Chemotherapy drugs pose hazard — but not for MS
Chemotherapy drugs pose hazard but not for MS
CDC: Emphasize training, protection
When three of the 13 nurses on an inpatient oncology unit in Wisconsin were diagnosed with multiple sclerosis, the employees were alarmed: Was something in the workplace triggering MS? An investigation found no relationship between the workplace and MS, but it did result in recommendations about handling hazardous drugs.
With more than 150 hazardous drugs in use in hospitals and other health care settings, ensuring that employees are using the proper handling, disposal and protection is a difficult but important task, says Thomas Connor, PhD, a research biologist with the National Institute for Occupational Safety and Health (NIOSH) in Cincinnati and an expert on hazardous drugs.
"The MS is just a red herring that brought attention to this unit," says Elena Page, MD, MPH, supervisory medical officer in the Hazard Evaluations and Technical Assistance branch of NIOSH. "In reality they were doing a pretty good job [of handling hazardous drugs]. They were very conscientious and very concerned about doing a good job."
Chemotherapy agents are usually not associated with MS, says Page. In fact, "severe refractory MS is often treated with high dose cyclophosphamide," she says. Exposure carries reproductive risks and can lead to cancer, though with a latency of 10 to 40 years, she says.
In the health hazard evaluation, Page and colleagues observed work practices, reviewed policies, took surface wipe samples and interviewed employees. In that regard, the workers were concerned about helicopter exhaust from a nearby landing area.
Investigators found some evidence of contamination from the chemotherapy drugs cyclophosphamide and ifosfamide and the potential for helicopter exhaust to enter the ventilation system. Some of the findings illustrate important concerns related to the use of hazardous drugs, including:
Crushing pills on the unit can create a hazard. As hazardous drugs change, it's important to keep on top of the training in use and cleanup, says Connor. For example, chemotherapy agents are now available in oral form. Crushing the pills to make them easier for patients to ingest can produce a fine dust that can be inhaled, he says.
"They have a small pharmacy on the floor and they had a pill crusher on the counter. It wasn't done under a hood," he says. Even before the NIOSH investigators arrived, the hospital changed that process.
Residue can spread from dirty gloves or contaminated packaging. Investigators found small amounts of the chemotherapy agents on surfaces, including in the family area. "This suggests breaches in hospital controls when handling these drugs," the report said. "This is important because even small amounts of these drugs can cause serious adverse effects, including cancer and adverse reproductive outcomes."
Preventive measures include double-bagging containers when they leave the pharmacy. Employees often aren't aware of the surface contamination, says Connor.
"We've found the drugs tracked outside the pharmacy area, people walking out with dirty gloves, having it on their shoes. It does spread around to other areas," he says. "We were able to track [the residue from] a broken drug vial for six months when it was dropped on a floor in a pharmacy."
The hospital in the health hazard evaluation decided to review its cleaning; different drugs require different cleaning protocols, notes Connor. Removing upholstered furniture and carpeting also may make it easier to clean, Page says.
All personnel with potential exposure need training, not just nurses. Nurses took a three-day certification course, one-day practicum and an assessment before administering chemotherapeutic agents. Their annual training did not include a refresher on safe handling. Other employees, such as housekeeping staff, didn't receive training in handling these hazardous drugs and there was no medical surveillance, the NIOSH investigators found.
Gaps in training about handling hazardous drugs are not uncommon, says Connor. "People in oncology wards and oncology pharmacies have extensive training. People in other specialties may get minimal training," he says.
The Hazard Communication Standard of the U.S. Occupational Safety and Health Administration requires employers to provide training about how to properly handle hazardous chemicals.
Protective equipment must be used consistently. Personal protective equipment is the last defense against exposure. In the evaluation, most nurses reported wearing double gloves and gowns when they handled the drugs. Nursing assistants were less likely to wear gowns and face shields when handling excreta from patients on cytotoxic precautions, as recommended. In fact, five of nine nursing assistants said they never wore face shields.
Training is important, but so is the expectation of supervisors, says Connor. "The safety culture in the workplace plays a big role," he says. The investigators recommended the creation of a hazardous drug safety and health committee, which would include at least one frontline worker and a safety and health professional.
Medical surveillance is difficult. NIOSH recommends medical surveillance for workers handling hazardous drugs, including periodic questionnaires about reproductive and general health and lab work including a complete blood count and urinalysis. Yet there's still no good biomarker of exposure and it's not clear how to interpret laboratory results, says Connor. NIOSH is currently reviewing its medical surveillance recommendations, he says.
When three of the 13 nurses on an inpatient oncology unit in Wisconsin were diagnosed with multiple sclerosis, the employees were alarmed: Was something in the workplace triggering MS? An investigation found no relationship between the workplace and MS, but it did result in recommendations about handling hazardous drugs.Subscribe Now for Access
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