Safe Handling. Objectives At the completion of this session the participant will be able to: ◦ Describe the occupational exposure risks of chemotherapy/biotherapy.

Safe HandlingSafe Handling

ObjectivesObjectivesAt the completion of this session the participant will be able to:◦Describe the occupational exposure risks of chemotherapy/biotherapy

◦List components of safe handling and disposal practices

◦Identify components of personal protection equipment

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IntroductionIntroductionChemotherapeutic agents are

used successfully to treat a variety of malignancies - these agents may also cause malignancy in individuals who handle them

The Occupational Safety and Health Administration (OSHA) (1995), reports that safe levels of occupational exposure to cytotoxic agents cannot be determined and no reliable method of monitoring exists

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IntroductionIntroductionThe National Institute for Occupational

Safety and Health (NIOSH) reports in studies that there is evidence of health risk, and safe levels of exposure to cytotoxic agents have not been determined by a reliable method (NIOSH, 2004).

Biotheraputic agents also can be associated with exposure risks. OSHA also has classified them as hazardous materials Use safe handling for any biotherapy agent labeled hazardous by the manufacturer or OSHA (e.g., interferon) (NIOSH, 2004).

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Occupational Occupational Exposure RiskExposure RiskHealth care workers handling

chemotherapy and biotherapy agents are at risk for occupational exposure to these toxins, and the long-term effects are unknown

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Occupational Occupational Exposure RiskExposure Risk

The potential health risks include: ◦Carcinogenicity◦Genotoxicity◦Teratogenicity◦Organ toxicity◦Acute symptoms such as headache,

nausea, dizziness and skin, eye or throat irritation

(Valanis, Vollmer, Labuhn, & Glass, 1993) Safe Handling 6

Occupational Occupational Exposure RiskExposure Risk

The potential routes of exposure are◦Injection through needle stick◦Ingestion: direct or through food or beverage

◦Inhalation of drug by aerosolization

◦Absorption through mucous membranes after direct contact

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Safe Handling Safe Handling PolicyPolicy

Institutions are required by OSHA to develop and implement policies regarding the safe handling of cytotoxic and biologic agents

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Safe Handling Safe Handling PolicyPolicyProtection measures must include at a minimum:◦Safe administration, storage, transport

and disposal of hazardous agents◦Provision of mandatory training of

employees regarding hazardous materials

◦Monitoring of long term occupational exposure and minimization of employee risk

◦Hazardous drug spill management

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Safe Handling Safe Handling PolicyPolicyProtection measures must include at a minimum:◦Prohibition of eating, drinking, chewing

gum, storing food, and applying cosmetics in areas where cytotoxic/biologic agents are prepared or administered

◦Provision of protection for employees who are pregnant, breast-feeding or planning a pregnancy

◦Monitoring compliance with the above indicated institutional policies and procedures

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Exposure Protection Exposure Protection GuidelinesGuidelinesPersonal Protective Equipment (PPE) is to

be used whenever there is a possibility of cytotoxic/biologic agents being released into the environment. This includes: ◦ Preparing or transferring

medications from vials, or ampoules; spiking, priming or changing IV equipment

◦ Expelling air or transferring medications using needles or syringes

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Exposure Protection Exposure Protection GuidelinesGuidelinesPPE usage (continued):

◦Contact with leaking tubing or connection sites

◦Managing cytotoxic spills◦Disposing of cytotoxic/biologic agents and mixing materials

◦When handling the body fluids of a patient for 48 hours after they receive chemotherapy

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Exposure Protection Exposure Protection GuidelinesGuidelinesPPE includes:

◦Gloves◦Gowns◦Face shield or goggles

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Exposure Protection Exposure Protection GuidelinesGuidelines

Labeling and Storage ◦Medications must be

clearly labeled for content and hazardous nature

◦Material Safety Data Sheets (MSDS) must be available for all medications

◦Any area that contains chemotherapeutic materials must be inaccessible to children with locked entry

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Exposure Protection Exposure Protection GuidelinesGuidelinesAdministration:

◦Obtain medication◦Wash hands and don PPE◦Place a sterile, plastic-backed

absorbent pad on the work surface◦Always work below eye level◦Ampoules: wrap absorbent sterile

pad around the neck of the ampoule and break away from yourself. Use a filtered straw for withdrawal

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Exposure Protection Exposure Protection GuidelinesGuidelines

Administration:◦Packaged medications, oral tablets and

capsules: avoid aerosolization, which results from pressure. Use venting devises to release the pressure. Capsules and tablets should be crushed under a BSC

◦Wear gloves when mixing agents that cause skin or other irritation (e.g., rituximab).

◦Do not overfill syringes to prevent the plunger from separating

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Exposure Protection Exposure Protection GuidelinesGuidelines

Administration:◦Excess medication or air contained

within a needleless syringe should never be expressed into the air, but should instead be expressed directly into a sterile gauze pad that is placed in a sealable plastic bag

◦Sterile technique should be maintained throughout parenteral drug preparation

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Exposure Exposure Protection Protection GuidelinesGuidelinesAdministration:◦ IV tubing should be primed

under a hood or be primed with 10-20ml of compatible solution using the backflow method

◦ IV tubing should have Luer-lock connections

◦ Wipe the tubing or syringe with moist gauze then place in a sealable plastic bag for transport

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Exposure Protection Exposure Protection GuidelinesGuidelines

Administration:◦An absorbent pad with a plastic back

is necessary for collecting any spill that may occur when connecting the tubing to the patient

◦A cytotoxic medication caution label is attached to the IV set for the duration of the chemotherapeutic/cytotoxic/biologic agent infusion

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Exposure Protection Exposure Protection GuidelinesGuidelines

Administration:◦ After administration, remove the IV bag with the

tubing attached (NIOSH, 2004). Do not remove the spike from the bag or reuse the tubing.

◦ Dispose of all equipment that has come in contact with the hazardous drug by placing the equipment in a container labeled “cytotoxic waste.”

◦ Use detergent and water to clean surfaces that have been in contact with hazardous drugs (Polovich, 2004).

◦ Remove and discard PPE◦ Wash your hands before leaving the preparation

and administration area

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Exposure Protection Exposure Protection GuidelinesGuidelinesAdministration

Review hospital-specific administration guidelines

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Exposure Protection Exposure Protection GuidelinesGuidelines

Disposal Guidelines◦Hazardous medical waste

containers must be available in all areas where hazardous medications are prepared and administered (NIOSH, 2004).

◦The waste containers should be puncture-proof, have a secure lid, and be clearly labeled as hazardous waste.

◦ Unused medicine returned to pharmacy

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Exposure Protection Exposure Protection GuidelinesGuidelinesBody Fluid Guidelines

◦Utilize PPE and standard universal precautions when handling patient’s body fluid or lines for 48 hours after administration of chemotherapy

◦Patients may use regular bathroom facilities

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Exposure Protection Exposure Protection GuidelinesGuidelines

Body Fluid Guidelines◦Diapers should be disposed of in the

same manner as other hazardous waste by placing them in appropriately labeled plastic hazardous waste bags

◦Bedpans, hats, urinals and emesis basins that are rinsed carefully with soap and water may be reused. After use, they should be discarded in the hazardous waste receptacle.

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Exposure Protection Exposure Protection GuidelinesGuidelines

Body Fluid Guidelines◦Linens that are contaminated with

body fluids should be placed in a plastic bag and labeled as contaminated by chemotherapy before placing them with other hospital laundry

◦The toilet should be flushed twice with the lid down after disposing of excreta from these patients for 48 hours following chemotherapy administration Safe Handling 25

Exposure Protection Exposure Protection GuidelinesGuidelinesSpill Guidelines

◦Spill kits should be available in all areas where cytotoxic drugs are stored, prepared, transported, and administered

◦Only trained personnel with appropriate PPE should clean up cytotoxic spills

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Exposure Protection Exposure Protection GuidelinesGuidelinesSpill Guidelines

Review hospital-specific spill kit and policy

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Safe Handling at Safe Handling at HomeHomePrecautions for family members to protect themselves from exposure ◦Pregnant caregivers should not mix or handle cytotoxic agents without appropriate PPE and education

◦Protective equipment use is demonstrated and a return demonstration given by the caregiver

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Safe Handling at Safe Handling at HomeHomePrecautions for family members to protect themselves from exposure ◦Designate a workplace in the home for handling cytotoxic agents

◦Special instructions for crushing tablets or opening capsules must be instituted in the home setting to protect caregivers and family members

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Safe Handling at Safe Handling at HomeHomeEmergency interventions and reporting mechanisms for accidental drug exposure◦Medication-specific exposure hazards reported by the manufacturer should be reviewed with the caregiver

◦Types of exposures and prevention/ precautions such as inhalation, splash, spill are reviewed with the caregiver

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Safe Handling at Safe Handling at HomeHomeEmergency interventions and reporting mechanisms for accidental drug exposure◦ Teaching sheets reviewed by the RN with the

caregiver must include safeguards such as: What to do for skin contact, eye contact

and environmental/clothing contact How to clean up a spill and dispose of

contaminated material Who to call and include the telephone

numbers

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Safe Handling at Safe Handling at HomeHomeSafe disposal of utensils, capsule remnants and contaminated materials◦Protection of children and pets in the

home from exposure to cytotoxic medication or waste products

◦Demonstration of appropriate disposable equipment should be provided to the caregiver

◦Explanation of safe disposal with specific individualized home setting considerations, as well as, county and state regulations

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Safe Handling at Safe Handling at HomeHome

Review hospital-specific teaching materials for

administering chemotherapy at home

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Questions?Questions?