1. Safe Handling

2. Objectives At 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 Safe Handling2

3. Introduction Chemotherapeutic 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 Safe Handling3

4. Introduction The 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). Safe Handling4

5. Occupational Exposure Risk Health care workers handling chemotherapy and biotherapy agents are at risk for occupational exposure to these toxins, and the long-term effects are unknown Safe Handling5

6. Occupational Exposure 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 Handling6

7. Occupational Exposure 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 Safe Handling7

8. Safe Handling Policy Institutions are required by OSHA to develop and implement policies regarding the safe handling of cytotoxic and biologic agents Safe Handling8

9. Safe Handling Policy Protection 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 Safe Handling9

10. Safe Handling Policy Protection 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 Safe Handling10

11. Exposure Protection Guidelines Personal 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 Safe Handling11

12. Exposure Protection Guidelines PPE 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 Safe Handling12

13. Exposure Protection Guidelines PPE includes: ◦ Gloves ◦ Gowns ◦ Face shield or goggles Safe Handling13

14. Exposure Protection Guidelines 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 Safe Handling14

15. Exposure Protection Guidelines Administration: ◦ 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 Safe Handling15

16. Exposure Protection Guidelines 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 Safe Handling16

17. Exposure Protection Guidelines 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 Safe Handling17

18. Exposure Protection Guidelines Administration: ◦ 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 Safe Handling18

19. Exposure Protection Guidelines 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 Safe Handling19

20. Exposure Protection Guidelines 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 Safe Handling20

21. Exposure Protection Guidelines Administration Review hospital-specific administration guidelines Safe Handling21

22. Exposure Protection Guidelines 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 Safe Handling22

23. Exposure Protection Guidelines Body 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 Safe Handling23

24. Exposure Protection Guidelines 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. Safe Handling24

25. Exposure Protection Guidelines 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 Handling25

26. Exposure Protection Guidelines Spill 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 Safe Handling26

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28. Exposure Protection Guidelines Spill Guidelines Review hospital-specific spill kit and policy Safe Handling28

29. Safe Handling at Home Precautions 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 Safe Handling29

30. Safe Handling at Home Precautions 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 Safe Handling30

31. Safe Handling at Home Emergency 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 Safe Handling31

32. Safe Handling at Home Emergency 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 Safe Handling32

33. Safe Handling at Home Safe 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 Safe Handling33

34. Safe Handling at Home Review hospital-specific teaching materials for administering chemotherapy at home Safe Handling34

35. Questions?