Hazardous Drug Exposure in the Healthcare Environment: Developing Best Practices for Exposure Prevention Kathy Sperrazza RN, MS Doctoral Candidate University of Massachusetts Lowell School of Health and Environment MNA Congress on Health and Safety

National Institute for Occupational Safety and Health (NIOSH) ALERT - Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings, September 2004 ALERT - Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings, September million workers potentially exposed 5.5 million workers potentially exposed

NIOSH Alert Warning – Working with or near hazardous drugs in health care settings may cause skin rashes, infertility, miscarriage, birth defects and possibly leukemia or other cancers. Warning – Working with or near hazardous drugs in health care settings may cause skin rashes, infertility, miscarriage, birth defects and possibly leukemia or other cancers.

Workers at risk for exposure Nursing personnel Nursing personnel Physicians Physicians OR personnel OR personnel Pharmacists/pharmacy technicians Pharmacists/pharmacy technicians Environmental services personnel Environmental services personnel Veterinarians/Animal technicians Veterinarians/Animal technicians Shipping and receiving personnel Shipping and receiving personnel

Background for hazardous drug use Successful treatment of illness and injury Successful treatment of illness and injury Almost all drugs have side effects Almost all drugs have side effects Exposure to very small concentrations may be hazardous Exposure to very small concentrations may be hazardous Potential therapeutic effects outweigh risk for patients Potential therapeutic effects outweigh risk for patients Healthcare personnel risk side effects without benefits Healthcare personnel risk side effects without benefits

Drugs considered hazardous –Antineoplastic agents –Vaccines –Gonadotropins –Estrogens –Oxytocics –Contraceptives –Androgens –Antibiotics –Antivirals –Progestins –Misc. skin and mucous membrane agents

Evidence for health effects in workers Carcinogenicity of several antineoplastic drugs well established in animals by 1970’s Carcinogenicity of several antineoplastic drugs well established in animals by 1970’s Therapeutic use of alkylating agents in humans linked to leukemias and other cancers Therapeutic use of alkylating agents in humans linked to leukemias and other cancers Studies indicate antineoplastic drugs may cause increased genotoxic effects in nurses and pharmacists Studies indicate antineoplastic drugs may cause increased genotoxic effects in nurses and pharmacists

Developmental and reproductive effects 14 studies describe association between exposure to antineoplastic drugs and adverse reproductive effects such as: 14 studies describe association between exposure to antineoplastic drugs and adverse reproductive effects such as: increased fetal loss increased fetal loss congenital malformations congenital malformations low birth weight low birth weight infertility infertility

Potential for exposure is growing More and more new drugs/combinations of drugs More and more new drugs/combinations of drugs Developmental use of drugs, i.e. nanomedicines Developmental use of drugs, i.e. nanomedicines Methods of treatment and administration to patients changing Methods of treatment and administration to patients changing Drugs are used in medical offices, free standing surgical and cancer treatment centers and in home care. Drugs are used in medical offices, free standing surgical and cancer treatment centers and in home care. Contamination is widespread Contamination is widespread

Nanotechnology Nanometer is one billionth of a meter Nanometer is one billionth of a meter Matter on near-atomic sized scale Matter on near-atomic sized scale Used to produce new structures, materials and devices Used to produce new structures, materials and devices Unique properties at nanoscale level Unique properties at nanoscale level Affect physical, chemical and biological properties Affect physical, chemical and biological properties

Emerging Nanomedicine and Bionanotechnology Nanotechnology at Northeastern University

Potential Risks of Nanomaterials Need to understand, predict and manage potential health risks Need to understand, predict and manage potential health risks Extremely small size may cause different interaction with human body Extremely small size may cause different interaction with human body Studies have established that larger surface area of inhaled nanoparticles may increase toxicity Studies have established that larger surface area of inhaled nanoparticles may increase toxicity Can penetrate deep into lungs and may move to other areas of the body, i.e. liver and brain Can penetrate deep into lungs and may move to other areas of the body, i.e. liver and brain

Adverse Effects The likelihood that a worker will experience adverse health effects from hazardous drugs increases with the amount and frequency of exposure and the lack of proper work practices The likelihood that a worker will experience adverse health effects from hazardous drugs increases with the amount and frequency of exposure and the lack of proper work practices

Work activities with the potential for exposure Preparation, administration, and/or disposal of hazardous drugs Preparation, administration, and/or disposal of hazardous drugs Handling body fluids Handling body fluids Handling/transporting contaminated waste Handling/transporting contaminated waste Decontamination and clean-up Decontamination and clean-up Removal and disposal of PPE after exposure to contaminated waste Removal and disposal of PPE after exposure to contaminated waste Performing specialized procedures i.e.: in OR, at the bedside Performing specialized procedures i.e.: in OR, at the bedside

Routes of exposure Inhalation Inhalation –Mixing liquids, expelling air from syringes, crushing pills, spills, priming an IV Injection Injection –Needlestick or sharps injury Ingestion Ingestion –Hand to mouth contact: eating/drinking in the work environment, handling food with contaminated hands Absorption Absorption –Skin contact/absorption, handling contaminated materials

Current state of practice Often inconsistent Often inconsistent May contain some of the program elements, but not all May contain some of the program elements, but not all May address some of the workers, but not all May address some of the workers, but not all May not be implemented and carried out May not be implemented and carried out

MNA Survey: Hazardous Drug Information Form nurses surveyed at 3 facilities 2000 nurses surveyed at 3 facilities 400 responses 400 responses 87% reported handling/administering hazardous drugs 87% reported handling/administering hazardous drugs Only 54% aware of programs re: safe handling of hazardous drugs and training Only 54% aware of programs re: safe handling of hazardous drugs and training Only 30% read programs Only 30% read programs Only 12% had classroom training Only 12% had classroom training Only 6% had hands-on-training Only 6% had hands-on-training

Survey results cont. Nurses do not identify many drugs they administer as hazardous Nurses do not identify many drugs they administer as hazardous Continue to handle in same manner Continue to handle in same manner Not aware of changes in controls Not aware of changes in controls 70% use personal protective equipment, likely gloves 70% use personal protective equipment, likely gloves Use of face shields, and gowns or lab coats much less likely Use of face shields, and gowns or lab coats much less likely 10% do not use any PPE 10% do not use any PPE

Some conclusions of MNA Survey Gap between NIOSH Alert and practice Gap between NIOSH Alert and practice Many nurses are unaware of issues of hazardous drug exposure and prevention programs Many nurses are unaware of issues of hazardous drug exposure and prevention programs Nurses who were aware of and had read hazardous drug programs were much more likely (85.6%) to use PPE Nurses who were aware of and had read hazardous drug programs were much more likely (85.6%) to use PPE

Protecting nurses and other workers As required by As required by –OSHA Hazard Communication Standard – Education – Education – –product information and MSDS for the drugs that are specific to work setting –recognize the sources of exposure –apply appropriate work practices

Protecting nurses and other workers Training – Training – –equipment and procedures for prevention Administrative controls Administrative controls – work setting designed to protect workers providing appropriate PPE medical surveillance provide safe areas for staff to eat

NIOSH suggests: Follow recommendations that are presented in the ALERT Follow recommendations that are presented in the ALERT –Assess hazards –Evaluate workplace –Review inventory of hazardous drugs –Seek input of workers with potential for exposure –Conduct training and evaluate practice –Reassess annually

Training includes: Safe handling Safe handling Spill procedures Spill procedures Equipment and PPE use Equipment and PPE use Reporting spills, exposures and symptoms Reporting spills, exposures and symptoms –Who, how and where Work practices Work practices –No eating or drinking in workplace

Medical surveillance Depending on exposure Depending on exposure –Physical exam –CBC –Monitoring urine dipstick or microscopic exam dipstick or microscopic exam –Monitoring the work area air and surface contamination air and surface contamination

Incorporating all the requirements can be overwhelming!!! How How When When Where Where Who Who –Is responsible –Must be trained

Developing a Comprehensive Model for Prevention and Implementation Identify problem Identify problem Seek resources, support, experts Seek resources, support, experts Start or join group-enlist colleagues, other stakeholders Start or join group-enlist colleagues, other stakeholders Investigate what is being done Investigate what is being done Set goals/timeline Set goals/timeline What are the barriers to prevention What are the barriers to prevention Who is responsible/needs to be? Who is responsible/needs to be? Develop process to assess prevention effectiveness Develop process to assess prevention effectiveness Collaborate! Don’t reinvent the wheel. Collaborate! Don’t reinvent the wheel.