A Clear and Present Danger: Awareness, Vigilance Remain Key to Safe Chemotherapy Handling

Christopher R. Friese,

PHD, RN, AOCN, FAAN

It has been nearly a decade since the National Institute on Occupational Safety and Health (NIOSH) issued its seminal 2004 Alert warning healthcare workers about the risks of working with hazardous drugs. Unfortunately, unintended exposure to these dangerous drugs through surface contamination persists. And, the problem may get worse with the expanding number of cancer patients and the corresponding workload demands on those who treat them.

The situation poses a “clear and present danger,” cautioned Christopher R. Friese, PhD, RN, AOCN, FAAN. Friese, an assistant professor at the University of Michigan School of Nursing in Ann Arbor, conducts research on nursing practice environments in outpatient chemotherapy settings. He expressed concern that following the NIOSH Alert, a degree of complacency set in, with clinicians believing that “we’re doing better than we actually are.”

“Surface contamination is still widespread,” he noted, a concern echoed by Martha Polovich, PhD, RN, AOCN, who said that surface contamination from hazardous drugs (HDs) was documented in some 30 studies she has seen, making it likely that “every setting where chemotherapy is administered has this contamination.”

Polovich, an instructor at Georgia State University’s Byrdine F. Lewis School of Nursing & Health Professions in Atlanta, has published extensively on the subject of safe handling and serves as one of the reviewers on an update of the NIOSH Alert currently in progress. She said that while the possibility that a patient’s family and others may be exposed to chemotherapy residue is concerning, it is the occupational exposure of nurses, pharmacists, and others “who work with these drugs daily and often, over many, many years” that most worries her.

“What I’m hearing from nurses is that many don’t know about the problem of surface contamination because they’re not reading the literature, while others may be aware of the problem and are either very concerned about it, or they think that their workplace is safe.” For some nurses, she said, the first time they hear about the issue of surface contamination is when they take the online chemotherapy course she co-teaches for the Oncology Nursing Society (ONS) that is offered several times throughout the year.

Gauging Exposure

Both experts agree that the problem of surface contamination is a multifaceted one, requiring a multipronged approach. “First and foremost,” said Friese, “we need to measure the degree to which exposure is happening,” adding that “we can’t recommend policy and practice changes for a particular site until we understand the size and scope of the problem.”

One obvious way to do this is through surface wipe testing, which takes place in some of the larger cancer centers, Friese noted, “but it is still a very expensive procedure, so that’s a deterrent,” especially for smaller practices which may not have the resources or facilities to do the testing.

Martha Polovich, PhD, RN, AOCN

Polovich added that the assays needed to measure surface contamination are not readily available. She said that there are only a few specialty labs in the United States and a couple in Europe that have the assays to do this testing.

Furthermore, there is currently no requirement or reimbursement for such routine testing, so that when surface-wide sampling for chemotherapy residue is conducted, it’s usually in the context of a study or when an organization is contemplating the purchase of a closed system transfer device (CSTD), whereby the testing is provided by the vendor as a way to demonstrate the need for its product, Polovich continued.

In addition to surface monitoring, said Friese, nurses must be encouraged to report spills when they occur to help develop a better understanding of when and why there is unintentional or accidental exposure.

“It is clear that nurses remain at risk of exposure,” Friese continued. He said that research that he and others have conducted has found that the hazardous agents are detected in the urine of nurses who handle them.

“We need to understand how often it is happening, under what circumstances. This is a ripe area of opportunity, because nurses are not routinely reporting these spills and the context in which they occur,” said Friese.

A Culture of Safety

Surveillance isn’t enough, however. As Friese noted, even among those larger centers that may be conducting more regular surface testing, the need to know how they are using the data to improve safety remains.

CSTDs are effective in reducing environmental contamination, explained Polovich, because, unlike routine IV equipment, these closed systems prevent leakage, thus controlling exposure. Yet currently, these devices increase costs, and there is no reimbursement. Interestingly, she added, Japan does provide reimbursement for their use.

Routine cleaning of the environment and wiping down surfaces where chemotherapy residue is likely to be present is extremely important. She added that some states, such as California, Washington, and North Carolina, are moving to enact measures mandating that employers comply with the NIOSH Alert requirements, such as use of personal protective equipment (PPE) and employee training, but there is currently no nationwide regulation that workplaces must do this.

Polovich said that much attention has been focused both on the need for nurses and other handlers to be educated on safety and on each individual worker’s commitment to take precautions. When employees don’t do this, “there can be some finger-pointing,” she said, and suggestions that the worker isn’t doing a good job.

However, she said, “My research really doesn’t show that.” She explained that the biggest predictor of compliance with HD handling precautions, or lack thereof, is the workplace safety climate. “How an organization addresses safety and supports safety is extremely important.”

Again, it comes back to workload, she said, noting that her research has found that as the number of patients treated per day increases, the use of safety precautions decreases. “What that tells me is that when you’re busy, you may take shortcuts, because that’s the only way you can get through your day, and that’s not the workplace supporting safety,” said Polovich, adding that patient assignment is not within the control of nurses.

In research published last year and based on responses to a mailed survey of nurses who handle chemotherapy and telephone interviews with managers, Polovich found that although nurses demonstrated knowledge of the risk of harm from exposure to HDs and a sense of self-efficacy about use of PPE, total use of precautions was low. The researchers determined that a better workplace safety climate and fewer patients per day were independent predictors of HD precaution use.¹

“I have found that nurses know what precautions are required to minimize exposure, but the circumstances in the workplace interfered with their ability to do that. In organizations where the issue is taken seriously and safety is a priority, precaution is better.”

Friese said that his research has found that nurses taking care of a higher number of patients were those who reported more spills, and that clinic congestion adds to the difficulties. “We found that the more congested areas of a cancer center tend to be the places where spills occur,” and he suggested that both workload and congestion warrant further investigation. In fact, he said, “Right now, we are working with colleagues in engineering to figure out better ways to assign patients to nurses in chemotherapy suites,” in an effort to make the workflow smoother and create a safer environment in which to practice.

Additional Resources

NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings (http://goo.gl/ZVFDxp)

Occupational Exposure to Antineoplastic Agents—National Institute for Occupational Safety and Health (http://goo.gl/jOMm9G)

ASCO/ONS Chemotherapy Administration Safety Standards—2013 Update (http://goo.gl/gm7bPL)

Safe Handling of Hazardous Drugs —2nd edition (http://goo.gl/OZsaAC)

Chemotherapy and Biotherapy Guidelines—3rd edition (http://goo.gl/6hPzE1)

Online Chemotherapy Courses—Oncology Nursing Society (http://ons.org/CNECentral/Chemo)

Lifesaving Drugs—Deadly Consequences —video (http://goo.gl/EyyVMA)

He noted that in ambulatory settings, less regulatory oversight occurs compared with an infusion room attached to a hospital. “That heightened sense of awareness of a safety problem may not be as apparent in the ambulatory setting.” Friese and colleagues have conducted research on exposure to chemotherapy in this setting and found that oncology nurses reported “substantial unintentional skin and eye exposure to chemotherapy,” and the likelihood of exposure was lower when nurses indicated sufficient resources and staffing.²

In addition to workload, Polovich offered some fundamental practical suggestions for increased use of PPE by nurses—including simply making the equipment available and readily accessible. “I’ve heard nurses say, ‘the gowns are so expensive and we only have a few, so we have to conserve their use.’” She added that studies have shown that when PPE is abundantly available, workers are more likely to understand that they need it and will use it.

Changing Behavior

Behavior shifts apply to both managers and staff, these experts emphasize. Managers need to give positive feedback when staff members follow the precautions and negative feedback when they don’t, said Polovich.

“And, there have to be consequences for not using the equipment. That is management’s responsibility—to encourage staff, to inform staff, that when you are exposed, we want to know; we want to document that and follow up on it, because your health and safety is important to us.”

Nurses themselves also must make a personal commitment to safety, Friese stressed. “It is up to individual nurses to make safety part of their practice, and say, ‘I’m going to do this for myself. I’m going to protect myself from this known risk.’”

In fact, some data show that nurses with more experience tend to be the ones having more spills but are the least likely to wear all of the equipment, he noted, because they believe that nothing bad has happened to them yet. “These are the nurses who need the most protection. Real behavior changes on the part of individual nurses are at the heart and soul of this.”

What, then, are the most important takeaway messages Friese has for today’s practitioners and the nursing students he teaches?

“First of all, they need to know and understand the NIOSH Alert. It is a very strongly worded summary that really identifies the risk of using these agents and the proper protections. They need to know which drugs are considered hazardous so that they can personally protect themselves regardless of hospital or clinic policy, making sure that they are taking the right precautions for their own personal health, and also, they need to review the updated ONS guidelines which Dr. Polovich and others have recently updated.”

Friese shared a link (see box) to a poignant video interview with an oncology pharmacist who ultimately lost her battle with pancreatic cancer after a long career mixing hazardous drugs, before improved safe handling procedures were rolled out.

“This is a personal story that makes us recognize what’s happening to our colleagues, and it is incumbent upon all of us to take the precautions and take responsibility for this issue,” he concluded.”

1. Polovich M, Clark PC. Factors influencing oncology nurses’ use of hazardous drug safe-handling precautions. Oncol Nurs Forum. 2012;39(3):E299-E309.
2. Friese C, Ferris LH, Frasier MN, McCullagh MC, Griggs JJ. Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. BMJ Qual Saf. 2012;21(9):753-759.