Protection from toxic drugs

New cytotoxic drug guidelines minimise nurses’ exposure to toxic cancer drugs.

Thirty years ago, nurses working in oncology wards would complain of having constantly sore eyes and yellow hands from working with cytotoxic drugs. Thankfully, times have changed and nurses can now expect to minimise exposure to these toxic chemicals, thanks to a new set of guidelines put together in part by one NSWNA member, oncology CNC Vivienne Freeman from Royal North Shore Hospital.

A cytotoxic drug has a toxic effect on cells. These drugs are often used in chemotherapy because they inhibit the growth of cancer cells. They are also used to alleviate autoimmune conditions like rheumatoid arthritis, to suppress rejection in organ transplant patients, or to treat severe skin conditions like psoriasis.

The problem with cytotoxic drugs is they are also dangerous, and can damage healthy cells. Chemotherapy patients often have toxic side effects from the drugs, including nausea and fatigue. The drugs are generally only given to patients when the benefits would outweigh the potential damage.

But many nurses have to work with these drugs every day and are exposed to the potential harm on an ongoing basis. Long-term exposure to the drugs can potentially cause liver problems, infertility, cumulative chromosome damage, and even cancer. Generally, the long-term risk is highest for patients who are treated with the drugs, but the long-term effects on nurses who work with them is unknown.

‘They can cause secondary cancer in one in 100 people who are treated with the drugs,’ said Professor Bernard Stewart, head of the cancer control program for South East Sydney and Illawarra Health. ‘There is no direct evidence for the causation of cancer for people who handle these drugs, but we still need to minimise exposure.’

A 1996 study published in the Archives of Environmental Health found that the cytotoxic drug methotrexate was present in urine samples of nurses who’d been caring for chemotherapy patients. The study also found that patients undergoing high-dose chemotherapy excreted methotrexate in their sweat. Since then, safety measures have improved, but sometimes still fall short.

Part of Vivienne’s job is educating nurses about chemo-safety – that is, making sure they understand how toxic these drugs are and that they require safety equipment to administer the drugs and deal with the waste.

‘In this age where the dollar counts, some of the chemo-safety gear is totally inadequate and unsafe,’ she said.

So far there have been no documented claims in NSW for nurses who have suffered from toxic exposure to cytotoxic drugs, but that doesn’t mean exposure doesn’t happen.

Vivienne spent up to ten hours a week for almost a year working on the new guidelines, in conjunction with WorkCover, the NSWNA and other organisations.

‘The guidelines were updated on the basis of a number of things, including other guidelines, professional knowledge, plus the evidence for what is safe and what is not safe,’ said Vivienne.

The new guidelines cover everything from handling and administering the drugs to dealing with the waste products safely.

‘We are the people who administer chemotherapy, we are the ones dealing with the material waste, the IV lines and things, and it’s really important that people know how to deal with these drugs,’ she said.

She said that it is important nurses are represented when putting together any type of guidelines. ‘Nurses, and cancer nurses in particular, are a large part of the workforce who deal with this,’ said Vivienne. ‘It’s important we use our experience and knowledge to have a say.’

From a career perspective, Vivienne learned a lot from her work on the guidelines, and it was a substantial career achievement.

‘From my point of view it was a privilege, as I have a strong belief in protection of all staff who are dealing with chemotherapy and the resultant waste,’ she said.

‘You learn a lot about your subject, you get to work with people from other health professions who are interesting and give you another perspective on the subject in question. You also need to learn a lot of patience as it is a lengthy process.’

Most importantly, nurses need to be protected from long-term exposure to potentially harmful substances, and have the right to a safe workplace, according to Vivienne. ‘We do not know what the effects on us will be in years to follow and while all patients deserve the best treatment, staff also deserve the best means of protection from the side effects and toxicities of these drugs.’

Cytotoxic drug guidelines: risk control for nurses

The OHS Regulation sets out a hierarchy of control (or ranking of controls) to manage workplace risks. The hierarchy takes the following order – elimination of the risk, substitution, isolation, engineering controls, administrative controls and personal protective equipment.

Eliminate the risk

Ways of achieving this include:

  • purchasing cytotoxic drugs in ready-to-use concentrations to eliminate pharmacy preparation
  • establishing supply arrangements with a company or health care institution that specialises in the preparation of cytotoxic drugs.

Substitution

Using a less hazardous substance or a substance in a less hazardous form. Ways of achieving this include:

  • purchasing single-dose preparations
  • purchasing cytotoxic drugs in a liquid form, rather than a powder form
  • using a least hazardous cytotoxic drug to achieve the desired therapeutic benefit
  • incorporating handling techniques that minimise aerosol generation
  • purchasing drugs in vials not ampoules
  • purchasing drugs in plastic vials, or vials reinforced with plastic casings.

Isolation

Separating people from the substance by distance or barriers to prevent or minimise exposure.

Ways of achieving this include:

  • adopting closed-system operations
  • conducting drug preparation work in a properly-designed and secure cleanroom
  • placing dispensed drugs in impermeable packaging for delivery to administration areas
  • designating a cytotoxic drug administration area, which only permits entry to authorised people.

Administrative controls

Adequate supervision and training is paramount if work practices are to play an effective part in reducing employee exposure to cytotoxic drugs and related waste.

Ways of achieving this include:

  • allocating responsibilities for health and safety
  • minimising the number of employees who work with cytotoxic drugs
  • cleaning work areas regularly
  • keeping containers of cytotoxic drugs secure
  • incorporating handling techniques that minimise aerosol generation
  • prohibiting eating, drinking and smoking in work areas
  • developing and implementing safe work procedures (safe working procedures) for all work activities
  • providing appropriate information, education and training to employees and carers
  • storing cytotoxic waste in specific, clearly-identified areas, separate from other waste
  • developing emergency procedures to deal with spills.

Personal protective equipment

Something worn that provides a barrier between the person and the hazard. This may include:

  • impermeable coveralls and gowns
  • head covering
  • closed footwear
  • overshoes
  • gloves of appropriate material and thickness
  • safety glasses
  • respiratory protective devices – respiratory filters must be inspected and maintained.

A full copy of the guidelines is available from WorkCover, or can be downloaded at: http://www.workcover.nsw.gov.au/Publications/OHS/Training/Pages/Cytotoxic