There was no change this year in the number of facilities with an environmental monitoring plan in place. Those without a plan tend to be facilities that compound fewer than 100 CSPs per day. It is very concerning that one-third of facilities compounding without a formal plan also do not have a plan to implement this practice.
While the number of facilities that have established an environmental monitoring plan is growing over time, the progression is ploddingly slow. Because environmental monitoring was a majority practice in 2008, it is quite surprising that 12 years hence, it has yet to become universal practice.
Among those facilities without an environmental monitoring plan in place, a slim majority (52%) plan to implement this practice within the year. It is concerning that some facilities continue to compound without a plan to implement environmental monitoring.
While the vast majority of pharmacies utilize plates to collect their samples, some facilities also rely on swabs and paddles, typically to access difficult-to-reach areas of the PECs.
There has been a growing commitment of late by pharmacy to invest in their own incubators to manage the monitoring of samples, rather than share space with the laboratory department’s equipment. This year saw the use of pharmacy incubators become the majority practice for the first time.
Environmental monitoring equipment inspires strong satisfaction, with 91% assigning top marks to their vendors. Environmental monitoring processes receive somewhat lower marks in comparison.
Volumetric air samplers are utilized by a majority of facilities.
While volumetric air sampling is almost always conducted via volumetric air viable samplers, just over one-third (34%) are also utilizing volumetric air non-viable samplers.
Volumetric air sampling is most commonly conducted in conjunction with the 6-month certification visit, although one-third of facilities utilize their volumetric air samplers on a more frequent basis.
Just 10% of facilities are collecting viable surface samples in PECs at least weekly. The most common approach is monthly sampling, although 4 out of 10 facilities are only sampling their PECs during the biannual certification process.
While outsourcing environmental monitoring is increasingly popular, most facilities rely on the pharmacy department to conduct environmental monitoring.
Hospital pharmacies are increasingly likely to test their growth media using a positive control; 59% of facilities have conducted such testing. It is notable that 44% of facilities have experienced no growth in their positive control, underscoring the importance of conducting this testing.