[Over the years we have received a number of inquiries from the field regarding chemotherapy and instrument reprocessing best practices. The following guest article by Keicha Brock, CSPM, CFER, MBA, Founder & CEO of Eyes to See Management & Consulting seeks to introduce you to the foundational concepts to consider as you prepare your own policies, procedures, and processes. We hope you enjoy! * Beyond Clean]
There are precautions that must be adhered to when handling instruments that may have been exposed to chemotherapy or Hazardous Drugs (HD).
Education, training and communication is the best resource for staff that may come into contact with or be exposed to Chemotherapy/Hazardous Drugs contaminated instruments. Any facility that has hazardous drugs, must remember that it is vital that each person understand the fundamental practices and precautions that are needed to prevent harm and minimize exposure.
So what is Chemotherapy?
Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemo drugs can be grouped by how they work, their chemical structure, and their relationships to other drugs.
Some drugs work in more than one way and may belong to more than one group.
National Institute for Occupational Safety and Health (NIOSH) has a list of Hazardous Drugs and updates the list every two years. www.cdc.gov/niosh NIOSH cautions that new drugs enter the marketplace often and the listed on the website is not all-inclusive.
Each facility is responsible for maintaining and developing a comprehensive list of HDs used at their facility as well as an ongoing process for drug evaluation through safety data sheets, product information and current literature that is available.
Chemotherapy drugs are considered Hazardous Drugs (HDs) because they meet these characteristics
Teratogenicity or other developmental toxicity
Organ toxicity at low doses
Complications that may come from exposure are rashes, nausea and vomiting, dizziness, abdominal pain, headache, nasal sores, and allergic reactions. Exposure over a long period of time can be associated with birth defects, reproductive losses, and cancer.
Reprocessing around Chemotherapy & other Hazardous Drugs (HD)
Anyone that works with instrumentation that encounters Chemotherapy/HDs must remember the possibility for potential contamination and exposure due to the three “S” splash, splatter, or spray. When handling Chemotherapy/HDs- contaminated instruments, personnel that handles instruments must wear Personal Protective Equipment (PPEs.) PPEs are a temporary barrier between hazardous drug contamination to prevent a health hazard. We must remember that all PPE’s are not created the equal. They are several companies on the market that provide PPEs for Chemotherapy/HDs exposure.
The PPEs consist of:
Glove thickness does not determine dermal safety from hazardous drugs. Exam gloves made from polyvinyl chloride do not protect the wearer from drug exposure. Look for glove manufacturer test data for permeation resistance compared to hazardous drugs/ chemotherapy glove guidelines.
Gowns Disposable gowns that are tested for chemotherapy/HDs offer temporary and partial defense against hazardous drugs. These gowns are an indispensable part of protective gear. A lab coat and/or scrubs do not provide the same protection as a disposable gown rated for Chemotherapy/HDs.
Respiratory Protection Surgical masks are not enough to prevent chemotherapy/hazardous drug exposure on their own. An N95 respirator paired with a surgical mask may be allowed for certain chemotherapy hazardous drugs, as listed on the drug information sheet.
Eye and Face Shields Vapors, aerosols and splashes from chemotherapy/hazardous drugs cause irritation and potential long-term damage not only to the eyes but also to other organs. Glasses alone do not provide sufficient protection. Those who wear glasses should choose full-face shields and/or goggles to avoid the risk of hazardous drug exposure.
Sleeve, Hair, and Shoe Coverage When wearing sleeve, hair, and shoe covers, it is recommended to always check for holes or other manufacturing defects before entering a place that has instruments that are contaminated.
Disposal of PPE after contact with hazardous materials must be done properly to avoid contamination. Never wear disposable PPE more than once. Adhere to these safety guidelines regarding PPE disposal:
View all PPE as contaminated to encourage safe handling.
SPD personnel should remove and discard PPEs into an appropriate, puncture-proof biohazard container and wash their hands.
The decision to change the scrub attire worn, is entirely up to the wearer.
Single Use (Disposable) or Reusable Instruments?
If possible, it is recommended that disposable instruments and equipment should be utilized for any Chemotherapy/ HDs portion of a procedure that utilizes surgical instrumentation and equipment. Using disposable instruments eliminates the need to process instruments that have been contaminated by Chemotherapy or HDs and it lessens the risk to staff members potentially being exposed or injured.
Any disposable items that are used during the procedure which utilizes Chemotherapy/HDs (e.g., instruments, syringes, gowns, gloves, and drapes) must be discarded into an approved and appropriate puncture-proof biohazard labeled closed container that is readily accessible and located at the point of use.
Note: Any disposable items from a procedure utilizing Chemotherapy/HDs should not be sent to another department for disposal. Do not send those used disposal items, to the Sterile Processing department.
However, if it is not possible to utilize disposable instruments during the procedure, the person who is handling the instruments should segregate and/or separate the instruments and supplies that are contaminated or exposed with the Chemotherapeutic agents or HDs from other instruments and supplies. Communication is vital and very important throughout this entire process.
Once the procedure has ended, the person who is handling the instruments should place any instruments that have been contaminated with Chemotherapy/HDs in an approved and appropriate puncture-proof biohazard labeled closed container that is large enough to contain all the contents. This container should have a lid that fits snugly and prevents splash or splatter. The container must be clearly and visibly labeled “Chemotherapy” or with the “Hazardous Drugs” name and sent to Sterile Processing Department (SPD) for immediate processing.
The appropriate personnel in SPD must be informed that they will receive instruments that have been contaminated with Chemotherapy/HD. In the SPD, a facility approved detergent/enzymatic should be added to the labeled Chemotherapy/HDs container, and the Chemotherapy/HDs contaminated instruments should be soaked according to the detergent instructions for use.
After the specified time frame for soaking has passed, then, the detergent/enzymatic should be drained from the Chemotherapy/HDs container. (Care should be taken to avoid the three “S” splash, spray, and splatter). The chemotherapy container should either be discarded into a Chemotherapy/HDs biohazard bin or (if validated for reprocessing) cleaned, thoroughly rinsed and dried according to the bin manufacturer's IFUs.
The instruments should be processed with proper decontamination and cleaning procedures and the sink should be rinsed with utility water and/or disinfected according to your facility guidelines. All personnel who have the potential to be exposed to Chemotherapy/HD contaminated instruments must receive initial and continuing education and have a complete competency verification. To ensure a culture of safety and to prevent unintended exposure, each facility should develop policies and procedures for processing Chemotherapy/HDs contaminated instruments and make sure they are readily available to all staff members.
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