Canadian Occupational Safety

JUNE/JULY 2018 25 exposed to cytotoxic drugs. It starts with the staff involved in the receiv- ing department, who rely on warning labels on the outside of the shipping and transport containers so they know what they are handling. Workers could be exposed if the vials of the drug are broken or if there are traces of it on the boxes. "If there's no safe handling pro- tocols in place, then there's that risk of touching it and being exposed to it," says Komal Patel, educator at the de Souza Institute in Toronto, which provides continuing education to health-care professionals. Pharmacy staff can be exposed when they are storing, mixing and preparing the drug or transporting it to the proper unit. While they are administering the drug, nurses and their aids can be exposed. For example, the drug can be absorbed through their skin if they are not wearing gloves or if it permeates through the gloves. Exposure can also occur when they are caring for the patient after treatment. Bodily fluids and excreta — such as saliva, sweat, urine, feces and vomit — may contain drug residue for up to one week. This means not only nurses can be exposed after the fact, but housekeeping and maintenance staff can be too. "These dangerous drugs carry that 48-hour to seven-day window where they can still be impacting the health- care workers out there who have to go in and change linens and clean the rooms and work on the facilities and mainte- nance of beds and toilets and sinks and that whole system," says Hansen. In addition, there's a whole range of support workers who may unknow- ingly face exposure at various points along the line, such as the dietary staff. "They are delivering the lunch trays and they may put the tray down and maybe the patient has asked them to move something and the object is contaminated, then there's that risk as well," says Patel. "It's not just neces- sarily the individuals who are around patients all the time." Anyone working with cytotoxic drugs or handling waste products should at least be wearing two pairs of chemo- therapy gloves and a non-permeable chemo gown. They may also need gog- gles or a face shield if there is a risk of splashing and a respirator if there is an airborne risk, says Hansen. When it comes to pharmacy staff, they have to wear two pairs of che- motherapy gloves, a chemotherapy gown, hair cover, a beard cover (if applicable), a respirator, shoe covers and safety goggles with side shields if there is a potential for splashing, says Lynne Nakashima, provincial pharmacy director at BC Cancer, which operates six cancer treatment centres across British Columbia. They are not allowed to wear any jewelry, rings or makeup, and they cannot wear contacts. A 2014 sur vey by the National Institute for Occupational Safety and Health (NIOSH) in Atlanta found 80 per cent of oncology nurses and other health-care personnel were not always wearing two pairs of chemo- therapy gloves and 15 per cent did not wear even a single pair. Forty- two per cent of the 2,100 sur vey respondents failed to always wear a non-absorbent gown with closed front and tight-fitting cuffs. One reason why health-care profes- sionals may not be wearing their PPE is because they are so patient-focused. "A lot of the times the health-care staff themselves get lost in safety requirements for them as workers," says Hansen. To get ahead of the problem, BC Cancer makes sure it hires individuals who are adapt at following very strict policies and procedures, such as wear- ing all necessary PPE. "We ask in the interview: 'Are you the sort of person who is good at following very strict policies and procedures?' Because if they're not, this isn't going to be a good place for them," says Nakashima. "You have to do all of these procedures and you have to follow them rigorously because not only are you protecting your own health, but you're protecting those around you." It's also important to foster a safety culture where not wearing PPE is simply regarded as unacceptable among staff. "If someone were to walk in with the wrong thing, everybody would turn around and say, 'Go back out,'" says Nakashima. "They do kind of self- monitor in that way." The PPE needs to be easily acces- sible and workers need to be trained on how to properly don and doff the equipment as well. POLICIES, PROCEDURES When it comes to cytotoxic drugs, there needs to be strict policies and procedures in place. Aside from the national and provincial standards it has to follow, BC Cancer has created its own standard for the pharmacy staff who work with these agents. The standard covers everything from the time the drug is received on site through the mixing and dispensing of the medication, counselling of the patient and cleaning procedures, to the time it is given to the patient or it leaves the premises, says Nakashima. One of the most important engi- neering controls at BC Cancer is the biological safety cabinet. It is a ven- tilated containment cabinet that is exhausted to the outside atmosphere to prevent re-circulation into the preparation room. For chemotherapy drugs, the exhaust and ventilation sys- tems should operate continuously to ensure that no contaminants escape from the cabinet into the workplace, according to WorkSafeBC. To ensure pharmacy staff are in fact following the many policies and procedures, BC Cancer requires them to complete an annual oncolog y certification. Every year they com- plete a written test and they are also observed in their day-to-day work. Evaluators have a checklist with spe- cific criteria the workers have to meet. If they don't score at least 85 per cent, they need to go through a re-training process, says Nakashima. "And there's certain aspects within those that we would consider an auto- matic fail if you don't do certain things," she says. "So some of them are smaller processes and we want you to do them and some are critical to the process." Closed system drug transfer devices have shown to be effective in control- ling exposure to chemotherapy drugs. The devices are designed to minimize potential exposure of hazardous drugs and their vapour concentrations when transferring the drugs between con- tainers or pieces of equipment. BC Cancer implemented this type of system about five years ago for both its nurses and pharmacists. Nakashima says the agency has been pleased with the reduction in surface contamination. "We take a swab and swab usual work spaces and the before and after's are quite striking," she says. "And once you implement, you maintain that low level of surface contamination. It's another way the staff know they are not being exposed." Good communication about the types of hazards workers may be exposed to is very important. One method of doing this is door signage, which is especially useful for the sup- port workers who do not have access to patient records, says Hansen. "It is as simple as putting up a type of symbol on the doorway to allow those workers — the environment staff, the maintenance staff, the dietary staff — to know what they are walking into," he says. Posters can be another means of communication. Employers may want to have posters for restricted access zones (such as the areas where the chemotherapy drugs are mixed), appropriate use of equipment, proper handwashing, hazardous drugs and the location of spill kits. Emergency procedures need to be clearly outlined for cytotoxic drugs in case of accidental exposure. According to the NIOSH survey, 12 per cent of respondents reported an antineoplastic drug spilled or leaked during administration. Workers need to be trained in all of the emergency response procedures for the different scenarios that could occur. "If it was to go into my eyes what do I do? What are the steps? If I were Routine observations When conducting a review of your policies and procedures for cytotoxic chemicals, walk around the work site and note your observations. Ask yourself the following questions when determining if your workplace is properly protecting its workers: • Are cytotoxic waste receptacles replaced when they are three- quarters full? • Is there a designated bathroom/ commode (if applicable) for any client on treatment? • Are antineoplastic drugs properly stored in a designated secured storage area? • Is there controlled access to medication by staff? • If the drug needs to be refrigerated, is a dedicated fridge used? • Are cytotoxic drugs labelled with the cytotoxic hazard symbol? • Do staff eat, drink, smoke, apply makeup or store food/drink in the drug administration, handling or storage areas? • Have arrangements been made with the pharmacy to provide the drugs in a ready-to-administer form to avoid crushing/cutting oral medication? • Is the cleaning staff following procedures to minimize drug contamination throughout the workplace? For example, are dedicated mops, buckets and cloths used to clean treatment areas only? • Are clothes, bedding, any slings, etc. of clients receiving antineoplastic drugs washed separately and immediately? Source: Public Services Health & Safety Association

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