Avoiding accidental exposure to intravenous cytotoxic drugs Elizabeth Meade
Many cytotoxic drugs have been shown to be mutagenic, teratogenic and carcinogenic with second malignancies known to be associated with several specific cancer drugs. Occupational exposure to cytotoxic drugs presents a signification danger to healthcare staff and unwarranted handling of these drugs should be avoided. Guidelines have been established for the safe handling of hazardous drugs but not all professionals are adhering to these recommendations. Recent environmental studies have demonstrated measurable drug contamination on surfaces even when recommended guidelines are followed. It is therefore imperative that healthcare workers are aware of the potential hazards of antineoplastic agents and employ the recommended precautions to minimise exposure. This article outlines the potential risks associated with exposure to cytotoxic drugs for healthcare staff. The safe-handling precautions required in the storage, preparation, transport, administration and waste disposal of cytotoxic drugs are presented. Key words: Cytotoxins agents ■ Risk ■ Safety
■
Pharmaceutical preparations
■
Antineoplastic
T
he introduction of cytotoxic drugs dates back to the 1940s (Polovich, 2004). Antineoplastic drugs are non-selective in their mechanism of action thereby affecting both cancerous and healthy cells with welldocumented toxic side effects in treated individuals (Vyas et al, 2014). These include hepatic, renal, cardiac, pulmonary and haematopoietic effect, reproductive toxicity, ototoxicity, immunotoxicity, dermal toxicity, and particular injury to tissues with rapid turnover rate (Connor and McDiarmid, 2006). In the 1970s second malignancies were reported in patients who had previously received chemotherapy for solid tumours. The most common of these were leukaemia and bladder cancer. Health professionals exposed to cytotoxic drugs can suffer the same potential toxicities (National Institute for Occupational Safety and Health (NIOSH), 2004; Green et al, 2009; Furlow, 2010; Health and Safety Executive (HSE), 2013). Despite the implementation of detailed guidelines and regulation for the safe handling of cytotoxic drugs many recent studies show that nurses and pharmacy personnel are still being Elizabeth Meade, Advanced Nurse Practitioner (Oncology), Health Service Executive, Dublin, Mid Leinster Midland Regional Hospital Tullamore, Co. Offaly Accepted for publication: August 2014
S34
exposed to these substances (Mason et al, 2005; Connor et al, 2010; Kopp et al, 2013; Queruau Lamerie et al, 2013; Ramphal et al, 2014). This article will identify potential risks for healthcare workers and discuss risk reduction management in the key areas of receipt and storage, preparation, transport, administration and disposal of hazardous drugs as well as the medical surveillance of healthcare workers.
Health effects of cytotoxic drugs Drugs classed as ‘hazardous’ include antineoplastic and cytotoxic agents, some hormonal agents, immunosuppressants, antiviral medications and some monoclonal antibodies (Table 1).Workers are exposed to a drug throughout its life cycle, during manufacture, transport, distribution, administration and disposal (Huber, 2010). The first evidence documenting occupational exposure to cytotoxic drugs in healthcare workers was provided by Falck et al (1979) in which nurses who prepared and administered antineoplastic drugs were shown to have higher indicators of mutagenic substances in their urine compared with nonexposed workers. Numerous studies have replicated this original work and highlighted the potential dangers associated with the preparation and administration of antineoplastic agents (Selevan et al, 1985; Valanis et al, 1997; Wick et al, 2003). Dranitsaris et al (2005), in their systematic review and meta-analysis, described an association between exposure to antineoplastic drugs and adverse reproductive effects in female health care workers. The most common reproductive effects were increased fetal loss, congenital abnormalities, low birth weight and infertility. Other potential consequences in exposed workers are outlined in Box 1. The number of healthcare workers potentially exposed to hazardous drugs is estimated in the USA to be in the region of 8 million and include all members of the multidisciplinary Table 1. Definitions of hazardous drugs Carcinogenicity
Can cause cancer in animals or humans
Genotoxicity
Ability to cause genetic changes or mutations
Teratogenicity
Fetal defects or malformation
Reproductive toxicity
Fertility impairment
Organ toxicity
Serious organ toxicity at low doses
Structure and toxicity profile of new drugs that mimic existing drugs determined to be hazardous Sources: American Society of Healthcare-Systems Pharmacists (ASHP), 1990; National Institute for Occupational Safety and Health (NIOSH), 2010
© 2014 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 16
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Hair loss ■ Vomiting, abdominal pain ■ Headaches, nasal sores, sore throat ■ Liver damage, alterations to normal blood cell count ■ Acute irritation, hypersensitivity ■ Adverse reproductive outcomes including infertility, spontaneous abortion and congenital malformations ■ Possible leukaemia and other cancers ■ Abnormal formations of cells and mutagenic activity or mutations forming. ■
Sources: NIOSH, 2004; Polovich, 2004; Connor at al, 2006; Health and Safety Executive (HSE), 2013
Box 2. Healthcare workers exposed to hazardous drugs as occupational risks Pharmacists and pharmacy technicians Nursing personnel ■ Physicians ■ Operating room personnel ■ Environmental services personnel including porters, housekeeping, laundry and maintenance workers ■ ■
Source: NIOSH, 2013
team (NIOSH 2013) (Box 2). Hon et al (2013) state that a broader range of workers and visitors are potentially exposed while Ramphal et al (2014) demonstrated that one third of oncology nurses in one hospital and local community setting in Canada tested positive for urinary cyclosphamide while one third of non-oncology nurses also tested positive suggesting environmental contamination was widespread within the hospital environment.
Occupational exposure The health risk of cytotoxic drugs is influenced by the extent of the exposure and the potency and toxicity of the hazardous drug (Yoshida et al, 2013). Healthcare workers have different types of exposure to cytotoxic drugs depending on their job description, e.g. pharmacy technicians involved in preparation of the drugs are exposed to a very concentrated form of the drug whereas nurses are exposed to a more dilute form during administration or handling patient waste. However, contamination and exposure can still occur with one study demonstrating that the highest concentrations of chemotherapy agents were found in areas contaminated with body fluids (Ramphal et al, 2014). In the 1980s the centralisation of the preparation of antineoplastic drugs in specialised pharmacies by specially trained staff, coupled with the use of isolators, biological Box 3. Core elements of international guidelines for the safe handling of hazardous drugs Exposure assessment of safe handling procedures throughout the entire drug life cycle from receipt to disposal. ■ Use of specialised equipment—biological safety cabinet and isolator ■ Wearing personnel protective equipment (PPE) ■ Training and education of workers handling antineoplastic drugs or workers at risk of exposure ■ Health surveillance ■
■ Implementation
Sources: NIOSH, 2004; ASHP, 2006; International Society of Oncology Pharmacy Practitioners, 2007; HSE, 2013; NIOSH 2013
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safety cabinets and personal protective equipment (PPE) was an important step in the protection of healthcare workers. Overall exposure was reduced by these measures but significant environmental contamination and antineoplastic drug exposure is still commonly observed (Fransman et al, 2005; Hedmer et al, 2005; Mason et al, 2005; Touzin et al , 2009; Connor at al, 2010; Sessink et al, 2011; Sottani et al, 2012; Odraska et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014) Adherence to recommended work practices and the use of engineering controls and PPE has been shown to substantially reduce worker exposure to cytotoxic drugs (Odraska et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014). However, several factors such as increased workload, understaffing, lack of knowledge, improper training, budgetary constraints, more complex regimes and the use of antineoplastic drugs in a non-oncology setting can adversely affect how these drugs are handled (Turk et al, 2004; Polovich, 2004; Power et al, 2012).
National and international guidelines Due to the potential health risks and the continuing environmental contamination of hazardous drugs the US National Institute for Occupational Safety and Health (NIOSH) (2004) produced an alert regarding the risks posed to exposed healthcare workers and the measures recommended to protect these workers’ health and safety. These guidelines were updated by the American Society of Health-Systems Pharmacists (ASHP) (2006) and International Society of Oncology Pharmacy Practitioners (ISOPP) (2007). In the UK the Health and Safety Executive (HSE) recently updated its guidelines on hazardous drugs (relating to the Control of Substances Hazardous to Health Regulations) (HSE, 2013). Detailed standards for the safe prescribing, preparation and administration of antineoplastic agents have also been developed by the HSE (2003), National Cancer Action Team (2011; 2012) and British Oncology Pharmacy Association (BOPA) (2013). It is recommended that only individuals trained in the safe handling of antineoplastic drugs should be involved in their handling and that retraining of staff and competency testing should be undertaken on an annual basis. The essential elements of international guidelines are outlined in Box 3.
Routes of exposure Exposure can be measured biologically by looking for the metabolites of cytotoxic drugs in urine or by environmentally wiping surfaces with special surface wipes and analysing these wipes for the specific drugs (Mason, 2005; Kopp et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014). Numerous studies have documented both surface and worker contamination by cytotoxic drugs. Routes of exposure include inhalation, dermal absorption, ingestion, and injection (Box 4).Workers are exposed by inhalation via droplets, particles and vapours. This can occur during preparation when vapour can escape from connections between the vial and syringe, or during administration from the syringe and port. A major source of exposure for nurses is spiking or unspiking intravenous solution (IV) bags and priming of the tubing. Vandenbrouke (2001) demonstrated that leakage of the drug during spiking
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Box 1. Health effects of hazardous drugs in exposed workers
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HEALTH AND SAFETY occurs 25% of the time and during unspiking 100% of the time. Needlestick injuries with contaminated needles results in exposure by injection (Huber, 2010; Power at al, 2012). The greatest risk is direct skin contact with the drug when a spill or leak occurs (ISOPP, 2007). Several studies have highlighted drug contamination on surfaces of vials, biological safe cabinets, countertops, floors, equipment and most surfaces in the areas where patients are treated (Sessink et al, 1992; Polovich, 2004; Connor and McDiarmid, 2006; Touzin at al, 2009; Kopp et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014). Dermal exposure also occurs when staff come into contact with contaminated surfaces during preparation, administration or disposal of hazardous drugs. Handling bodily fluids or contaminated clothing, linen, dressings and other materials also increases the risk of exposure (NIOSH, 2004; Huber, 2010; Kopp et al, 2013). Oral exposure may occur from hand to mouth contact. When food and beverages are prepared, stored or consumed in the work area they may easily become contaminated with airborne particles of antineoplastic drugs. Similarly hands, cigarettes, cosmetics and chewing gum can be contaminated. Inadvertent ingestion may be an additional route of exposure (Connor et al, 2006; Huber, 2010).
Box 4. Routes of exposure Inhalation Dermal absorption ■ Ingestion ■ Injection ■ ■
Sources: NIOSH, 2004; HSE, 2013
Box 5. Personal protective equipment (PPE) ■ Gowns:
disposable, made of fabric that has low permeability to the agents used with closed front and cuffs, intended for single use ■ Gloves: powder free, labelled and tested for use with chemotherapy drugs made of nitrile or neoprene ■ Face and eye protection when splashing is possible ■ An approved respirator when there is a risk of inhalation. Choose products which are CE marked in accordance with the PPE Regulations 2002 Sources: HSE, 2013; NIOSH, 2008; 2013
The use of safe-handling practices for healthcare workers can dramatically reduce the potential exposure to these drugs (NIOSH, 2004; HSE, 2013). These practices include: ■■ Receipt and storage of drugs ■■ Drug preparation ■■ Transportation of the drug ■■ Administration of the drug to the patient ■■ Drug waste handling—including patient waste, drug waste and laundry ■■ Spill control (HSE, 2013).
contamination and exposure (Vyas et al, 2014). It is essential that personnel follow all recommendations for PPE consistently during drug preparation: double gloves with the outer extending over the cuff of the gown and gowns with closed fronts, long sleeves and elastic or knit closed cuffs (Figure 2). Adherence to strict hand-washing techniques before donning gloves and immediately after removal is recommended. The disposal of all sharps should be performed without crushing, capping or clipping. When drug preparation is complete the drug should be placed in a sealed plastic bag before removal from the cabinet with hazard warning label clearly displayed (Figure 3). The attachment of the drug administration set in the BSC eliminates the escape of the hazardous drug during priming. All PPE and other materials should be disposed of in hazardous waste containers.
Receipt and storage of antineoplastic drugs
Antineoplastic drug transportation
Personnel unpacking containers of cytotoxic drugs should open the containers carefully and inspect on arrival. They should be prepared for the possibility that spills may occur. Personnel must wear PPE that is recommended for handling cytotoxic drugs in order to protect themselves from dermal and inhalation exposure (Box 5). Cytotoxic drugs require warning labels and safe storage in a well-ventilated area separate from other drugs. Spill kits should be available wherever cytotoxic drugs are stored, prepared and administered.
In order to minimise exposure risk, cytotoxic drugs should be transported within a special sealed bag in a properly labelled leak-proof container by personnel who are educated on emergency procedures in the case of a spill and who have access to a spill kit. It is important that staff wear chemotherapy gloves during transportation.
Safe handling of cytotoxic drugs
Figure 1. Closed system devices
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Antineoplastic drug preparation Asepsis and containment is required during preparation of antineoplastic drugs using a Class 2 or Class 3 biological safety cabinet (BSC) or an isolator. All healthcare workers using ventilated cabinets must be trained in their particular use and safety. Preparation is performed in a controlled environment where access is limited to authorised personnel only. It is important to keep the BSC and isolators free from clutter, properly cleaned, maintained and upgraded according to the manufacturer’s instructions. Closed systems (Figure 1) used in the preparation and administration of cytotoxic drugs are designed to reduce environmental
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the BSC. However, when priming lines at the administration site it is important to use a non-drug solution. Venting tubes must not be used. In order to prevent unintended exposure tubing must not be removed or disconnected from an IV bag containing a hazardous drug (Huber, 2010). Items for waste disposal must be placed directly in chemotherapy waste container at the site of administration keeping the lid of the chemotherapy waste container closed between uses. Reusable items should be washed twice in detergent wearing double latex gloves and gown. Soap and water must be used to wash hands before leaving the drug administration site. Figure 1. Reconstitution of cytotoxic drugs
Antineoplastic drug waste handling Each institution should have a policy for the segregation of waste materials resulting from antineoplastic drug preparation and administration. Patient waste (urine, blood, vomit, sweat, faeces) and materials are considered to contain the drug and its metabolites and are handled as hazardous. These materials include used vials, IV sets, syringes, gloves, gowns, bedpans and linen. All employees handling hazardous waste are required to wear PPE designated for this purpose.
Spill control
Figure 3. Hazard warning labels must be displayed clearly
Emergency procedure to cover spills must be managed according to established, written policy. Hazard spills are considered small when their volume is less than 5 ml and are considered large when the volume is over 5 ml (Huber, 2010). All contaminated clothing must be removed immediately. When managing small and large spills it is essential that staff wear PPE including recommended gloves, a gown, eye wear, shoe protection and if necessary a face shield. Spills must be cleaned up immediately by properly trained and protected staff members. Warning signs must be used to limit access to the area and all clean-up materials disposed of in a hazardous waste container. All incidences should be reported documenting the spill and the personnel exposed (HSE, 2013).
Routine cleaning and decontamination
Antineoplastic drug administration It is essential that all personnel administering chemotherapy wear recommended PPE and adhere to strict hand-washing techniques before donning gloves and immediately after removal. Contaminated or damaged gloves must be changed immediately. In order to reduce exposure infusion sets and pumps should have a Luer lock system and be observed for leakage during use. A plastic-backed absorbent pad placed under the tubing during administration and sterile gauze around any push site will help reduce patient dermal exposure. Drug administration is safer using needless and closed systems (Figure 4) (Wick et al, 2003;Yoshida et al, 2009; Sessink et al, 2011; Kopp et al, 2013; Miyake et al, 2013). The priming of the line or expelling air from the line should be done in
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Medical surveillance Medical surveillance involves collecting and interpreting data to detect changes in the health status of the working population exposed to hazardous substances. The elements of medical surveillance are used to establish baseline health and to monitor the future health of professionals as it relates to their potential exposure to hazardous agents. It is recommended that personnel exposed to hazards of antineoplastic drugs should
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Figure 4. Chemotherapy administration
It is essential that all healthcare workers wear recommended PPE when carrying out cleaning and decontamination. Cleaning and decontamination work should be performed in areas that are sufficiently ventilated. Work surfaces and equipment should be cleaned with an appropriate deactivation agent and cleaning agent before and after each activity and at the ends of the work shift. The use of separate cleaning equipment to clean the rooms and bathrooms of patients receiving chemotherapy will help reduce the spread of chemotherapy-containing secretions to non-chemotherapy rooms (Ramphal et al, 2014).
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HEALTH AND SAFETY be monitored in a medical programme that takes a medical and exposure history, physical examination and laboratory testing. Medical surveillance is one element of a comprehensive approach to minimising worker exposure to the hazardous of antineoplastic exposure and should be used as part of a safety and health programme that includes engineering controls, good work practices and PPE (HSE, 2013; NIOSH, 2013).
Conclusion The toxicities associated with antineoplastic agents have been well documented since their initial clinical use. Healthcare workers are at constant risk of exposure to these potential toxicities. Improving heath and safety should be an essential commitment for healthcare management and it is incumbent on all employees to adhere to recommended work practices. The use of engineering controls and PPE has been shown to substantially reduce worker exposure to antineoplastic drugs. Comprehensive and ongoing education and training for all staff involved in this process is vital. Management must ensure that appropriate policies, procedures, protocols and guidelines are in place regarding health and safety and that they are BJN implemented and evaluated regularly.
© 2014 MA Healthcare Ltd
Conflict of interest: this article was supported by CareFusion
American Society of Health-System Pharmacists (1990) ASHP technical assistance bulletin on handling cytotoxic and hazardous drugs. Am J Hosp Pharm 47:1033-49 American Society of Health-System Pharmacists (2006) ASHP Guidelines on Handling Hazardous Drugs. Am J Health-Syst Pharm 63: 1172-93 British Oncology Pharmacy Association (2013) Standards for Clinical Pharmacy Verification of Prescriptions for Cancer Medicines. April. http://tinyurl.com/ p2lh97p (accessed 27 August 2014) Connor T, McDiarmid M (2006) Preventing occupational exposures to antineoplastic drugs in health care settings. CA Cancer J Clin 56: 354-65 Connor T, Debord G, Pretty J et al (2010) Evaluation of antineoplastic drug exposure of health care workers at three university–based US cancer centres. J Occup Environ Med 52(10) 1019-27. doi: 10.1097/JOM.0b013e3181f72b63. Dranitsaris G, Johnson M, Poirier S et al (2005) Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and metaanalysis of the literature. J Oncol Pharm Pract 11(2) 69-78. Falck K, Gröhn P, Sorsa M, Vainio H, Heinonen E, Holsti LR (1979) Mutagenicity in urine of nurses handling cytostatic drugs. Lancet 1(12):12501 Fransman W, Vermeulen R, Kromhout H (2005) Dermal exposure to cyclosphamide in hospitals during preparation, nursing and cleaning activities. Int Arch Occup Environ Health 78(5):403-12 Furlow B (2010) How to improve the safety of chemotherapy administration. Oncology Nurse Advisor June: 21–5 Green E, Johnson M, Tradeau M et al (2009) Safe handling of parenteral cytotoxics: recommendations for Ontario. J Oncol Pract 5(5): 245–9. doi: 10.1200/JOP.091014 Hedmer M, Georgiadi A, Ramme Bremberg E, Jönsson BAG, Eksborg S (2005) Surface contamination of cyclophosphamide packaging and surface contamination with antineoplastic drugs in a hospital pharmacy in Sweden. Ann Occup Hyg 49(7): 629-37 Health and Safety Executive (2003) Safe Handling of Cytotoxic Drugs. Information sheet MISC615. HSE, Bootle Health and Safety Executive (2013) Control of Substances Hazardous to Health: The Control of Substances Hazardous to Health Regulations 2002 (as amended) Approved Code of Practice and Guidance. 6th edn. HSE Books, London Hon CY, Teschke K, Chu W, Demers P, Venners S (2013) Antineoplastic drug contamination of surfaces throughout the hospital medication system in Canadian hospitals. J Occup Environ Hyg 10(7): 374-83. doi: 10.1080/15459624.2013.789743 Huber C (2010) The safe handling of hazardous drugs. Am J Nurs 110(10): 61-3. doi: 10.1097/01.NAJ.0000389679.57273.c1 International Society of Oncology Pharmacy Practitioners (2007) ISOPP standards of practice. Safe handling of cytotoxics. J Oncol Pharm Pract 13(1): 1-81 Kopp B, Crauste-Manciet S, Guibert A et al (2013) Environmental and biological monitoring of platinum-containing drugs in two hospital pharmacies using positive air pressure isolators. Ann Occup Hyg 57(3): 374-83. doi: 10.1093/annhyg/mes073. Epub 2012 Mason H, Blair S, Sams C et al (2005) Exposure to antineoplastic drugs in two UK hospital pharmacy units. Ann Occup Hyg 49(7) 603-610. Miyake T, Iwanto T, Tanimura M, Okuda M. (2013) Impact of a closed-system drug transfer device on exposure of environment and healthcare provider to cyclosphamide in Japanese hospital. Springerplus 2:273. doi:10.1186/21931801-2-273
British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 16
KEY POINTS n The management of cytotoxic drugs with potentially serious side effects continues to pose a risk for all staff involved in their handling throughout the life cycle of the drug from receipt, preparation, administration and disposal n All healthcare workers involved in the handling and administration of cytotoxic drugs must have up-to-date and comprehensive education and training n Adherence to a comprehensive safe-handling programme must involve all members of the multidisciplinary team n Healthcare workers must always use safe-handling procedures and compliance with these procedures must be monitored n Adherence to current recommendations will reduce healthcare worker exposure National Institute for Occupational Safety and Health (2004) NIOSH Alert: Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Setting. http://tinyurl.com/csg8eds (accessed 27 August 2014) National Institute for Occupational Safety and Health (2008) Personal Protective Equipment for Health Care Workers Who Work with Hazardous Drugs. http:// tinyurl.com/k68pzr2 (accessed 27 August 2014) National Institute for Occupational Safety and Health (2010) NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Setting 2010. http://tinyurl.com/ctecpga (accessed 27 August 2014) National Institute for Occupational Safety and Health (2013) Medical Surveillance for healthcare workers exposed to hazardous drugs. http:// tinyurl.com/kawk7c5 (accessed 27 August 2014) National Cancer Action Team (2011) National Cancer Peer Review Programme Manual for Cancer Services: Chemotherapy Measures Version1.0. National Cancer Action Team, National Cancer Programme National Cancer Action Team (2012) Quality in Nursing: A census of the Chemotherapy nursing workforce in England 2012. National Cancer Action Team. Odraska P, Dolezalova L, Kuta J, Oravec M, Piler P, Blaha L (2013) Evaluation of the efficiency of additional measures introduced for the protection of healthcare personnel handling antineoplastic drugs. Ann Occup Hyg 57(2): 240-50. doi: 10.1093/annhyg/mes057. Epub 2012 Polovich M (2004) Safe handling of hazardous drugs. Online J Issues Nurs. 9(3):6 Power L, Polovich M (2012) Safe handling of hazardous drugs: Reviewing standards for worker protection. Pharmacy Practice News Special Edition: 31-42 Queruau Lamerie T, Nussbaumer S, Décaudin B (2013) Evaluation of decontamination efficacy of cleaning solutions on stainless steel and glass surfaces contaminated by 10 antineoplastic agents.. Ann Occup Hyg 57(4): 456-69. doi: 10.1093/annhyg/mes087. Epub 2012 Ramphal R, Bains T, Vaillancourt R, Osmond M, Barrowman N (2014) Occupational exposure to cyclosphamide in nurses at a single centre. J Occup Environ Med 56(3): 304-12. doi: 10.1097/JOM.0000000000000097. Selevan S, Lindbohm M, Hornung R, Hemminki K (1985) A study of occupational exposure to antineoplastic drugs and fetal loss in nurses. N Engl J Med 313(19): 1173-8 Sessink P, Boer K, Scheefhals A, Anzion B, Bos R (1992) Occupational exposure to antineoplastic agents at several departments in a hospital. Int Arch Occup Environ Health 64(2): 105-12 Sessink P, Connor T, Jorgenson J, Tyler T (2011) Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed system drug transfer device. J Oncol Pharm Pract 17(1): 39-48. doi: 10.1177/1078155210361431. Epub 2010 Sottani C, Porro B, Imbriani M, Minoia C (2012) Occupational exposure to antineoplastic drugs in four Italian health care settings. Toxicol Lett 213(1):107-15. doi: 10.1016/j.toxlet.2011.03.028. Epub 2011 Touzin K, Bussières JF, Langlois E, Lefebvre M (2009) Evaluation of surface contamination in a hospital hematology-oncology pharmacy. J Oncol Pharm Pract 15(1):53-61. doi: 10.1177/1078155208096904. Epub 2008 Turk M, Davas A, Ciceklioglu M, Sacaklioglu F, Mercan T (2004) Knowledge, attitude and safe behaviour of nurses handling cytotoxic anticancer drugs in Ege University Hospital. Asian Pac J Cancer Prev 5(2) 164-8. Valanis B, Vollmer W, Labuhn K, Glass A (1997) Occupational exposure to antineoplastic agents and self-reported infertility among nurses and pharmacists J Occup Environ Med 39(6): 574-80 Vandenbroucke J, Robays H (2001) How to protect environments and employees against cytotoxic agents, the UZ Ghent experience. Journal of Oncology Pharmacy Practice 6(4): 146-152. doi: 10.1177/107815520100600403 Vyas N, Yiannakis D, Turner A, Sewell G (2014) Occupational exposure to anti-cancer drugs: A review of effects of new technology. J Oncol Pharm Pract 20(4): 278-87 Wick C, Slawson M, Jorgenson J, Tyler L (2003) Using a closed system protective device to reduce personnel exposure to antineoplastic agents. Am J Health Syst Pharm 60(15): 2314-9 Yoshida J, Koda S, Nishida S, Nakono H, Tei G, Kumagai S (2013) Association between occupational exposure and control measures for antineoplastic drugs in a pharmacy of a hospital. Ann Occup Hyg 57(2): 251-60. doi: 10.1093/annhyg/mes061. Epub 2012
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Many cytotoxic drugs have been shown to be mutagenic, teratogenic and carcinogenic with second malignancies known to be associated with several specific cancer drugs. Occupational exposure to cytotoxic drugs presents a signification danger to healthcare staff and unwarranted handling of these drugs should be avoided. Guidelines have been established for the safe handling of hazardous drugs but not all professionals are adhering to these recommendations. Recent environmental studies have demonstrated measurable drug contamination on surfaces even when recommended guidelines are followed. It is therefore imperative that healthcare workers are aware of the potential hazards of antineoplastic agents and employ the recommended precautions to minimise exposure. This article outlines the potential risks associated with exposure to cytotoxic drugs for healthcare staff. The safe-handling precautions required in the storage, preparation, transport, administration and waste disposal of cytotoxic drugs are presented. Key words: Cytotoxins agents ■ Risk ■ Safety
■
Pharmaceutical preparations
■
Antineoplastic
T
he introduction of cytotoxic drugs dates back to the 1940s (Polovich, 2004). Antineoplastic drugs are non-selective in their mechanism of action thereby affecting both cancerous and healthy cells with welldocumented toxic side effects in treated individuals (Vyas et al, 2014). These include hepatic, renal, cardiac, pulmonary and haematopoietic effect, reproductive toxicity, ototoxicity, immunotoxicity, dermal toxicity, and particular injury to tissues with rapid turnover rate (Connor and McDiarmid, 2006). In the 1970s second malignancies were reported in patients who had previously received chemotherapy for solid tumours. The most common of these were leukaemia and bladder cancer. Health professionals exposed to cytotoxic drugs can suffer the same potential toxicities (National Institute for Occupational Safety and Health (NIOSH), 2004; Green et al, 2009; Furlow, 2010; Health and Safety Executive (HSE), 2013). Despite the implementation of detailed guidelines and regulation for the safe handling of cytotoxic drugs many recent studies show that nurses and pharmacy personnel are still being Elizabeth Meade, Advanced Nurse Practitioner (Oncology), Health Service Executive, Dublin, Mid Leinster Midland Regional Hospital Tullamore, Co. Offaly Accepted for publication: August 2014
S34
exposed to these substances (Mason et al, 2005; Connor et al, 2010; Kopp et al, 2013; Queruau Lamerie et al, 2013; Ramphal et al, 2014). This article will identify potential risks for healthcare workers and discuss risk reduction management in the key areas of receipt and storage, preparation, transport, administration and disposal of hazardous drugs as well as the medical surveillance of healthcare workers.
Health effects of cytotoxic drugs Drugs classed as ‘hazardous’ include antineoplastic and cytotoxic agents, some hormonal agents, immunosuppressants, antiviral medications and some monoclonal antibodies (Table 1).Workers are exposed to a drug throughout its life cycle, during manufacture, transport, distribution, administration and disposal (Huber, 2010). The first evidence documenting occupational exposure to cytotoxic drugs in healthcare workers was provided by Falck et al (1979) in which nurses who prepared and administered antineoplastic drugs were shown to have higher indicators of mutagenic substances in their urine compared with nonexposed workers. Numerous studies have replicated this original work and highlighted the potential dangers associated with the preparation and administration of antineoplastic agents (Selevan et al, 1985; Valanis et al, 1997; Wick et al, 2003). Dranitsaris et al (2005), in their systematic review and meta-analysis, described an association between exposure to antineoplastic drugs and adverse reproductive effects in female health care workers. The most common reproductive effects were increased fetal loss, congenital abnormalities, low birth weight and infertility. Other potential consequences in exposed workers are outlined in Box 1. The number of healthcare workers potentially exposed to hazardous drugs is estimated in the USA to be in the region of 8 million and include all members of the multidisciplinary Table 1. Definitions of hazardous drugs Carcinogenicity
Can cause cancer in animals or humans
Genotoxicity
Ability to cause genetic changes or mutations
Teratogenicity
Fetal defects or malformation
Reproductive toxicity
Fertility impairment
Organ toxicity
Serious organ toxicity at low doses
Structure and toxicity profile of new drugs that mimic existing drugs determined to be hazardous Sources: American Society of Healthcare-Systems Pharmacists (ASHP), 1990; National Institute for Occupational Safety and Health (NIOSH), 2010
© 2014 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 16
British Journal of Nursing.Downloaded from magonlinelibrary.com by 129.180.001.217 on October 27, 2014. For personal use only. No other uses without permission. . All rights reserved.
Hair loss ■ Vomiting, abdominal pain ■ Headaches, nasal sores, sore throat ■ Liver damage, alterations to normal blood cell count ■ Acute irritation, hypersensitivity ■ Adverse reproductive outcomes including infertility, spontaneous abortion and congenital malformations ■ Possible leukaemia and other cancers ■ Abnormal formations of cells and mutagenic activity or mutations forming. ■
Sources: NIOSH, 2004; Polovich, 2004; Connor at al, 2006; Health and Safety Executive (HSE), 2013
Box 2. Healthcare workers exposed to hazardous drugs as occupational risks Pharmacists and pharmacy technicians Nursing personnel ■ Physicians ■ Operating room personnel ■ Environmental services personnel including porters, housekeeping, laundry and maintenance workers ■ ■
Source: NIOSH, 2013
team (NIOSH 2013) (Box 2). Hon et al (2013) state that a broader range of workers and visitors are potentially exposed while Ramphal et al (2014) demonstrated that one third of oncology nurses in one hospital and local community setting in Canada tested positive for urinary cyclosphamide while one third of non-oncology nurses also tested positive suggesting environmental contamination was widespread within the hospital environment.
Occupational exposure The health risk of cytotoxic drugs is influenced by the extent of the exposure and the potency and toxicity of the hazardous drug (Yoshida et al, 2013). Healthcare workers have different types of exposure to cytotoxic drugs depending on their job description, e.g. pharmacy technicians involved in preparation of the drugs are exposed to a very concentrated form of the drug whereas nurses are exposed to a more dilute form during administration or handling patient waste. However, contamination and exposure can still occur with one study demonstrating that the highest concentrations of chemotherapy agents were found in areas contaminated with body fluids (Ramphal et al, 2014). In the 1980s the centralisation of the preparation of antineoplastic drugs in specialised pharmacies by specially trained staff, coupled with the use of isolators, biological Box 3. Core elements of international guidelines for the safe handling of hazardous drugs Exposure assessment of safe handling procedures throughout the entire drug life cycle from receipt to disposal. ■ Use of specialised equipment—biological safety cabinet and isolator ■ Wearing personnel protective equipment (PPE) ■ Training and education of workers handling antineoplastic drugs or workers at risk of exposure ■ Health surveillance ■
■ Implementation
Sources: NIOSH, 2004; ASHP, 2006; International Society of Oncology Pharmacy Practitioners, 2007; HSE, 2013; NIOSH 2013
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safety cabinets and personal protective equipment (PPE) was an important step in the protection of healthcare workers. Overall exposure was reduced by these measures but significant environmental contamination and antineoplastic drug exposure is still commonly observed (Fransman et al, 2005; Hedmer et al, 2005; Mason et al, 2005; Touzin et al , 2009; Connor at al, 2010; Sessink et al, 2011; Sottani et al, 2012; Odraska et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014) Adherence to recommended work practices and the use of engineering controls and PPE has been shown to substantially reduce worker exposure to cytotoxic drugs (Odraska et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014). However, several factors such as increased workload, understaffing, lack of knowledge, improper training, budgetary constraints, more complex regimes and the use of antineoplastic drugs in a non-oncology setting can adversely affect how these drugs are handled (Turk et al, 2004; Polovich, 2004; Power et al, 2012).
National and international guidelines Due to the potential health risks and the continuing environmental contamination of hazardous drugs the US National Institute for Occupational Safety and Health (NIOSH) (2004) produced an alert regarding the risks posed to exposed healthcare workers and the measures recommended to protect these workers’ health and safety. These guidelines were updated by the American Society of Health-Systems Pharmacists (ASHP) (2006) and International Society of Oncology Pharmacy Practitioners (ISOPP) (2007). In the UK the Health and Safety Executive (HSE) recently updated its guidelines on hazardous drugs (relating to the Control of Substances Hazardous to Health Regulations) (HSE, 2013). Detailed standards for the safe prescribing, preparation and administration of antineoplastic agents have also been developed by the HSE (2003), National Cancer Action Team (2011; 2012) and British Oncology Pharmacy Association (BOPA) (2013). It is recommended that only individuals trained in the safe handling of antineoplastic drugs should be involved in their handling and that retraining of staff and competency testing should be undertaken on an annual basis. The essential elements of international guidelines are outlined in Box 3.
Routes of exposure Exposure can be measured biologically by looking for the metabolites of cytotoxic drugs in urine or by environmentally wiping surfaces with special surface wipes and analysing these wipes for the specific drugs (Mason, 2005; Kopp et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014). Numerous studies have documented both surface and worker contamination by cytotoxic drugs. Routes of exposure include inhalation, dermal absorption, ingestion, and injection (Box 4).Workers are exposed by inhalation via droplets, particles and vapours. This can occur during preparation when vapour can escape from connections between the vial and syringe, or during administration from the syringe and port. A major source of exposure for nurses is spiking or unspiking intravenous solution (IV) bags and priming of the tubing. Vandenbrouke (2001) demonstrated that leakage of the drug during spiking
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Box 1. Health effects of hazardous drugs in exposed workers
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HEALTH AND SAFETY occurs 25% of the time and during unspiking 100% of the time. Needlestick injuries with contaminated needles results in exposure by injection (Huber, 2010; Power at al, 2012). The greatest risk is direct skin contact with the drug when a spill or leak occurs (ISOPP, 2007). Several studies have highlighted drug contamination on surfaces of vials, biological safe cabinets, countertops, floors, equipment and most surfaces in the areas where patients are treated (Sessink et al, 1992; Polovich, 2004; Connor and McDiarmid, 2006; Touzin at al, 2009; Kopp et al, 2013; Yoshida et al, 2013; Ramphal et al, 2014). Dermal exposure also occurs when staff come into contact with contaminated surfaces during preparation, administration or disposal of hazardous drugs. Handling bodily fluids or contaminated clothing, linen, dressings and other materials also increases the risk of exposure (NIOSH, 2004; Huber, 2010; Kopp et al, 2013). Oral exposure may occur from hand to mouth contact. When food and beverages are prepared, stored or consumed in the work area they may easily become contaminated with airborne particles of antineoplastic drugs. Similarly hands, cigarettes, cosmetics and chewing gum can be contaminated. Inadvertent ingestion may be an additional route of exposure (Connor et al, 2006; Huber, 2010).
Box 4. Routes of exposure Inhalation Dermal absorption ■ Ingestion ■ Injection ■ ■
Sources: NIOSH, 2004; HSE, 2013
Box 5. Personal protective equipment (PPE) ■ Gowns:
disposable, made of fabric that has low permeability to the agents used with closed front and cuffs, intended for single use ■ Gloves: powder free, labelled and tested for use with chemotherapy drugs made of nitrile or neoprene ■ Face and eye protection when splashing is possible ■ An approved respirator when there is a risk of inhalation. Choose products which are CE marked in accordance with the PPE Regulations 2002 Sources: HSE, 2013; NIOSH, 2008; 2013
The use of safe-handling practices for healthcare workers can dramatically reduce the potential exposure to these drugs (NIOSH, 2004; HSE, 2013). These practices include: ■■ Receipt and storage of drugs ■■ Drug preparation ■■ Transportation of the drug ■■ Administration of the drug to the patient ■■ Drug waste handling—including patient waste, drug waste and laundry ■■ Spill control (HSE, 2013).
contamination and exposure (Vyas et al, 2014). It is essential that personnel follow all recommendations for PPE consistently during drug preparation: double gloves with the outer extending over the cuff of the gown and gowns with closed fronts, long sleeves and elastic or knit closed cuffs (Figure 2). Adherence to strict hand-washing techniques before donning gloves and immediately after removal is recommended. The disposal of all sharps should be performed without crushing, capping or clipping. When drug preparation is complete the drug should be placed in a sealed plastic bag before removal from the cabinet with hazard warning label clearly displayed (Figure 3). The attachment of the drug administration set in the BSC eliminates the escape of the hazardous drug during priming. All PPE and other materials should be disposed of in hazardous waste containers.
Receipt and storage of antineoplastic drugs
Antineoplastic drug transportation
Personnel unpacking containers of cytotoxic drugs should open the containers carefully and inspect on arrival. They should be prepared for the possibility that spills may occur. Personnel must wear PPE that is recommended for handling cytotoxic drugs in order to protect themselves from dermal and inhalation exposure (Box 5). Cytotoxic drugs require warning labels and safe storage in a well-ventilated area separate from other drugs. Spill kits should be available wherever cytotoxic drugs are stored, prepared and administered.
In order to minimise exposure risk, cytotoxic drugs should be transported within a special sealed bag in a properly labelled leak-proof container by personnel who are educated on emergency procedures in the case of a spill and who have access to a spill kit. It is important that staff wear chemotherapy gloves during transportation.
Safe handling of cytotoxic drugs
Figure 1. Closed system devices
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Antineoplastic drug preparation Asepsis and containment is required during preparation of antineoplastic drugs using a Class 2 or Class 3 biological safety cabinet (BSC) or an isolator. All healthcare workers using ventilated cabinets must be trained in their particular use and safety. Preparation is performed in a controlled environment where access is limited to authorised personnel only. It is important to keep the BSC and isolators free from clutter, properly cleaned, maintained and upgraded according to the manufacturer’s instructions. Closed systems (Figure 1) used in the preparation and administration of cytotoxic drugs are designed to reduce environmental
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the BSC. However, when priming lines at the administration site it is important to use a non-drug solution. Venting tubes must not be used. In order to prevent unintended exposure tubing must not be removed or disconnected from an IV bag containing a hazardous drug (Huber, 2010). Items for waste disposal must be placed directly in chemotherapy waste container at the site of administration keeping the lid of the chemotherapy waste container closed between uses. Reusable items should be washed twice in detergent wearing double latex gloves and gown. Soap and water must be used to wash hands before leaving the drug administration site. Figure 1. Reconstitution of cytotoxic drugs
Antineoplastic drug waste handling Each institution should have a policy for the segregation of waste materials resulting from antineoplastic drug preparation and administration. Patient waste (urine, blood, vomit, sweat, faeces) and materials are considered to contain the drug and its metabolites and are handled as hazardous. These materials include used vials, IV sets, syringes, gloves, gowns, bedpans and linen. All employees handling hazardous waste are required to wear PPE designated for this purpose.
Spill control
Figure 3. Hazard warning labels must be displayed clearly
Emergency procedure to cover spills must be managed according to established, written policy. Hazard spills are considered small when their volume is less than 5 ml and are considered large when the volume is over 5 ml (Huber, 2010). All contaminated clothing must be removed immediately. When managing small and large spills it is essential that staff wear PPE including recommended gloves, a gown, eye wear, shoe protection and if necessary a face shield. Spills must be cleaned up immediately by properly trained and protected staff members. Warning signs must be used to limit access to the area and all clean-up materials disposed of in a hazardous waste container. All incidences should be reported documenting the spill and the personnel exposed (HSE, 2013).
Routine cleaning and decontamination
Antineoplastic drug administration It is essential that all personnel administering chemotherapy wear recommended PPE and adhere to strict hand-washing techniques before donning gloves and immediately after removal. Contaminated or damaged gloves must be changed immediately. In order to reduce exposure infusion sets and pumps should have a Luer lock system and be observed for leakage during use. A plastic-backed absorbent pad placed under the tubing during administration and sterile gauze around any push site will help reduce patient dermal exposure. Drug administration is safer using needless and closed systems (Figure 4) (Wick et al, 2003;Yoshida et al, 2009; Sessink et al, 2011; Kopp et al, 2013; Miyake et al, 2013). The priming of the line or expelling air from the line should be done in
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Medical surveillance Medical surveillance involves collecting and interpreting data to detect changes in the health status of the working population exposed to hazardous substances. The elements of medical surveillance are used to establish baseline health and to monitor the future health of professionals as it relates to their potential exposure to hazardous agents. It is recommended that personnel exposed to hazards of antineoplastic drugs should
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Figure 4. Chemotherapy administration
It is essential that all healthcare workers wear recommended PPE when carrying out cleaning and decontamination. Cleaning and decontamination work should be performed in areas that are sufficiently ventilated. Work surfaces and equipment should be cleaned with an appropriate deactivation agent and cleaning agent before and after each activity and at the ends of the work shift. The use of separate cleaning equipment to clean the rooms and bathrooms of patients receiving chemotherapy will help reduce the spread of chemotherapy-containing secretions to non-chemotherapy rooms (Ramphal et al, 2014).
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HEALTH AND SAFETY be monitored in a medical programme that takes a medical and exposure history, physical examination and laboratory testing. Medical surveillance is one element of a comprehensive approach to minimising worker exposure to the hazardous of antineoplastic exposure and should be used as part of a safety and health programme that includes engineering controls, good work practices and PPE (HSE, 2013; NIOSH, 2013).
Conclusion The toxicities associated with antineoplastic agents have been well documented since their initial clinical use. Healthcare workers are at constant risk of exposure to these potential toxicities. Improving heath and safety should be an essential commitment for healthcare management and it is incumbent on all employees to adhere to recommended work practices. The use of engineering controls and PPE has been shown to substantially reduce worker exposure to antineoplastic drugs. Comprehensive and ongoing education and training for all staff involved in this process is vital. Management must ensure that appropriate policies, procedures, protocols and guidelines are in place regarding health and safety and that they are BJN implemented and evaluated regularly.
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Conflict of interest: this article was supported by CareFusion
American Society of Health-System Pharmacists (1990) ASHP technical assistance bulletin on handling cytotoxic and hazardous drugs. Am J Hosp Pharm 47:1033-49 American Society of Health-System Pharmacists (2006) ASHP Guidelines on Handling Hazardous Drugs. Am J Health-Syst Pharm 63: 1172-93 British Oncology Pharmacy Association (2013) Standards for Clinical Pharmacy Verification of Prescriptions for Cancer Medicines. April. http://tinyurl.com/ p2lh97p (accessed 27 August 2014) Connor T, McDiarmid M (2006) Preventing occupational exposures to antineoplastic drugs in health care settings. CA Cancer J Clin 56: 354-65 Connor T, Debord G, Pretty J et al (2010) Evaluation of antineoplastic drug exposure of health care workers at three university–based US cancer centres. J Occup Environ Med 52(10) 1019-27. doi: 10.1097/JOM.0b013e3181f72b63. Dranitsaris G, Johnson M, Poirier S et al (2005) Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and metaanalysis of the literature. J Oncol Pharm Pract 11(2) 69-78. Falck K, Gröhn P, Sorsa M, Vainio H, Heinonen E, Holsti LR (1979) Mutagenicity in urine of nurses handling cytostatic drugs. Lancet 1(12):12501 Fransman W, Vermeulen R, Kromhout H (2005) Dermal exposure to cyclosphamide in hospitals during preparation, nursing and cleaning activities. Int Arch Occup Environ Health 78(5):403-12 Furlow B (2010) How to improve the safety of chemotherapy administration. Oncology Nurse Advisor June: 21–5 Green E, Johnson M, Tradeau M et al (2009) Safe handling of parenteral cytotoxics: recommendations for Ontario. J Oncol Pract 5(5): 245–9. doi: 10.1200/JOP.091014 Hedmer M, Georgiadi A, Ramme Bremberg E, Jönsson BAG, Eksborg S (2005) Surface contamination of cyclophosphamide packaging and surface contamination with antineoplastic drugs in a hospital pharmacy in Sweden. Ann Occup Hyg 49(7): 629-37 Health and Safety Executive (2003) Safe Handling of Cytotoxic Drugs. Information sheet MISC615. HSE, Bootle Health and Safety Executive (2013) Control of Substances Hazardous to Health: The Control of Substances Hazardous to Health Regulations 2002 (as amended) Approved Code of Practice and Guidance. 6th edn. HSE Books, London Hon CY, Teschke K, Chu W, Demers P, Venners S (2013) Antineoplastic drug contamination of surfaces throughout the hospital medication system in Canadian hospitals. J Occup Environ Hyg 10(7): 374-83. doi: 10.1080/15459624.2013.789743 Huber C (2010) The safe handling of hazardous drugs. Am J Nurs 110(10): 61-3. doi: 10.1097/01.NAJ.0000389679.57273.c1 International Society of Oncology Pharmacy Practitioners (2007) ISOPP standards of practice. Safe handling of cytotoxics. J Oncol Pharm Pract 13(1): 1-81 Kopp B, Crauste-Manciet S, Guibert A et al (2013) Environmental and biological monitoring of platinum-containing drugs in two hospital pharmacies using positive air pressure isolators. Ann Occup Hyg 57(3): 374-83. doi: 10.1093/annhyg/mes073. Epub 2012 Mason H, Blair S, Sams C et al (2005) Exposure to antineoplastic drugs in two UK hospital pharmacy units. Ann Occup Hyg 49(7) 603-610. Miyake T, Iwanto T, Tanimura M, Okuda M. (2013) Impact of a closed-system drug transfer device on exposure of environment and healthcare provider to cyclosphamide in Japanese hospital. Springerplus 2:273. doi:10.1186/21931801-2-273
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KEY POINTS n The management of cytotoxic drugs with potentially serious side effects continues to pose a risk for all staff involved in their handling throughout the life cycle of the drug from receipt, preparation, administration and disposal n All healthcare workers involved in the handling and administration of cytotoxic drugs must have up-to-date and comprehensive education and training n Adherence to a comprehensive safe-handling programme must involve all members of the multidisciplinary team n Healthcare workers must always use safe-handling procedures and compliance with these procedures must be monitored n Adherence to current recommendations will reduce healthcare worker exposure National Institute for Occupational Safety and Health (2004) NIOSH Alert: Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Setting. http://tinyurl.com/csg8eds (accessed 27 August 2014) National Institute for Occupational Safety and Health (2008) Personal Protective Equipment for Health Care Workers Who Work with Hazardous Drugs. http:// tinyurl.com/k68pzr2 (accessed 27 August 2014) National Institute for Occupational Safety and Health (2010) NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Setting 2010. http://tinyurl.com/ctecpga (accessed 27 August 2014) National Institute for Occupational Safety and Health (2013) Medical Surveillance for healthcare workers exposed to hazardous drugs. http:// tinyurl.com/kawk7c5 (accessed 27 August 2014) National Cancer Action Team (2011) National Cancer Peer Review Programme Manual for Cancer Services: Chemotherapy Measures Version1.0. National Cancer Action Team, National Cancer Programme National Cancer Action Team (2012) Quality in Nursing: A census of the Chemotherapy nursing workforce in England 2012. National Cancer Action Team. Odraska P, Dolezalova L, Kuta J, Oravec M, Piler P, Blaha L (2013) Evaluation of the efficiency of additional measures introduced for the protection of healthcare personnel handling antineoplastic drugs. Ann Occup Hyg 57(2): 240-50. doi: 10.1093/annhyg/mes057. Epub 2012 Polovich M (2004) Safe handling of hazardous drugs. Online J Issues Nurs. 9(3):6 Power L, Polovich M (2012) Safe handling of hazardous drugs: Reviewing standards for worker protection. Pharmacy Practice News Special Edition: 31-42 Queruau Lamerie T, Nussbaumer S, Décaudin B (2013) Evaluation of decontamination efficacy of cleaning solutions on stainless steel and glass surfaces contaminated by 10 antineoplastic agents.. Ann Occup Hyg 57(4): 456-69. doi: 10.1093/annhyg/mes087. Epub 2012 Ramphal R, Bains T, Vaillancourt R, Osmond M, Barrowman N (2014) Occupational exposure to cyclosphamide in nurses at a single centre. J Occup Environ Med 56(3): 304-12. doi: 10.1097/JOM.0000000000000097. Selevan S, Lindbohm M, Hornung R, Hemminki K (1985) A study of occupational exposure to antineoplastic drugs and fetal loss in nurses. N Engl J Med 313(19): 1173-8 Sessink P, Boer K, Scheefhals A, Anzion B, Bos R (1992) Occupational exposure to antineoplastic agents at several departments in a hospital. Int Arch Occup Environ Health 64(2): 105-12 Sessink P, Connor T, Jorgenson J, Tyler T (2011) Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed system drug transfer device. J Oncol Pharm Pract 17(1): 39-48. doi: 10.1177/1078155210361431. Epub 2010 Sottani C, Porro B, Imbriani M, Minoia C (2012) Occupational exposure to antineoplastic drugs in four Italian health care settings. Toxicol Lett 213(1):107-15. doi: 10.1016/j.toxlet.2011.03.028. Epub 2011 Touzin K, Bussières JF, Langlois E, Lefebvre M (2009) Evaluation of surface contamination in a hospital hematology-oncology pharmacy. J Oncol Pharm Pract 15(1):53-61. doi: 10.1177/1078155208096904. Epub 2008 Turk M, Davas A, Ciceklioglu M, Sacaklioglu F, Mercan T (2004) Knowledge, attitude and safe behaviour of nurses handling cytotoxic anticancer drugs in Ege University Hospital. Asian Pac J Cancer Prev 5(2) 164-8. Valanis B, Vollmer W, Labuhn K, Glass A (1997) Occupational exposure to antineoplastic agents and self-reported infertility among nurses and pharmacists J Occup Environ Med 39(6): 574-80 Vandenbroucke J, Robays H (2001) How to protect environments and employees against cytotoxic agents, the UZ Ghent experience. Journal of Oncology Pharmacy Practice 6(4): 146-152. doi: 10.1177/107815520100600403 Vyas N, Yiannakis D, Turner A, Sewell G (2014) Occupational exposure to anti-cancer drugs: A review of effects of new technology. J Oncol Pharm Pract 20(4): 278-87 Wick C, Slawson M, Jorgenson J, Tyler L (2003) Using a closed system protective device to reduce personnel exposure to antineoplastic agents. Am J Health Syst Pharm 60(15): 2314-9 Yoshida J, Koda S, Nishida S, Nakono H, Tei G, Kumagai S (2013) Association between occupational exposure and control measures for antineoplastic drugs in a pharmacy of a hospital. Ann Occup Hyg 57(2): 251-60. doi: 10.1093/annhyg/mes061. Epub 2012
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