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Veterinary Forum October 2007 (Vol 24, No 10)

Business Skills: Current trends in oncology safety

by Philip Seibert, Jr., CVT

    Editor's Note: The treatment of cancer with drugs, surgery and radiation has become increasingly common in veterinary specialty practices. More general practitioners are becoming involved in surgical and chemotherapeutic therapies. With this increased use of chemotherapy comes the need to be aware of the proper procedures for the handling, administration and disposal of these agents. In this column, our safety and OSHA expert, Phil Seibert, discusses the proper protocols for handling these drugs. — Stephen Fisher, DVM, Column Editor

    With the increased use of oncology treatments in private practices, there is concern that veterinary health care workers may be exposed to high levels of cytotoxic drugs (CDs) during preparation, storage, administration and disposal.

    Although little research has been done on the long-term risks for health care workers, these drugs have been associated with human cancers at therapeutic levels and are carcinogens and teratogens in many animals. In addition, they have been implicated in acute problems, such as damage to normal skin and localized skin necrosis after contact with abraded skin.

    There also are potential long-term effects. Most CDs either bind directly to genetic material or affect cellular protein synthesis and may damage the growth and reproduction of normal cells. Organ damage also has been associated with CDs, not only in patients but also among employees administering treatments.

    The National Institutes for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) have developed guidelines that are designed to assist workers who may be exposed to CDs. These guidelines are not mandatory, but if a worker is hurt because the employer ignored such directions, it is not difficult to imagine the civil liabilities involved.

    Facility precautions and proper attire

    The occupational risks associated with CDs depend on a combination of drug toxicity and the extent of exposure. The chance of exposure can occur at many points during handling.

    It is strongly suggested that all CDs be prepared in one central area. When possible, a biological safety cabinet (BSC) should be designated for CD preparation. If the BSC does not vent to the outside, an appropriate HEPA filter must be installed. If the hood is exhausted outside, the discharge opening should be at an appropriate level and away from air intake units.

    Warning signs designating the area as a CD preparation area and spill cleanup procedures should be posted.

    Solutions should be mixed and prepared on a disposable absorbent pad. The pad should be discarded in an appropriate waste container after the procedure has been completed or if it becomes soiled.

    Closable, puncture-resistant, shatterproof containers should be used for disposal of contaminated sharps and breakable materials. Labeled sealable plastic or wire-tie bags also should be available so that contaminated boxes, gloves, gowns and paper liners can be contained properly.

    The area should be cleaned thoroughly with 70% alcohol after the procedure is completed or if a spill occurs.

    Getting ready for the procedure is as important to safety as the actual drug administration. In fact, most accidental exposures occur from mishaps during the mixing and loading process.

    Surgical latex gloves may be less permeable to many CDs than the polyvinyl chloride (PVC) gloves recommended in older guidelines. Therefore, surgical latex gloves should be worn unless the manufacturer specifically stipulates that different gloves provide better protection (powdered gloves should never be used). A double layer of gloves is substantially less permeable and is recommended. Gloves should be changed regularly (preferably hourly) and immediately if they become torn or punctured.

    A protective disposable gown made of lint-free low-permeability fabric with a closed front, long sleeves and elastic or knit-closed cuffs must be worn. The cuffs should be tucked under the gloves. Gowns and gloves should not be worn outside the preparation or administration area.

    If you do not have a BSC, a respirator with a high-efficiency filter will provide the best protection until a BSC is installed. Surgical masks do not offer the needed protection.

    A plastic face shield or splash goggles also should be worn if a BSC is not used. Finally, an appropriate eye- wash fountain must be easily accessible.

    Syringes and intravenous (IV) sets with Luer-lock fittings should always be used, and syringes should be large enough that they never need to be more than three-quarters full. A nonsplash disposal collection vessel, such as a plastic or metal tray lined with sterile gauze pads, should be on hand to collect excess solution. All items should be assembled before work is begun, and extraneous items should be kept out of the work area to avoid contamination.

    All syringes, IV bags and bottles containing CDs should be labeled with a distinctive warning, such as "Chemotherapy — handle with gloves — dispose of properly."

    For reconstituting powders, using a large-bore (18- to 20-gauge) needle will reduce the need for high-pressure syringing of the solution.

    IV and drug administration sets should be attached and primed before the drug is added to the fluid to ensure that any fluid that may escape during priming contains no drug.

    All syringes and needles should be placed in a puncture-proof container for disposal without being crushed, clipped or recapped. (Some professionals believe that capping the needle before disposal reduces the generation of aerosols; others warn that it increases the chances of needlesticks.)

    Handling of vials

    Generally, medication vials should not be vented unless a BSC is used. Syringe and needle fittings should be of the Luer-lock variety.

    Do not inject all the diluent at once: A large volume of displaced air will cause the syringe's plunger to back up and possibly spray the drug or leak. Diluent should be added slowly to the vial by alternately injecting small amounts, allowing displaced air to escape into the syringe. When all diluent has been added, a small amount of additional air may be withdrawn to create negative pressure in the vial. The air in the syringe should not be expelled into the room because it may contain drug residue. It should be injected into a vacuum vial or left in the syringe to be discarded.

    Sterile gauze should be wrapped around the needle and vial top when withdrawing solution. The drug should be withdrawn from the vial while negative pressure is maintained. If this use of negative pressure is not practical, a syringe should be filled with air equal to the volume of drug required and the solution withdrawn by alternately injecting small amounts of air into the vial and withdrawing equal amounts of liquid until the required volume is withdrawn.

    If the needle is to be changed before administration, the drug should be cleared from the needle and hub of the syringe before separating to avoid spraying.

    Any material remaining in the top of an ampule should be tapped down before opening. A sterile gauze pad should be wrapped around the ampule neck before breaking the top to protect against cuts and to catch aerosolized material.

    If diluent is to be added, it should be injected slowly down the inside wall of the ampule. The ampule should be tilted gently to ensure that all the powder is wet before agitating it to dissolve the contents.

    The needle should be held vertically with the needle upward; the syringe should be tapped lightly to remove air bubbles and the air bubbles expelled into sterile gauze in a pan or bag, not into the air.

    Equipment

    Although the specifics of each situation will differ, personal protective equipment (PPE), such as proper gloves and gown, should be used by everyone who is administering the drug or restraining the patient. Staff should wash their hands before putting on gloves. A surgical mask can provide protection from splashing on the mucous membranes, but not from respiratory contact because the mask provides only minimal protection against CD aerosols.

    Having the proper equipment ready and assembled can increase the efficiency of the operation as well as the safety margin. At a minimum, the following equipment and supplies are essential:

    • Gauze (4 x 4)
    • Alcohol or alcohol wipes
    • Disposable plastic-backed absorbent liner
    • Empty vials to be used as receptacles for excess drug solution
    • Puncture-proof container for needles and syringes
    • A 4-ml sealable plastic or wire-tie bag (with warning label) large enough to contain waste materials and accessory warning labels
    • Splash-proof goggles and convenient access to eye- or facewash for emergencies

    Syringes, infusion sets and other delivery devices should be checked for leakage. A plastic-backed absorbent pad should be placed under the connection during administration to catch any leakage.

    Needles and syringes should be placed in a puncture-resistant container for disposal. Contaminated non-sharps should be placed in a plastic bag for disposal. The bag should be disposed of in accordance with the hospital's toxic waste disposal procedures.

    Nondisposable items should be wiped several times with an alcohol wipe and properly rinsed. Hands should be washed after gloves are removed. All gauze and alcohol wipes must be put in an appropriate container for disposal.

    Post-treatment measures

    Patients can excrete the drugs in body fluids for up to 48 hours after administration. Therefore, anyone who cleans up after these animals should follow precautions and wear PPE.

    Housekeeping personnel should wear gowns and surgical latex gloves when handling waste containers and should be instructed on the necessity of handling this waste with care, regarding it as hazardous material. Disposal must be in accordance with applicable regulations, which normally means incineration or a licensed sanitary landfill for toxic waste. If the waste is to be picked up by a commercial disposal firm, the company must be licensed, and the waste must be held in a secure area in covered, labeled containers lined with thick plastic bags.

    When possible, patients receiving CD therapy should be exercised in a separate area from other patients. Feces from patients deposited in exercise areas should be removed promptly. Materials like cage paper also should be considered hazardous waste.

    Disposal of waste materials from CD procedures is not difficult if two basic concepts are followed: containment and segregation. All non-sharps waste should be collected in a thick plastic bag with a cytotoxic hazard label and, preferably, of a different color than other hospital trash bags.

    At least one receptacle should be located in every area where the drugs are prepared or administered so that the waste need not be moved from one area to another. The bag should be sealed when it is filled or at the end of the procedure or shift and kept inside a covered waste container clearly labeled "cytotoxic waste only."

    NEXT: Clinical Ethics: Are we consistent in our treatment of all animals?

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