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Oregon Cancer Care for Animals
172 Magruder Hall
Corvallis, Oregon 97331-4803
Oncology: 541-737-4838
Reception: 541-737-4812
Fax: 541-737-4818
I.
Title of Policy:
Safe Handling of Cytotoxic Drugs
Effective Date:
11-22-2010
PURPOSE:
Cytotoxic drugs are the family of drugs used to treat cancer. To ensure that staff
exposure to cytotoxic drugs is minimized and to maintain a safe working environment
OSU-CVM provides information and resources to staff regarding exposure risks and the
safe use of cytotoxic drugs in a work environment.
II.
FORMS USED:
Minimizing Occupational Exposure to Cytotoxic Drugs – Employee Handout (Attached)
Accident Report form
Cytotoxic Drug Spill Report Form (Attached)
III.
PROCEDURE:
A.
Protective Clothing
1. Cover clothes with a protective disposal gown made of material that is
protective against chemotherapeutic agents. The gown should have
long sleeves and elastic or knit closed cuffs. The cuffs should be
tucked under the gloves. The gown should be worn during
compounding, administration, and when handling waste from patients.
Once gowned, the person must not leave the area where mixing or
drug administration is occurring. Gowns must be removed with care
to avoid spreading contamination and must be disposed of as
contaminated waste. Protective eyeglasses must be worn and powderless chemotherapy-approved gloves. Face shields, hair and shoe
covers are recommended but not required. Respirators are available
for use during compounding and administration of cytotoxic drugs.
Double gloving is recommended if going from mixing directly to
administration – the outer glove would be removed before
administration. If continuously worn, gloves and gowns should be
changed every 30 minutes or immediately if damaged.
2. Preparation of cytotoxic injectable agents should be done in a certified
Biological Safety Cabinet (BSC), Class II, Type B. Personnel
OSU AAHA Standard PH26.1
preparing cytotoxic prescriptions in the oncology ward should wear
protect personal equipment (PPE) as described and work at the BSC.
Women who are pregnant, lactating, immunosupressed, or taking
immunosupressive medications or trying to conceive should avoid
preparation of cytotoxic agents. It is recommended that the hood
surface, minus the air vents, be covered with a plastic-backed
absorbent paper to reduce the potential for dispersion of droplets and
spills and to facilitate cleanup. All manipulations should be done over
the pad. All work within the hood shall be six inches from either side
of the hood and a minimum of six inches from the front. The outside
of the hood and front opening and the floor in front should be wiped
down after the last mix of the day with detergent and bleach. It is
recommended that the BSC should be decontaminated monthly with
appropriate ingredients listed by the BSC manufacturer.
B.
Agent Administration
1. The area beneath the administration site must be protected with a
plastic-lined disposable pad of sufficient size to provide protection.
2. Prepared, or unprepared, chemotherapy comes from the drug room in a
clear plastic zip-lock bag with an orange chemotherapy/biohazard
sticker affixed or commercial yellow chemotherapy zip-lock container.
The removal of chemotherapy items from the zip-lock should be
minimized to the immediate period of drug delivery to the patient. All
sharps and disposables should be immediately returned to the zip-lock
bag after drug administration and the zip-lock bag shall be placed in a
gray plastic sharps/chemotherapy disposal container. Sharps may also
be immediately placed directly into the gray sharps container. Gray
sharps/chemotherapy disposal containers are for cytotoxic materials
only. Do not recap needles used for reconstituting cytotoxic agents.
The lid of the sharps container should be kept closed.
3. If it is necessary to prime the IV set, use a compatible IV solution.
Prime the IV set with the IV solution. Do not use a cytotoxic agent for
priming.
4. A gauze pad shall be placed around the luer-lock connection before
disconnecting.
C.
Patient Waste Precautions
1. Gloves must be worn when handling or collecting urine, blood or
fecal material from patients that have received cytotoxic drugs, and
while handling the linen used with or trash generated from those
animals.
OSU AAHA Standard PH26.1
2. Linen, overtly soiled with discharge from an animal receiving
cytotoxic agents, must be placed in a clear plastic linen bag. An
orange chemotherapy/biohazard sticker shall be affixed to this bag and
the bag taped shut. In areas where cloth linen bags are routinely used,
the cloth bag shall be placed in a clear plastic bag as above.
3. Excreta may be disposed of through the sewer system.
4. All contaminated disposable supplies, such as dressings and specimen
containers must be placed in clear plastic waste bags as described in
C.2. above.
5. All needles and syringes must be placed into the gray sharps/chemotherapy
disposal containers.
D.
Drug Spills Outside of the BSC
1. When a cytotoxic drug spill occurs outside the BSC, the clinician on
clinic must be immediately notified to assess the size and scope of the
spill. If it appears that the spill cannot be contained with two spill kits
then:
a) Isolate the area of the spill as much as is possible by preventing
other persons and/or animals from entering the area,
b) Use available absorbent materials (paper towels) to contain spread
as much as possible without placing yourself in danger of unnecessary
exposure,
c) Call EH&S response phone at 230-0129 or landline at 7372273 (M-F 8-5) or Public Safety at 737-7000.
2. Chemotherapy spill kits are located in the oncology ward. To clean up
a cytotoxic drug that is spilled outside the BSC staff must wear double
gloves and a chemo block protection gown [These gowns are found in
the chemotherapy spill kit]. In no case should an attempt be made to
clean up a spill without first donning proper personal protective
equipment. Solid materials, such as syringes and broken glass must be
placed in a gray plastic sharps/chemotherapy disposal container.
3. Powders must be covered with a paper towel wetted with alcohol and
then wiped up. Liquids must be cleaned up with a paper towel.
4.
The affected area must then be rinsed with water then cleaned with
detergent and bleach solution. The MSDS for the particular spilled
agent should be reviewed to determine if a neutralizer is also
suggested. MSDS for each cytotoxic drug should be kept in the
oncology ward.
OSU AAHA Standard PH26.1
5. Spills inside the BSC should be cleaned up immediately. If the spill
exceeds 30ml or the entire contents of one vial or ampule a spill kit
should be used.
6. All materials used in cleaning must be placed in a gray plastic,
sharps/chemotherapy disposal container.
7. All chemo spill kits have an attached Chemo Spill Report Form.
These forms must be completed following each chemo spill clean up.
A copy of the completed form shall be provided to the oncologist onduty. The original form is given to the pharmacist for the Drug Room.
F.
Inadvertent Patient or Staff Exposure
1. Exposure or splash in eyes must be flushed with water for 15-20
minutes at the nearest eyewash station or sink. The staff member
should be taken to student health or emergency department for further
treatment and evaluation.
2. If a cytotoxic drug is inadvertently spilled on a staff member, all PPE
should be removed and the affected area must be thoroughly washed
with soap and water, the clinician on service notified, and an accident
report from completed within 48 hours of the accident. The staff
member will be offered the opportunity to go to the student health
center or other medical service for further evaluation. If the offer is
declined a notation to this effect shall be made on the accident form
and be initialed and dated by the staff member.
3. If a cytotoxic drug is inadvertently spilled on a patient, the patient
must be thoroughly washed with soap and water, and the attending
veterinarian must be informed.
4. In all exposures the MSDS for the particular agent should be
consulted. All appropriate accident and incident forms should be
completed as required.
G.
Patient Identification System.
1. An orange chemotherapy/biohazard sticker is placed on the
identification card by the cage/run door to identify patients who are
receiving or have received cytotoxic drugs within the last 48 hours.
The sign should be removed 24 hours after the last dose of
chemotherapy or following appropriate cleaning of cage/run after
the patient is discharged.
2. The staff technician with the primary responsibility for the patient
when chemotherapy is started is responsible for posting the sticker at
OSU AAHA Standard PH26.1
the start of chemotherapy, and for removing the sign 48 hours after
completion of chemotherapy.
H.
Employee Information
1. The Oncology Service Head shall distribute this Policy with
attachments to all new employees, faculty, and students.
2. Personnel working in the oncology ward who are pregnant or
attempting to become pregnant are encouraged to discuss how their
exposure to cytotoxic drugs might affect their pregnancy with their
supervisor and their personal physician.
3. Clients and their children should not be allowed in the oncology ward
during treatment and administration of cytotoxic medications.
4. Children under the age of 18 must be accompanied by an adult to the
treatment area.
I.
Patients being treated with cytotoxic drugs at home.
1. The clinician on service dispensing the drug shall inform clients
receiving cytotoxic drugs for in-home injections or infusions of
potential hazards to household members. All dispensed medications
will be provided in child-resistant containers unless a signed wavier
for the removal of child resistant containers is contained within the
client’s file. At a minimum, this wavier should be reassessed annually.
2. Any containers of cytotoxic drug solution (ie., syringes, infusion bags)
that are not the manufacturer’s container shall be dispensed in a sealed,
zip-lock-type bag with an orange, chemotherapy/biohazard sticker
affixed. This applies to client transport and common parcel carrier
transport.
3. Clients and family members shall be encouraged to wear powder-free
latex or nitrile gloves when handling syringes, infusion bags, and
drugs.
4. Clients shall be instructed to protect the surface area beneath the
preparation and injection sites.
5. Clients shall be instructed to place all materials, including used
needles and syringes, and vials into the zip-lock bag and return this to
the OSU-CVM Oncology ward or the referring veterinarian’s practice
for disposal.
6. Clients shall be advised that in the case of an inadvertent spill, the area
will be treated as noted above in Section F.
OSU AAHA Standard PH26.1
7. Clients must keep all cytotoxic drugs out of the reach of children.
J.
Large Animal Policy
Staff should wear gloves when handling any large animal patient or any
fluid or tissue samples from that patient if it is receiving chemotherapeutic
agents until 48 hours after the last dose is administered. Likewise,
laboratory staff handling samples from any large animal patient receiving
chemotherapeutic agents should be appropriately warned and samples
labeled with a biohazard warning sticker where appropriate.
A Biohazard sign should be posted on the animal’s stall that it is receiving
chemotherapeutic agents until 48 hours after the last dose is administered.
If appropriate and practical, cat litter should be placed beneath the area of
the large animal receiving cytoxic agents. When administration is
complete, this litter should be swept up and put into a chemotherapeutic
waste receptacle.
Stall cleaners should wear gloves and masks when cleaning the animal’s
stall but can dispose of straw, shavings and excreta by traditional means.
All waste, such as syringes, needles, urine samples, associated with or
potentially affected by administration of a chemotherapeutic agent should
be disposed of ONLY in an official chemotherapeutic waste container
available from central supply. This container should be left outside the
stall of any animal receiving chemotherapeutic treatment at all times until
48 hours after treatment is complete.
Staff administering chemotherapeutic agents should wear chemo-rated
gloves, and gowns and safety glasses where spill or splashing of the
chemotherapeutic agent is possible. A mask should be worn where there
is potential for respiratory contamination with the agent (e.g.
cyclophosphamide). These items should be disposed of in an official
chemotherapeutic waste container.
Chemotherapeutic agents should only be administered by a clinician, or
under the direct supervision of a clinician of the large animal hospital
associated with the case.
Visitation by clients should be strictly controlled up until 48 hours after
the last dose of chemotherapy is administered with clients either visiting
their animals from outside the stall, or only having contact when
appropriately clothed with latex gloves and a mask if appropriate.
OSU AAHA Standard PH26.1
IV.
REFERENCES:
ASHP Guidelines on Handling Hazardous Drugs, American Society of Hospital
Pharmacists (ASHP), vol. 63, June 15, 2006.
OSHA Technical Manual, Section VI: Chapter 2: controlling Occupational
Exposure to Hazardous Drugs.
National Institute for Occupational Safety and Health (NIOSH). Preventing
Occupational Exposure to Antineoplastics and Other Hazardous Drugs in
Health Care Settings. NIOSH Publication No. 2004-165.
The Office of Health and Safety Information Systems (OHASIS). Primary
containment for biohazards.
Cancer Chemotherapy Guidelines and Recommendations for Practice – Oncology
Nursing Society – Oncology Nursing Press, Inc., 1999.
Safe Handling of Cytotoxic Drugs – An Independent Study Module – Oncology
Nursing Society – Oncology Nursing Press, Inc. 1997.
V.
COORDINATION
Oncology Service Head, Director VTH, VTH Pharmacist
Signed:
Stuart C. Helfand, DVM
Service Head, Oncology
Concurrence:
Helen E. Diggs, DVM
Director, Veterinary Teaching Hospital
Christopher Cebra, DVM
Department Head Clinical Services
Terry Crowder, RPh, PhD
Pharmacist
OSU AAHA Standard PH26.1
MINIMIZING OCCUPATIONAL EXPOSURE TO CYTOTOXIC DRUGS
AN EMPLOYEE HANDOUT
This handout provides information to employees of the Oregon State University College
of Veterinary Medicine about potential hazards of occupational exposure to cytotoxic
drugs. It also explains the hospital’s policy on handling cytotoxic drugs.
Q.
What are cytotoxic drugs and how do they work?
A.
Cytotoxic drugs (CDs) are the family of drugs used to treat cancer. At the OSUCVM, this includes some 40-50 drugs, including experimental study drugs. CDs
can inhibit the growth of tumors by disrupting basic cellular processes. This
disruption kills cancer cells. Most of these drugs bind directly to DNA or RNA
(genetic material or affect other protein synthesis in cells. Normal cells can be
damaged, as well as cancer cells. This is one reason why chemotherapy patients
often experience debilitating side effects. Staff may also experience effects if
they are routinely exposed to these drugs.
Q.
How does occupational exposure to CDs take place?
A.
Exposure can occur by ingestion, inhalation, or absorption through the skin or
mucous membranes. Although no immediate health effects are usually noticed,
rare instances of nausea, headache, dizziness, skin irritation, sores on the mucous
lining of the nose, and allergic reactions have been reported.
Q.
Why is there concern about exposure to health care workers?
A.
The adverse effects to health care personnel exposed to lower levels of CDs over
long periods of time are not known. There are studies that document the presence
of small amounts of CDs in the urine of pharmacists who routinely prepare these
drugs without proper precautions. There has been no documented connection
between occupational exposure and related health problems. The amount of CDs
which a patient receives at treatment is considerably greater than staff are exposed
to. Yet, the potential adverse side effects of CDs and the concern for the longterm effects of contact with these drugs make it prudent to limit exposure.
OSU AAHA Standard PH26.1
Q.
Why not measure each individual’s exposure and limit it to a certain safe
level?
A.
At this time, no device or test exists which can satisfactorily monitor the degree of
exposure to CDs. The goal is to reduce everyone’s exposure to as close to zero as
possible.
Q.
If exposure cannot be measured and limits cannot be set, how can exposure
be controlled?
A.
A number of studies have demonstrated that exposure can be reduced by the use
of gloves, gowns or lab coats, and eye protection and/or face masks.
Q.
How should employees regard the possible exposure to CDs if they are
pregnant or attempting to conceive?
A.
Employees who are pregnant or attempting to become pregnant are encouraged to
discuss how their exposure to CDs might affect their pregnancy with both their
supervisor and personal physician. The consensus of OSHA and professional
pharmacy, and nursing organizations is that protective measures such as those
recommended in the VTH policy are effective in all situations, including possible
or actual pregnancy. Because, some CDs are potential teratogens adherence to
these safety procedures is strongly encouraged.
(03-31-2009)
OSU AAHA Standard PH26.1
(03/31/2009)
Cytotoxic Drug Spill Report Form
(This form is intended to provide documentation of a cytotoxic drug spill. Complete
this form and return it to the Drug Room.)
Name of drug spilled: ____________________________________________
Spill reported by:
(name)______________________________________
(title)________________________________________
Date of spill:
Time of spill:
Location of spill (Room #):
_____________
_____________
_____________
When in relation to administration of the drug did the spill occur?
_________Before
__________During
________After
Cause of spill: ____________________________________________________________
________________________________________________________________________
________________________________________________________________________
Approximate volume spilled: (circle one)
Less than 10 cc
More than 50cc
10cc
20cc
30cc
40cc
Who cleaned up the spill?
OSU AAHA Standard PH26.1