Occupational Exposure to Hazardous Drugs

Some of the same pharmaceutical agents that can be lifesaving for patients with cancer and other complex health conditions pose serious risks for the healthcare professionals who may come into contact with them. Occupational exposure to hazardous drugs has been linked to a range of health problems, and it doesn't take much to cause harm.

Accidental exposure can happen through ingestion, injection, inhalation of powders or fumes, and absorption through the skin. It can be something as simple as accidentally touching your nose or mouth with a contaminated glove or hand after handling a drug. It's critical to have protocols for the management of hazardous drugs, as well as comprehensive training for all staff along with reliable, proven safety equipment, such as closed-system drug transfer devices or CSTDs.

Understanding the risks and how to effectively mitigate them can help keep both clinical and non-clinical staff safe while providing patients with the treatments they need

Doctors today have a full range of pharmaceutical options to help treat patients. Because of the complex nature of certain conditions, clinically effective medications may pose some serious risks to healthcare and pharmaceutical staff. A common example is antineoplastic agents, which are frequently used in chemotherapy.

These drugs can effectively kill cancer cells. The trade-off is that they also kill healthy cells in the process, which is why patients undergoing chemotherapy experience undesirable side effects such as hair loss.

For people who are battling cancer, often, the benefits outweigh the risks and side effects. For people who don't have cancer, though, exposure offers no benefit. And harmful effects can multiply if they come into contact with hazardous drugs over long periods of time.

According to the National Institute for Occupational Safety and Health (NIOSH) regulations, "About 8 million U.S. healthcare workers are potentially exposed to hazardous drugs, including pharmacy and nursing personnel, physicians, operating room staff, environmental services workers, workers in research laboratories, veterinary care workers, and shipping and receiving personnel."¹

Exposure to antineoplastic agents can cause a range of harmful effects. Some are acute, such as headaches, rashes, dizziness, sore throat, or cough. More serious health consequences include impaired fertility, pregnancy loss, congenital disabilities, or even some types of cancer.²

There are a number of measures healthcare leaders can put in place, including the use of CSTDs, that can help minimize dangerous exposure to these drugs. This makes pharmaceutical care safer for everyone involved, including patients and caregivers.

Potentially harmful exposure can occur whenever hazardous drugs are handled. Labs and manufacturing facilities usually have very stringent safety protocols in place for this reason. Managing safety in a clinical care setting can be more challenging because of the nature of working with patients, the number of people in various roles, and more direct interaction with the public.

However, it's important to be aware that harmful exposure can happen easily and in many different ways when working with hazardous drugs. The following are some examples of how hazardous substances can be risky for those in the clinical care setting:²

• When preparing drugs for patients -- This includes reconstituting powders, diluting drug mixtures, measuring doses, counting uncoated tablets, crushing tablets, or prepping IV sets with hazardous drugs. These tasks may be conducted in the facility's pharmacy to minimize potential exposure in the treatment room. Any surface or equipment involved in these tasks, including personal protective equipment, is also a source of potential contamination.
• Harmful particles may be in the air -- Obvious examples include when aerosolizing drugs for inhalation, but sometimes particles can be released into the air other ways, too. For instance, when pushing air out of a syringe that contains a hazardous drug, you may also be releasing tiny bits of the chemical into the room. This amount may seem incidental, but some substances can be harmful even in minute quantities. And for a worker who is exposed to this day after day, exposure builds up.
• When administering the drug through injection or intravenously -- This can expose the clinician to both the drug and the patient's bodily fluids. There's also an obvious risk here of a healthcare worker accidentally pricking their own skin with the needle.
• Clean-up of contaminated items, including spills, disposing of used vials or syringes, or discarding unused amounts of a hazardous drug -- These items should never be discarded in the regular trash, and protective equipment should be used even at this stage.
• When handling bodily fluids, waste, bedding, or clothing from the patient -- Any of these materials could include traces of the hazardous drug used during treatment.
• When cleaning the room or rooms where potentially hazardous drugs were stored, prepared, handled, or administered. This may include both the pharmacy and treatment rooms.
• When removing gloves, gowns, masks, or other personal protective equipment worn during the handling or administration of the drug -- Removing these items improperly can increase the risk of contamination.

Effectively minimizing the risks of occupational exposure to hazardous drugs requires a multifaceted approach. Specific rules may vary a bit based on the types of hazardous drugs administered or stored on the premises, the layout of the building, how many people are typically present, what the ventilation is like, and other factors. However, there are some general rules that make sense for any clinical setting where hazardous drugs are present:

• There should be specific protocols for storage, labeling, and transport of hazardous drugs, even for moving them from one room to another. It's important to keep a careful inventory and make sure members of staff know these rules. This may include designating certain personnel as the only people allowed the handle these products.
• Workers who are at higher risk, such as pregnant individuals, shouldn't handle hazardous drugs.
• Workers should know when and how to use personal protective equipment (PPE) such as gowns, gloves, protective eyewear and masks, including when and how to remove and discard them properly.
• There should be a plan in place for dealing with spills quickly and with easy access to spill kits in any area where hazardous drugs are regularly present. All spill kits should include instructions for proper disposal of cleaning equipment after use.
• Establish guidelines for safely discarding potentially contaminated items, including used patient bedding or clothing, vials or other containers, syringes, and IV kits (ex. paclitaxel infusion kits).
• Have clear rules about not eating or drinking in rooms where contamination could occur, such as in a pharmacy or treatment areas.
• Conduct regular training to ensure all personnel understand the guidelines around handling hazardous drugs, even for staff who don't have direct contact with these drugs.
• Have a plan in place for when an accidental exposures occurs. Include rules for documentation and reporting, in addition to ensuring the person who was exposed gets any immediate medical care if needed.
• Make sure staff members who handle hazardous drugs understand how to use equipment such as CSTDs.³

Closed system drug-transfer devices or CSTDs are devices designed specifically for the safe handling of hazardous drugs. CSTDs prevent leakage of vapors, powders, or liquids while preparing, mixing, handling or administering these drugs. CSTDs can work in one of two ways: they may provide a physical airtight barrier or use air-cleaning technology.

CSTDs provide a more reliable level of protection than gloves, masks, or other PPE items alone. Studies have shown that the proper use of CSTDs dramatically reduces the risk of contamination from hazardous drugs. NIOSH recommends their use while preparing and compounding hazardous drugs through the point of administration to protect healthcare workers from being exposed.

Pharmaceutical breakthroughs are happening at an exciting pace, with new medicines that can target diseases in innovative ways coming to market every day. And some of these emerging pharmaceuticals will also pose risks to the people who handle or are around them.

Having solid plans and protocols in place, as well as the right safety equipment, including CSTDs, will enable pharmacies, healthcare systems, hospitals, and medical practices to deliver cutting-edge patient treatment without risking employee safety.