up to the elbows and remove visible debris from underneath the fingernails with soap and water for at least thirty (30) seconds. Low-lint disposable towels or wipes shall be used to dry hands and forearm. Brushes and hand dryers shall not be used for hand hygiene;

(ii) After handwashing, and alcohol-based hand rub shall be applied to dry hands prior to donning sterile gloves;

(iii) Garb shall consist of the following minimum requirements:

(A) Low-lint garment with sleeves that fit snugly around the wrists and that is enclosed at the neck;

(B) Low-lint, disposable shoe covers;

(C) Low-lint, disposable cover for head that covers the hair and ears, and if applicable, a disposable cover for facial hair;

(D) Face mask;

(E) Sterile, powder-free gloves; and

(F) If using a RABS, disposable gloves should be worn inside the gloves attached to the RABS sleeves. Sterile gloves shall be worn over the gloves attached to the RABS sleeves.

(iv) Garb shall be donned or doffed in an order that reduces the risk of contamination. Skin shall not be exposed inside the PEC. Garb shall be replaced immediately if it becomes visibly soiled or if its integrity is compromised;

(v) Compounding pharmacy staff may re-use gowns within the same shift if the gown is maintained in the classified area or within the perimeter of the SCA and used for non-hazardous drug compounding. All other gab shall be discarded after use;

(vi) All gloves shall be inspected for holes, punctures, or tears and shall be replaced immediately if such defects are detected. The RABS sleeves and gloves should be changed per the manufacturer's recommendations and as defined in the facility's policies and procedures; and

(vii) Compounding pharmacy staff shall apply sterile 70% isopropyl alcohol (IPA) to gloves regularly throughout the compounding process and whenever nonsterile surfaces are touched.

Notes

059-17 Wyo. Code R. §§ 17-4

Amended, Eff. 5/16/2017. Amended, Eff. 12/19/2018. Amended, Eff. 5/13/2021.