MASSACHUSETTS GENERAL HOSPITAL P 18.15

DEPARTMENT OF PHARMACY

OPERATIONS MANUAL

SECTION: Professional TOPIC: 18.0 Blake Infusion Center Pharmacy Satellite
SUBTOPIC: 18.15 Laminar Flow Hoods MATERIALS:
TRAINING: Classroom DATE: 5/89 PREPARED BY: M.D. Clapp, G. Siegmann, L.F. Parker, R. Stabile
REV: 11/92;1/95


The laminar flow hoods in the pharmacy are used to assure that a product is prepared in the most aseptic manner possible. The vertical air flow through the hood is filtered through a high-efficiency particulate air (HEPA) filter. All manipulations in the hood are designed to maintain this constant air flow around the products being prepared.

cf P 11.28

HOOD CLEANING

The technician in the pharmacy is responsible for daily cleaning of the hood, as well as a monthly thorough cleaning of the surface below the grill pans. This is documented on the Daily Work log and initialed by the technician.

PROCEDURE:

1. Wet all surfaces with sterile water and wipe clean.

2. Wet hood surfaces with LpHse solution and allow to stand for 5 minutes. Using a lint free absorbent cloth, wipe the solution throughout the hood, using a side-to-side, back-to-front motion. Allow excess solution to air dry.

3. All side walls and hanging racks are to be cleaned in a similar manner.

4. Complete Daily/Monthly Cleaning of Laminar Flow Hoods Form.

5. During the work day, wipe downs are to be performed, first with sterile water and a lint-free absorbent cloth, and then 70% isopropyl alcohol (Use squirt bottle or alcohol-dampaned cloth. Do not use spray bottles). Wipe the solution throughout the hood, using side-to-side, back-to-front motion. Allow excess solution to air dry.

6. The pans on the inside of the hoods should be removed monthly and the surface below the pans cleaned. Technicians must follow policy 18.14 with regard to proper dress when handling chemotherapeutic drugs. Also, please refer to OSHA guidelines for handling of cytotoxic drugs and universal precautions.

a. Cleaning of pans and surfaces below pans must be performed in the hood, behind glass. Do not take pans out of hood.

b. Wet pans and surface below pans with sterile water and allow to stand for 5 minutes. Wipe clean as described above. Use a brush with handle to get in back of hood. Keep your head behind glass. Finally, wipe down surface with LpHse as described above.

7. HEPA filters are tested for integrity every six months.

8. Air velocity in hoods should be read daily recorded on log (see Cox Ambulatory Pharmacy Daily Work Log). If the readings are not within normal limits, notify the pharmacist so that the hood can be checked.

cf P 11.31, P 11.30, P 11.32

WORKING IN THE LAMINAR FLOW HOOD

All intravenous admixtures shall be prepared aseptically in a vertical laminar air flow hood.

PROCEDURE:

1. The laminar flow workbench should be operated continuously, 24 hours a day. Should it have been off, the blower must be turned and operated for at least 20 minutes before aseptic procedures are performed in the work space.

2. Prepare laminar flow workbench for operation.

3. The operator shall follow proper handwashing and dressing procedures.

4. Assemble supplies necessary for procedures being performed.

5. Carefully inspect all containers and products to assure they are in good condition before use. Bring all damaged or expired products to the attention of the pharmacist.

6. Before transferring any materials into the laminar air flow hood, wipe the outer surface with 70% alcohol lint free wipe.

7. Arrange all items needed for admixture to the right or left in the laminar flow workbench to provide a work area that is directly bathed with clean air from an HEPA filter. Consideration must be given to an efficient and logical order for the proper addition of additives.

8. The vertical flow workbench sliding panel must be closed to within 8 inches.

9. The hands and fingers of the operator must have only been cleaned, not sterilized; therefore, all procedures must be performed in a manner which will keep the fingers and hands away from contact with critical sites. These sites include all vial tops and needle surfaces.

10. Rubber stoppers of the vials, injection port covers, and the neck of ampules must be cleaned with a 70% isopropyl alcohol wipe prior to the insertion of the needle for the removal or addition of drugs or fluid.

11. The completed preparation should be provided with an appropriate tamper-proof cap or closure.

12. Inspect product for physical incompatibilities and particulate matter.

13. Upon completion of procedure, the work surface should be cleared of used and unused supply items and cleansed with 70% isopropyl alcohol.

14. The product container should be properly and appropriately labeled.

cf P11.29

MONTHLY CLEANING OF STAINLESS STEEL PAN

1. Put on blue gown and gloves.

2. Take out all the articles from the hood.

3. Take out the stainless steel pan and the stainless steel grill from the hood.

4. Put the 4 liter glass beaker under the water outlet.

5. Pour about 500 ml of water in the hood and leave for 15 minutes.

6. Scrub the entire hood with the hood cleaning brush.

7. Drain out the dirty water in the glass beaker.

8. Repeat steps 5, 6, and 7 again.

9. Wipe out the hood with napkins with LpHse.

10. Wipe through with alcohol.

11. Wipe out and clean the stainless steel pan and grill with water and alcohol.

12. Place the stainless steel pan and grill back in the hood.

13. Wipe out the entire hood with alcohol.

cf P 11.32

1/18/95

P18lami