Lesson 13: Safe Handling

biologic safety cabinets

- A class II type B or class III vertical airflow cabinet exhausted to the outside air is recommended to protect personnel and the drug. - Personal protective equipment should be worn when working with a biologic safety cabinet. - The biologic safety cabinet should be cleaned by wiping the surfaces with a detergent. - The exhaust blower should remain on at all times, and the cabinet should be maintained by a qualified technician at least every six months and any time the cabinet is repaired or moved.

face shields

- A face shield provides better protection than goggles because it covers more of the face. Wear whenever splashing is possible. - Use when locking connections are not available for hazardous drug administration. - Consider using a face shield if you have to spike into an IV bag containing hazardous drugs because splashes can occur.

environmental contamination areas

- Air samples in preparation areas - Floors in the drug preparation and administration areas - Surface of drug vials - Surfaces in preparation areas, storage areas, and administration areas - Skin under gloves

oral administration techniques

- Do not break, crush, or mix tablets with food or fluid outside of a primary engineering control. - Wear gloves to administer oral hazardous drugs. - Wear a gown and face shield if potential exists for sprays, aerosols, or splattering. - Open directly into a medicine cup. - Use a plastic-backed absorbent pad if necessary.

new recommendations from the US Pharmacopeial (USP) Convention

- Each entity is required to have a designated trained and qualified individual in charge of hazardous drug oversight. - Documentation and standard operating procedures are needed for all handling activities, and these procedures must be communicated to all staff involved and consistent across the organization (i.e., inpatient and outpatient). - Areas where hazardous drug preparation occurs must have signage and access restricted to those trained to work with hazardous drugs. These areas should have negative air pressure and ensure an uninterrupted power supply to ensure continued negative air flow in the event of power failure. - Hazardous drugs are to be stored separate from non-hazardous drugs. The storage room is neutral or negative air pressure. Hazardous drugs requiring refrigeration should be in a refrigerator separate from non-hazardous drugs. - Closed-system transfer devices must be used when administering antineoplastic hazardous drugs when the dosage form allows. - Hazard communication program: Policies and procedures must be in place to ensure worker safety during hazardous drug handling. A written plan of education, drug handling, and disposal with reference materials must be readily available for all workers. - Personnel of reproductive capability must confirm in writing that they understand the risks of handling hazardous drugs. - Administration requires the use of protective devices and techniques, such as needleless systems and closed-system transfer devices.Prime tubing with non-hazardous drug fluid. If crushing or manipulating tablets is necessary, this should be done under the biologic safety cabinet. When a biologic safety cabinet is not available (e.g., in the home), tablets must be crushed within a plastic pouch to minimize drug exposure. - Medical surveillance: Healthcare workers who handle hazardous drugs as a regular part of their job assignment should be enrolled in a medical surveillance program.

hazardous drug administration recommendations

- Ensure appropriate supplies for administration are available. - Ensure a spill kit is readily available. - Wash hands thoroughly before donning PPE. - Wear two pairs of chemotherapy-tested gloves. - Wear a face shield if there is a chance of the hazardous drug splashing. - Wear a NIOSH-approved respirator if hazardous drug aerosols may be present. - Inspect the drug delivery bag and its contents prior to handling. - Don PPE before reaching into the delivery bag to remove the drug container. - Remove gloves and gown in such a way as to prevent transfer of hazardous drug contamination to the skin. - Whenever possible, avoid touching equipment with gloved hands after handling hazardous drugs. - Do not hang up gowns and reuse them. - Wash hands with soap and water (as opposed to using alcohol-based hand gels) because friction and rinsing are necessary to assist in removing hazardous drug contamination. - Perform all work below eye level. - Use a closed-system transfer device when available.

spill management recommendations

- Even a small-volume spill should be considered a source of exposure and handled appropriately. - The longer the delay in cleaning a spill, the lower the cleaning effectiveness; the quicker a spill is cleaned, the more effective the decontamination process will be. - Only personnel who are properly trained in spill management and the use of PPE and NIOSH-certified respirators should be handling spill management. Organizations may choose to use a hazardous material response team for large-volume hazardous drug spills. - All workplaces should have written standard operating procedures that cover the important points around spill management, including the following: -- PPE required for various spill sizes -- Location of spill kits (including capacity of kits), cleanup materials, and signs to be posted; these should be located in all areas where hazardous drugs are routinely handled and should be made available if hazardous drugs are being prepared or administered in a non-routine area -- Restricting access to areas where hazardous drug spills have occurred to decrease the risk of spreading contamination -- Appropriate use of full-face, chemical cartridge-type respirators (PAPRs) if the capacity of the spill kit exceeded or if airborne exposure to vapors or gases is knon or suspectd -- Required documentation around the circumstances and management of spills - All spill clean materials should be disposed in accordance with environmental regulations regarding hazardous waste, not in a biohazard container - Personnel who are potentially exposed during the spill or spill cleanup or who have direct skin or eye contact with hazardous drugs require immediate evaluation. Non-employees exposed to a hazardous drug spill should follow institutional policy, which may include reporting to the designated emergency service for initial evaluation and completion of an incident report or exposure form.

respirators

- For most activities requiring respiratory protection, a NIOSH-certified N95 or higher protective respirator is sufficient to protect against airborne particles. A powered respirator may be required for some situations. - Surgical masks do not provide respiratory protection. - Consider using a respirator if you have to spike into an IV bag containing hazardous drugs because aerosols may be released. - Check the material safety data sheet for the appropriate respirator for the situation.

chemotherapy-tested gloves

- Gloves of several materials are acceptable (e.g., latex, nitrile, neoprene) as long as they are tested for use with chemotherapy. But remember, not all gloves are created equal—not all nitrile gloves provide protection. - Wear double gloves—inner gloves under the gown cuff and outer gloves over the gown cuff. - Consider gloves to be contaminated after use—be careful what you touch! - Wash hands with soap and water after removing and discarding gloves.

chemotherapy-designated gowns

- Gowns should be disposable and have back closure and cuffs. - Gowns must provide chemical protection, which means they may be uncomfortable to wear. If air can pass through the gown, so can chemotherapy. - Gowns are meant for single use, which means they are discarded when removed and not hung up for reuse.

Surface Safe®

- Intended for neutralizing hazardous drugs. The product uses two saturated pads: -- One containing 2% sodium hypochlorite and detergent -- One containing sodium thiosulfate, which inactivates the bleach while also binding to platinum compounds and nitrogen mustard

IV administration techniques

- Secondary tubings, which are primed with a neutral solution prior to spiking the hazardous drug in a biologic safety cabinet, prevent contamination at the bedside and allow for the tubing to be flushed upon completion. This eliminates the need to unspike the hazardous drug bag at the bedside to flush the tubing. - Placing an absorbent pad under the work area - Using 2" x 2" gauze around syringe connections for IV push administration - Not filling syringes more than 75% full and placing an absorbent pad beneath the work area when attaching needles for SC or IM administration

engineering controls

- Strive to isolate the worker from hazardous drugs. They include the use of machines and equipment that contain the hazard or provide needed ventilation. - The HEPA filtration of the air in a compounding room and biologic safety cabinets, where drugs are mixed, are examples of primary controls used to provide a clean environment for preparing chemotherapy drugs.

closed-system transfer devices

- Supplementary engineering controls that reduce exposure during hazardous drug compounding and administration. Some components equalize pressure in vials and prevent leakage during drug transfers from one container to another. - These systems are not a substitute for primary engineering controls. - For drug compounding, they should be used in combination with a primary engineering control, such as a biologic safety cabinet. - They are the only type of engineering control available for hazardous drug administration.

techniques to limit drug exposure

- Using containment devices, including placing in a clear, sealable plastic bag - Using locking connections - Using closed-system transfer devices, if available - Avoiding spiking and unspiking at the bedside or chairside - Using dry spiking and back-priming technique when needed - Wiping down the outside of drug containers - Considering the infusion tubing, connectors, and pumps available to determine the optimal technique for connecting IV hazardous drugs - Using plastic-backed absorbent pads to absorb leaks - Using gauze squares around injection ports or connections to absorb leaks - Avoiding ejecting air from syringes for intramuscular or subcutaneous injections outside the biologic safety cabinet - Managing skin, mucous membrane, or ocular contamination

handling excreta

- Wear a gown and double gloves, just as you would when administering hazardous drugs. - Wear a face shield whenever splashing is likely.

when to wear PPE

- Whenever there is a chance of releasing hazardous drugs into the environment, such as the following: -- Handling vials, ampules, or packaging materials of hazardous drugs -- Hazardous drug compounding -- Hazardous drug administration by any route -- Discontinuation of hazardous drug infusions -- Hazardous drug spill cleanup -- Handling hazardous drug-contaminated waste

times when drug exposure can occur

- While transporting hazardous drugs to the administration area - During hazardous drug verification - While priming tubing - When connecting bags, bottles, syringes, and tubing - When disconnecting components - When syringes are connected or disconnected during administration and when flushing tubing and bags (potential of leakage) - During disposal of hazardous drugs and administration components - When removing and disposing of PPE

hazardous drug waste disposal

-In many centers, these are black hazardous waste containers and would be used when bags and vials contain more than a trace of hazardous waste. These are often found in the drug preparation area. - Yellow trace chemotherapy waste containers should be used for any items that have come into contact with a hazardous drug during preparation or administration. For example, items can be disposed of as trace waste when less than 3% of the volume remains in the bottle or tubing.

doffing PPE

1. Remove outer gloves, turning them inside out 2. Remove the gown 3. Remove the face shield 4. Properly dispose. 5. Remove inner gloves, turning them inside out 6. Wash hands

donning PPE

1. Wash hands 2. Inspect gloves 3. Apply first pair of gloves 4. Apply gown. Close in the back and tuck gloves into the cuffs. 5. Apply second pair of gloves over the cuffs 6. Put on your eye or face protection

drugs that vaporize at room temperature

Carmustine Cisplatin Cyclophosphamide Etoposide 5-FU Ifosfamide Nitrogen mustard Thiotepa -If a large spill occurs with any of these drugs, a powered air-purifying respirator (PAPR) will provide better protection. - Wear a respirator when administering an aerosolized hazardous drug or cleaning a hazardous drug spill.