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Hazardous drug exposures: Implications for the oncology APP
Editor’s note: HemOnc Today’s columns for advanced practice providers (APPs) tackle common issues APPs face, discuss day-to-day practice and regulatory concerns, and share research advances. To contribute to this column, contact Alexandra Todak at stodak@healio.com.
Patients with cancer routinely receive drugs classified by the National Institute for Occupational Safety and Health, or NIOSH, as hazardous to workers who handle them.
Advanced practice clinicians in oncology settings face potential exposure to hazardous drugs. It is important for these clinicians to understand the routes and potential consequences of exposure, organizational and personal strategies to reduce exposure risk, and what to do when exposures occur.
Exposure sources
In 2016, NIOSH published a revised list of antineoplastic and other hazardous drugs in health care.
The list is divided into three categories: antineoplastic drugs (hazardous by definition), nonantineoplastic hazardous drugs, and drugs with potentially adverse reproductive effects. NIOSH periodically updates the hazardous drugs list as more data emerge. Clinicians are encouraged to review the list at the website included in the references at the end of this column.
Clinicians face the risk for indirect and direct exposures. Indirect exposures include contact with contaminated surfaces in the clinical environment (eg, counters and furniture). Direct exposures include dermal, oral or vapor exposure when an agent is handled or spilled.
Advanced practice clinicians often administer hazardous drugs through lumbar puncture, bladder instillation or other intracavitary systems, such as Ommaya reservoirs, pleural or peritoneal injection. Direct exposure also can occur during a patient emergency when a drug has spilled, or when handling patient excreta.
Need for ‘optimal protection’
Case-control studies have confirmed the relationship between hazardous drug exposure and adverse reproductive effects.
Additional case reports have identified airway and dermal ailments, as well as the diagnosis of rare cancers and leukemias.
The earliest data on adverse health events associated with hazardous drug exposures was published over 40 years ago. Despite this, oncology clinicians do not fully follow recommendations from NIOSH, Oncology Nursing Society and American Society for Health System Pharmacists.
We conducted a pilot study in 2015 at one cancer center to provide feedback to clinicians on exposures. The feedback intervention motivated clinicians and their leaders to implement several policy and equipment changes to align practice to hazardous drug-handling recommendations.
Anecdotal reports suggested that individual clinicians also increased their use of personal protective equipment when handling hazardous drugs. Unlike needlestick injuries, no national registry currently exists to track hazardous drug exposures and related adverse health events.
Motivated by this pilot study, we launched a 4-year, cluster-randomized trial in 12 cancer centers across the United States. We compared a static 1-hour continuing education module on hazardous drug handling to receipt of the module plus tailored messages on how to overcome common barriers to wearing personal protective equipment, with quarterly feedback on study results. We enrolled 396 registered nurses in ambulatory oncology settings.
The study results were disappointing. Personal protective equipment use did not improve from baseline to 1 year after either intervention. Further, protective equipment use was no better among the nurses randomly assigned to receive the enhanced intervention.
These findings suggest that a pervasive and challenging set of barriers exists to optimal protection of oncology clinicians.
To achieve progress and protect workers, meaningful partnerships among clinician teams and leaders can promote a culture of safety and hold clinicians accountable for adhering to hazardous drug-handling guidelines. In addition, we call on industry to develop and test novel drug preparation and administration devices to reduce exposure risks.
Implications for APPs
There are three key implications for oncology APPs.
First, for those who administer hazardous drugs, be sure your institution prepares them in accordance with the latest safety standards.
Second, be sure to wear recommended personal protective equipment during the entire time you are handling hazardous drugs.
Third, if a spill occurs, immediately don personal protective equipment, seek help, and report the exposure to your manager and occupational health professional. It is important to protect yourself first, before you assist others.
Antineoplastic and other hazardous drugs are an essential component of cancer treatment. APPs play several roles in anticancer drug treatment. It is important for these clinicians to understand the potential exposure risks, given their role and their clinical environment. Ensuring the practice setting adheres to the latest safety standards, coupled with personal responsibility for protecting oneself, is important to keep the practice environment as safe as possible for patients and for clinicians.
One final crucial point is that there is only so much that an APP can do if the environment is unsafe. There are national standards for safe environment for the administration of cytotoxic and other dangerous agents, and it behooves hospital and clinic administrators to ensure that the appropriate facilities for chemotherapy preparation and delivery, including optimal air handling and extraction systems, are in place.
References:
CDC. Hazardous drug exposures in health care. Available at: www.cdc.gov/niosh/topics/hazdrug/default.html. Accessed on March 25, 2019.
CDC. NIOSH list of antineoplastic and other hazardous drugs in health care settings, 2016. Available at: www.cdc.gov/niosh/docs/2016-161/default.html. Accessed on March 25, 2019.
Friese CR, et al. Cancer Nurs. 2015;doi:10.1097/NCC.0000000000000143.
Friese CR, et al. Oncol Nurs Forum. 2019;doi:10.1188/19.ONF.248-256.
Friese CR, et al. Trials. 2015;doi:10.1186/s13063-015-0674-5.
Lawson CC, et al. Am J Obstet Gynecol. 2012;doi:10.1016/j.ajog.2011.12.030.
U.S. Pharmacopeia. Hazardous drugs — Handling in health care settings. Available at: www.usp.org/sites/default/files/usp/document/our-work/healthcare-quality-safety/general-chapter-800.pdf. Accessed on March 25, 2019.
For more information:
Christopher R. Friese, PhD, RN, AOCN®, FAAN, is Elizabeth Tone Hosmer professor of nursing, health management and policy at University of Michigan, where he directs the Center for Improving Patient and Population Health. He also is a full member and nurse clinician at University of Michigan Rogel Cancer Center. He can be reached at cfriese@umich.edu or on Twitter @ChrisFriese_RN.
Disclosure: Friese reports research funding from the National Institute for Occupational Safety and Health (R01-OH-10582). The contents of this article are solely the responsibility of the author and do not necessarily represent the official views of the NIH, CDC or HHS.