Handling chemo safely: Your concern, too
RN/MCPHU Home Study Program
Handling chemo safely: Your concern, too
CE credit is no longer available for this article. (Expired May 2004)
Originally posted May 2002
Handling chemo safely: Your concern, too
SUSAN NEWTON, RN, MS, AOCN
SUSAN NEWTON is associated with a private practice oncology office in Dayton, Ohio, and is clinical affairs manager, oncology, at Ortho Biotech Oncology, also in Dayton.
KEY WORDS: chemotherapy, cytotoxic drugs, carcinogenic, mutagenic, teratogenic, extravasation
Oncology nurses aren't the only ones who must worry about the safe handling of chemotherapy agents. More and more, ICU and med/surg nurses are administering these drugs, too. If you were asked to administer a drug like fluorouracil, would you know how to do so safely?
You're working the evening shift on a med/surg unit. Your first admission is a 59-year-old male with rectal cancer. He needs to receive a continuous infusion of chemotherapy and the oncology unit is full. Your first response is, "How do I administer this chemotherapy? I don't want to touch it!"
No doubt about it, the cytotoxic drugs used in cancer chemotherapy are hazardous. They work by disrupting the growth and reproduction of cancer cells. Unfortunately, that action often afflicts certain healthy cells as well, causing toxic side effects in the patients who receive chemotherapy and posing health risks to the nurses who administer it without taking protective measures.
Increasingly, patients are being given chemotherapy outside of the oncology unitmost often in outpatient centers, but also in ICUs and med/surg units. In addition, drugs typically used for cancer chemotherapy are also prescribed for conditions other than cancer, such as arthritis or multiple sclerosis. So even if you are not in oncology, at some point you may have to administer these agents. Knowing the recommended safety procedures for handling them is essential for protecting yourself from accidental exposure.
Repeated exposures are especially dangerous
The chemotherapy drugs nurses are most likely to administer are paclitaxel (Taxol); doxorubicin HCl (Adriamycin, Doxil); cyclophosphamide (Cytoxan); cisplatin (Platinol); docetaxel (Taxotere); etoposide, which is commonly known as VP-16 (VePesid); methotrexate; fluorouracil, which is commonly known as 5-FU (Adrucil); and carboplatin (Paraplatin).
Accidental exposure to such agents can occur in several ways: by direct absorption of a drug through the skin; by ingestion while eating or drinking after hand contact with a drug; and by inhalation of airborne droplets.
You may have an exposure without realizing it. In a study of 83 nurses and pharmacists who handled or administered chemotherapy drugs, a specialized scanning device revealed that 13% of the group had one or more spots of drug contamination on their gloved or ungloved hands, gowns, or shoes.1
Acute exposure generally causes transient symptoms such as headache, nausea, dizziness, rash, skin and mucous membrane irritation, and eye or throat irritation. However, repeated exposure to chemotherapeutic agents is especially dangerous. Chemotherapy drugs are carcinogenic, mutagenic (induces or increases genetic mutations), and/or teratogenic (causes malformations in developing embryos). They can cause organ toxicity, including damage to a woman's reproductive system.
The adverse reproductive effects associated with occupational exposure to these drugssuch as temporary and permanent infertility, birth defects, menstrual dysfunction, ectopic pregnancies, and spontaneous abortionshave been documented in a number of studies.2,3
One study compared the reproductive outcomes of 663 women. 4 About one-third were oncology nurses, one-third were non-oncology nurses, and the other third weren't nurses at all. The percentage of birth defects was 3.1% for oncology nurses, 1.5% for the non-oncology nurses, and 0.3% for the non-nurses.
It's more difficult to connect long-term exposure in healthcare workers to an increased risk of developing malignancies because of the time interval between exposure and the onset of malignancy. It's also difficult to differentiate the influence of individual risk factors for cancer from occupational ones.
Some studies have found increased chromosomal aberrations and evidence of mutagenicity in the urine of nurses who handle cytotoxic drugs, while other studies have failed to find a relationship between exposure and these measures.1,2 These disparate results may be due to differences in levels of exposure between studies, differences in the use of personal protective equipment (PPE) and work techniques, and differences in urine collection timing.2
While the long-term effects on nurses who are occupationally exposed to these drugs require further study, much research has already been done on the long-term effects on patients receiving chemotherapy. The development of secondary malignancies such as leukemia, bladder cancer, and lymphoma is well documented.2
Tips for minimizing your risk of exposure
To learn how to handle chemotherapy drugs in a safe and conscientious manner, you should ideally have formal classroom training as well as hands-on competency training. Most facilities offer such training and prohibit nurses from administering chemotherapy without it.3 At minimum, you should be instructed on safe handling procedures.
The Oncology Nursing Society (ONS) provides comprehensive guidelines on administration (Chemotherapy and Biotherapy Guidelines and Recommendations for Practice)5 and a separate set of guidelines on safe handling (Safe Handling of Cytotoxic Drugs: An Independent Study Module).6 Much of the following information is based on ONS guidelines, which include the recommendations of the Occupational Safety and Health Administration (OSHA).2
Preparation. Be sure to follow your facility's policies and procedures when preparing to administer chemotherapy. When a patient who needs chemotherapy arrives at your unit, the first thing you should do is double-check the chemotherapy orders with a nurse from the oncology unit and send the orders to the pharmacy. Making sure that your patient is well informed of the process and has received adequate teaching about the potential side effects of the drug(s) is a standard of care for chemotherapy patients.
Check to ensure that a chemotherapy spill kitwhich typically contains chemical splash goggles, gloves, a gown, sheets of absorbent material, spill control pillows, a "sharps" container, a scoop to collect glass fragments, and waste disposal bagsand emergency skin and eye decontamination kits are nearby.2 In addition, material safety data sheets (MSDS) that include information on health hazards, acute exposure treatment, PPE, and spill procedures should be accessible.
Put on PPE that includes a disposable, fluid-resistant, closed-front gown; disposable, powder-free gloves with a thickness of at least 0.007 inch that cover the gown cuff; and goggles or other eye protection.6 It's important to wash your hands both before you put on and after you take off gloves.
Next, using either your patient's existing vascular access device or an IV that you initiate, infuse an appropriate IV solution that's compatible with the specific drug to be administered.
If you're administering chemotherapy in a hospital, it's likely that the drugs used will be prepared in the pharmacy. IV bags with chemotherapy drugs must be spiked in a biological safety cabinet or hood. To prevent having to spike bags at the bedside, new tubing should be connected to each bag of chemotherapy before it's sent to the nursing unit. IV tubing should also be primed with a non-drug solution before the chemotherapy drug is added, or a back-flow closed system should be used.2
If at any point you need to transport chemotherapy, make sure you do so properly. The chemotherapy bags should be placed in another bag and appropriately labeled as chemotherapeutic agents. Many facilities use a hard-plastic carrying case for these drugs. A pneumatic tube system should never be used to transport them.
Administration. When the chemotherapy arrives, double-check the dose for accuracy with another RN. When administering chemotherapy, it's important to use a main IV line to provide direct access to the patient in the event of an adverse reaction to the chemotherapy drug.
Before administering the drug, verify the patency of the IV site. Extravasation can cause severe damage to tissue, especially in the case of vesicant drugs, which should be infused via a central IV line. Instruct your patient to immediately report any pain, irritation, redness, or swelling at the IV site.
Place a disposable drape under the patient's arm where the tubing from the chemotherapy bag will be connected. Hang the chemotherapy bag on the pole of your infusion pump, remove the cap from the tubing, and then use a Luer-Lok to connect the tubing to the main line on the IV port closest to the patient. Set the pump to infuse at the rate ordered.
Waste disposal and spills. After infusion is complete, promptly dispose of any equipment that contains or contained the drug. Wrap the equipment in the disposable drape from under the patient's arm and place it in a leak-proof, puncture-proof container that's clearly marked as "biohazard waste," "infectious material waste," or "chemotherapy/cytotoxic drug waste." Your facility should have these containers available and accessible wherever chemotherapy will be administered.
If a spill occurs at some stage during infusion, ideally, specially trained personnel should clean it. However, if that's not possible and you have to clean it, be sure you're still wearing PPE, including eye protection, before you begin. The materials you use to clean a spill should be disposed of in an appropriate biohazard container.
Because chemotherapy agents may be excreted in body fluids, the patient's urine and stool (and, to a lesser degree, his saliva, emesis, perspiration, mucus, and tears) may be contaminated for 48 hours after the last drug dose. Wear PPE when handling such excreta, and wash your hands after removing your gloves. Glassware or other contaminated reusable items should be washed twice with detergent by a trained employee wearing double latex gloves and a gown.2
Check your facility's policies about handling linen that's been contaminated with chemotherapy. Generally, any linen contaminated with the body fluids of a patient who receives chemotherapy should be placed in specially marked laundry bags and then placed in a second impervious bag that's also labeled.2
Accidental exposures. If a chemotherapy drug comes into contact with your skin or a patient's skin, thoroughly wash the affected area with soap and water, but don't abrade the skin with a scrub brush.7 If the drug gets in your eye(s), flush with copious amounts of water for at least 15 minutes while holding back your eyelids. Then get evaluated by employee health or the ED. Be sure to follow your facility's policies and procedures for reporting such incidents.
The bottom line is that all nursesnot just those who work in oncologyshould know their hospital's policies and procedures on safe handling and administration of chemotherapy agents. Believing that you'll never have to handle these agents, and thus being unprepared if asked to do so, could be harmful to your health.
1. Labuhn, K., Valanis, B., et al. (1998). Nurses' and pharmacists' exposure to antineoplastic drugs: Findings from industrial hygiene scans and urine mutagenicity tests. Cancer Nurs, 21(2), 79.
2. Occupational Safety & Health Administration. "Controlling occupational exposure to hazardous drugs." OSHA technical manual. 1999. www.osha-slc.gov/dts/osta/otm/otm_vi/otm_vi_2.html (31 Jan. 2002).
3. Del Gaudio, D., & Menonna-Quinn, D. (1998). Chemotherapy: Potential occupational hazards. Am J Nurs, 98(11), 59.
4. McAbee, R. R., Gallucci, B. J., & Checkoway, H. (1993). Adverse reproductive outcomes and occupational exposures among nurses: An investigation of multiple hazardous exposures. AAOHN J, 41(3), 110.
5. Brown, K., Esper, P., et al. (Eds.). (2001). Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh: Oncology Nursing Press, Inc.
6. Welch, J., & Silveira, J. (Eds.). (1997). Safe handling of cytotoxic drugs: An independent study module (2nd ed.). Pittsburgh: Oncology Nursing Press, Inc.
7. National Institutes of Health, Division of Safety, Clinical Center Pharmacy Department and Cancer Nursing Service. "Recommendations for the safe handling of cytotoxic drugs." 1992. www.nih.gov/od/ors/ds/pubs/cyto/index.htm (31 Jan. 2002).
The following groups can provide information on the safe handling of chemotherapy agents.
Occupational Safety & Health Administration U.S. Department of Labor|
OSHA Technical Manual,
Section VI, Chapter 2, which can be found at: www.osha-slc.gov/dts/osta/otm/otm_vi/otm_vi_2.html
Oncology Nursing Society
The University of Texas-Houston Health Science Center
Connor, T. H. "Occupational Hazards Related To Antineoplastic Agents,"
which can be found at: www.uth.tmc.edu/schools/sph/an_agents/index.htm
Emil Vernarec, ed. Susan Newton. Handling chemo safely: Your concern, too. RN 2002;5:38.
Published in RN Magazine.
MORE ARTICLES IN THIS ISSUE
Bad outcomes can, and do, occur as the result of staffing problems. Here are three situations you might find yourself in and what you can do to protect your patients and your license.
FDA advisory for kava * COX-2s vs. acetaminophen * and more ...
Kim, a 19-year-old, is brain-dead as the result of severe head trauma she suffered in a Jet Ski accident. Her mother indicates that Kim had always said, "I'd donate my organs to help someone else live." Her father, who remains extremely distraught, refuses to even talk about the issue. Both look to you for support. What would you do?