NIOSH: Track HCWs who handle hazardous drugs

Get baseline, post-exposure lab work

Hospitals should identify which employees could be exposed to hazardous drugs and should track their medical history in a surveillance program, the National Institute for Occupational Safety and Health (NIOSH) said in a recent notice.

NIOSH stopped short of recommending annual clinical testing of employees, but did advise employers to obtain baseline laboratory testing and health history and to track employees with the potential for exposure with periodic reproductive and general health questionnaires.

Regular medical testing has been controversial because changes in results can occur as part of normal variation, notes Thomas H. Connor, PhD, research biologist with NIOSH's Division of Applied Research and Technology and an expert on hazardous drugs and occupational safety. With a wide range of hazardous drugs, it isn't clear what clinical markers are significant, he says.

Some hospitals may have halted their medical surveillance because of uncertainty about the lab testing, says Martha Polovich, PhD, RN, AOCN, director of clinical practice at the Duke Oncology Network in Durham, NC, who helped develop the NIOSH "Workplace Solutions" document. (The document is available at

The NIOSH guidance makes it clear that hospitals should have ongoing medical surveillance, she notes. "This serves to encourage organizations to begin — or resume — some kind of health monitoring of employees, even if it's only the questionnaire," she says.

The medical surveillance should be part of a broader program to reduce the hazards to employees who may come into contact with antineoplastic agents and other hazardous drugs, NIOSH says.

"An effective surveillance program begins with a hazard identification program that is integrated with surveillance for disease or illness," the document says.

Baseline monitoring is essential, Polovich notes. "If you monitor following an [exposure] acute event and you don't know what the person's baseline values are, then what you find after a known exposure means nothing," she says.

Health questionnaires, including any history of reproductive problems, can be revealing, she says. "People should have their health evaluated over the lifetime of handling [hazardous drugs]," she says.

According to NIOSH, health care employers should:

  1. Identify health care workers who may be exposed to hazardous drugs. In addition to pharmacy employees who handle the drugs and nurses who administer them, this may include OR personnel, housekeepers, and workers who receive or transport the shipments of drugs.
  2. Use various methods to reduce the hazards, including work practice and engineering controls and personal protective equipment. Educate workers about the hazards.
  3. Establish a medical surveillance program that gathers information on medical and occupational history. The program also may gather information from physical examination, laboratory studies and biological monitoring. The monitoring should be adapted to the specific characteristics of the drugs the employees could be exposed to. For example, if a drug has liver toxicity, monitoring may include a measure of liver enzymes.
  4. Gather information on reproductive problems or events. "Unless information about relevant symptoms and medical events such as spontaneous abortions is deliberately sought, their occurrence is likely to go unreported," NIOSH says.
  5. Be alert for trends. The surveillance should detect any patterns in the health events or reproductive health of workers who could be exposed to hazardous drugs.
  6. Conduct baseline laboratory testing and follow up with workers who have had an acute exposure. An acute exposure would include skin contact or inhalation due to spill or leak, such as a leaking IV bag.