Gowning and Garbing procedure VANCHCS.pdf

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Attached to
H266--Pharmaceutical Compounding Room/Hood Testing - VANCHCS Federal contract opportunity
Solicitation number
36C26124Q0390
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

About this file

This document is the Gowning and Garbing Procedure for the VA Northern California Health Care System (VANCHCS). It outlines the required garbing steps for entering non-hazardous drug (non-HD) and hazardous drug (HD) compounding areas, including donning facemasks, hair/facial hair covers, shoe covers, gowns, and gloves. Additional requirements are specified for entering HD compounding areas, such as donning an impermeable gown and a second pair of gloves. The procedure also provides instructions for exiting HD compounding areas. This document appears to be an appendix to a larger Pharmacy/EMS Service Level Agreement.

The related federal contract opportunity is for "H266--Pharmaceutical Compounding Room/Hood Testing - VANCHCS", solicitation number 36C26124Q0390, issued by the Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 21. The solicitation seeks services for pharmaceutical compounding room and hood testing at the VANCHCS facility.

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Text version

May 1, 2024 Pharmacy/EMS SLA

APPENDIX D

D-1

GARBING WITH SINK ON THE CLEAN SIDE OF ANTEROOM

Garbing for Non-HD Compounding Area

Before Entering Ante-room

Wear clean freshly laundered appropriate attire (e.g., no stains, ripped attire, open toe shoes, jackets, sweaters, hats). Sleeves must be rolled up past the elbows to facilitate good hand hygiene.

Remove unnecessary items to classified compounding area such as outer garments, cosmetics, jewelry, piercings, earbuds, headphones, electronic devices, nail products (e.g., polish, artificial nails, extenders).

Clean personal eyeglasses.

Dirty Side Ante-room

Don an approved facemask with folds down on outside, bend nose bar, pull down under chin; no gaps.

Don a low-lint or lint-free facial hair cover over mask if applicable.

Don disposable low-lint or lint-free head cover that covers hair and ears.

Don disposable low-lint or lint-free shoe covers, one at a time, crossing over the line of demarcation.

Clean Side Ante-room

Perform hand hygiene as outlined in the hand hygiene procedure.

Don low-lint or lint-free gown (do not put thumb loops in place).

Apply alcohol-based hand rub to nails, hands, wrists, and allow to dry.

Put on thumb loops if applicable and don a pair of gloves.

Application of 70% IPA to gloves.

Additional Steps for Entering a HD Compounding Area Clean Side Ante-room or Non-HD Side HD Buffer (ISO-7)

Don a disposable low-lint impermeable gown.

Don a second pair of gloves over the cuff of the impermeable gown.

Gown must be changed as needed per manufacturer’s information.

Don a second set of shoe covers before crossing over the line of demarcation in HD buffer room.

Steps for Exiting a HD Compounding Area HD Side HD Buffer (ISO-7)

Dispose gloves and impermeable gown in Yellow Waste Bin.

Remove the second set of shoe covers, one at a time, crossing over the line of demarcation to the Non-HD Side.

Note: Sterile 70% IPA and sterile gloves must be used for all compounding activities and drugs.

Additional garbing steps for HD handling areas where applicable.

File details come from the government source that posted it. Updated .