Safe Handling of Cytotoxic Materials Kara Henman RN, MN, CON(C) Oncology Practice Consultant Cancer Care Nova Scotia What are hazardous drugs? Chemotherapy Immunosuppressive agents Biological agents Antiviral agents OSHA (1995) Capable of causing toxicity to those who come in contact with them Hazardous Drugs Genotoxicity Carcinogenicity Teratogenicity Fertility impairment or reproductive toxicity Organ toxicity at low doses Chemical structure or toxicity profile that mimics existing drugs determined to be hazerdous 1
What is Systemic Therapy? Also called chemotherapy Systemic therapy for cancer patients is a high risk area of pharmacotherapy May be used alone or along with other treatment such as surgery or radiation therapy How is systemic therapy given? Can be given Intravenously Oral Other What is cytotoxic waste? All materials used for preparation and administration of cytotoxic drugs Body fluids Thus it needs to be: separated from general waste disposed of according to provincial/institutional guidelines 2
Are there occupational health risks? No safe level of exposure has been established No exposure is safest Efforts to reduce risk of exposure should be made Follow your district/facility policy on safe handling What are the major routes of exposure? Inhalation of vapors of drug from uncovered waste container or spill By contact with skin or mucous membranes Ingestion of drug by eating or drinking in administration area Where is the risk for health care providers? Handling cytotoxic medication Handling cytotoxic waste & body fluids Cleaning a spill Inadequate cleaning of spill Performing research 3
Safe Practice Guidelines NS policies/procedures based on: Occupational Safety & Health (OSHA) American Society of Oncology Pharmacists (ASOP) Oncology Nurses Society (ONS) National Institute of Occupational Safety & Health (NIOSH) Safe Practices Safe Cleaning Safe preparation Safe administration Safe disposal Safe transport Cytotoxic Safety Equipment Approved cytotoxic disposal containers, signage, equipment 4
Disposal Containers These containers should have a lid and be kept covered Should have a lid Should be kept closed Cytotoxic Sharps Container Leak proof, puncture proof with a secure lid and clearly labeled with the cytotoxic hazard symbol Use for disposal of things such as needles, syringes, glass bottles, tubing, bags Cytotoxic Non- Sharps Container Closed-lid waste container lined with a red/yellow plastic bag that has cytotoxic hazard symbol Use for disposal of things such as gloves, gowns, dressings, guaze, etc. In preparation for removal from unit, securely tie red bag and place in cardboard box Tape box closed and label as cytotoxic 5
Personal Protective Equipment Used during chemotherapy administration, patient care and disposal of cytotoxic waste Safe Handling of Oral Systemic Therapy Always wear gloves avoid touching tablets Always prepared in Pharmacy Never alter medication crush, split, open capsules Always give as directed Store separately in leak proof container with lid and labeled as cytotoxic Dispose of equipment used to administer in cytotoxic waste ie; med cup, gloves Administration of Oral Systemic Therapy o Plastic backed absorbent pad o Wash hands o Don appropriate Personal Protective Equipment (PPE) o Inspect drug o Drop medication into med cup o Dispose of all equipment used (med cup, gloves, etc) in appropriate cytotoxic waste container o Wash hands o Implement cytotoxic precautions o Patient teaching 6
Cytotoxic Waste: Body Fluids Cytotoxic waste can be excreted thru patient body fluids urine, emesis, feces, saliva, semen, vaginal fluid Cytotoxic precautions during and for 48 hours after last dose of chemotherapy Safe Disposal of Body Fluids PPE should be worn. Always wear gloves Cover bedpans, urinals, emesis basins during transport. Empty waste close to water surfacedo not use hoppers or sprays Time frame: during & 48 hours after last dose Cytotoxic caution sign Safe Disposal of Body Fluids If sharing room, isolate personal hygienic equipment Clean shared equipment Encourage use of toilets if possible Lower toilet lid cover Double flush toilet 7
Safety Precautions Wash hands Encourage men to sit to toilet Collect drainage of body fluids in closed system Use flushable/disposable items Protect skin of incontinent patients Wash perineal areas with soap and water Contaminated non-disposable equipment/linen Contaminated equipment Rinse if grossly contaminated - soak in detergent Place in closed cytotoxic bag Place in SPD pick up container Contaminated linen Place in yellow cytotoxic bag then regular laundry bag Cleaning Patient Care Area Personal protective equipment if risk of splashing or exposure ie; cleaning bathroom Routine cleaning with facility cleaning solutions For spill clean up, solution with sodium hypocholorite (ie: chlorox) recommended Designated mops and cloths Disposal or microfibre cloths and mops 8
Cleaning Work surfaces Counters, tables Patient chairs IV poles Sinks and toilets Floors Phones Lid & outside of cytotoxic containers Empty garbage Regular scheduled deep cleaning Spill Kit Contents Spill Kit including (but may not be limited to): 2 pairs disposable non-latex chemotherapy gloveslarge size Low permeability disposable gown and shoe covers Safety glasses, splash goggles or face shield N95 Respirator mask (unless included in face shield) Absorbent plastic backed pads (sufficient to absorb a spill of up to 1000mL) Disposable towels for absorbing and cleaning liquid spills 2 red/yellow plastic cytotoxic waste bags Cleaning solution for cleaning and decontamination of area Instructions on the management of a cytotoxic chemotherapy spill. Warning signs to alert other staff to the hazard and isolate the area of the spill What to do for a Spill?? 1. Alert staff, remove patients, get help & spill kit 2. Limit access to area 3. Apply PPE 4. Place absorbent pads on spill and absorb as much as possible into the pad. Repeat until spill has been cleared 5. Place contaminated pads in to cytotoxic waste container or bag 6. Use cleaning solution to wash the area thoroughly, discard all waste into container/bag 9
Spill 8. Rinse area with water and dry well 9. Discard used items including PPE (in sequence), double bag, to go to designated area for disposal 10. Wash hands, replace spill kit 11. Notify Environmental Services/housekeeping for 2 nd cleaning and decontamination 12. Notify manager 13. Document What to do if you are splashed? Remove contaminated PPE Remove contaminated personal clothing Wash area with soap/water, rinse well Irrigate contaminated eye at eyewash station up to 15 minutes Seek medical help if appropriate Notify OH&S Documentation: PSLR, WC If the nurse is pregnant, should this alter her practice? 10
Patient Education Practical advice for family protection from risk exposure What is considered cytotoxic? Time frame of precautions? How to protect others and the environment Store all cytotoxic drugs in a leak proof container out of the reach of children and pets Flush all that is flushable Use condom during sexual activity Caregivers wear gloves when handling cytotoxic drugs, waste or soiled items Quick Review What about handling wastes do we need to be concerned about safety? Wear PPE Use cytotoxic waste containers Wash hands following removal or disposal of PPE/wastes Keep lids closed on containers; don t over fill Filled containers stored in secure waste holding area Unused meds returned to pharmacy Resources 11
Oncology Practice Consultants Kara Henman-Halifax 473-1796 Kara.henman@ccns.nshealth.ca Michele Rogez-Sydney 567-8555 Michele.rogez@ccns.nshealth.ca Questions? 12