Hazardous Drug Hazardous Drug Exposure in the Exposure in the Healthcare Healthcare Environment: Environment: Developing Best Developing Best Practices for Exposure Practices for Exposure PreventionPrevention

Kathy Sperrazza RN, MSKathy Sperrazza RN, MSDoctoral CandidateDoctoral CandidateUniversity of Massachusetts LowellUniversity of Massachusetts LowellSchool of Health and EnvironmentSchool of Health and EnvironmentMNA Congress on Health and SafetyMNA Congress on Health and Safety

National Institute for National Institute for Occupational Safety and Occupational Safety and Health (NIOSH)Health (NIOSH)

ALERT - Preventing Occupational ALERT - Preventing Occupational Exposures to Antineoplastic and Exposures to Antineoplastic and Other Hazardous Drugs in Health Other Hazardous Drugs in Health Care Settings, September 2004Care Settings, September 2004

5.5 million workers potentially 5.5 million workers potentially exposedexposed

NIOSH AlertNIOSH Alert

Warning – Working with or near Warning – Working with or near hazardous drugs in health care hazardous drugs in health care settings may cause skin rashes, settings may cause skin rashes, infertility, miscarriage, birth infertility, miscarriage, birth defects and possibly leukemia or defects and possibly leukemia or other cancers.other cancers.

Workers at risk for Workers at risk for exposure exposure Nursing personnel Nursing personnel PhysiciansPhysicians OR personnelOR personnel Pharmacists/pharmacy techniciansPharmacists/pharmacy technicians Environmental services personnelEnvironmental services personnel Veterinarians/Animal techniciansVeterinarians/Animal technicians Shipping and receiving personnelShipping and receiving personnel

Background for Background for hazardous drug usehazardous drug use Successful treatment of illness and Successful treatment of illness and

injuryinjury Almost all drugs have side effectsAlmost all drugs have side effects Exposure to very small concentrations Exposure to very small concentrations

may be hazardousmay be hazardous Potential therapeutic effects outweigh Potential therapeutic effects outweigh

risk for patientsrisk for patients Healthcare personnel risk side effects Healthcare personnel risk side effects

without benefitswithout benefits

Drugs considered Drugs considered hazardoushazardous

– Antineoplastic agentsAntineoplastic agents– VaccinesVaccines– GonadotropinsGonadotropins– EstrogensEstrogens– OxytocicsOxytocics– Contraceptives Contraceptives – AndrogensAndrogens– AntibioticsAntibiotics– AntiviralsAntivirals– ProgestinsProgestins– Misc. skin and mucous membrane agentsMisc. skin and mucous membrane agents

Evidence for health Evidence for health effects in workerseffects in workers Carcinogenicity of several Carcinogenicity of several

antineoplastic drugs well established antineoplastic drugs well established in animals by 1970’sin animals by 1970’s

Therapeutic use of alkylating agents in Therapeutic use of alkylating agents in humans linked to leukemias and other humans linked to leukemias and other cancerscancers

Studies indicate antineoplastic drugs Studies indicate antineoplastic drugs may cause increased genotoxic effects may cause increased genotoxic effects in nurses and pharmacistsin nurses and pharmacists

Developmental and Developmental and reproductive effectsreproductive effects 14 studies describe association 14 studies describe association

between exposure to between exposure to antineoplastic drugs and adverse antineoplastic drugs and adverse reproductive effects such as:reproductive effects such as:

increased fetal lossincreased fetal loss congenital malformationscongenital malformations low birth weightlow birth weight infertilityinfertility

Potential for exposure Potential for exposure is growingis growing More and more new drugs/combinations of More and more new drugs/combinations of

drugs drugs

Developmental use of drugs, i.e. nanomedicinesDevelopmental use of drugs, i.e. nanomedicines

Methods of treatment and administration to Methods of treatment and administration to patients changingpatients changing

Drugs are used in medical offices, free standing Drugs are used in medical offices, free standing surgical and cancer treatment centers and in surgical and cancer treatment centers and in home care.home care.

Contamination is widespread Contamination is widespread

NanotechnologyNanotechnology

Nanometer is one billionth of a meterNanometer is one billionth of a meter Matter on near-atomic sized scaleMatter on near-atomic sized scale Used to produce new structures, Used to produce new structures,

materials and devices materials and devices Unique properties at nanoscale levelUnique properties at nanoscale level Affect physical, chemical and Affect physical, chemical and

biological properties biological properties

Emerging Nanomedicine Emerging Nanomedicine and Bionanotechnologyand Bionanotechnology Nanotechnology at Northeastern Nanotechnology at Northeastern

University University

Potential Risks of Potential Risks of NanomaterialsNanomaterials Need to understand, predict and Need to understand, predict and

manage potential health risksmanage potential health risks Extremely small size may cause Extremely small size may cause

different interaction with human bodydifferent interaction with human body Studies have established that larger Studies have established that larger

surface area of inhaled nanoparticles surface area of inhaled nanoparticles may increase toxicitymay increase toxicity

Can penetrate deep into lungs and Can penetrate deep into lungs and may move to other areas of the body, may move to other areas of the body, i.e. liver and braini.e. liver and brain

Adverse EffectsAdverse Effects

The likelihood that a worker will The likelihood that a worker will experience adverse health effects experience adverse health effects from hazardous drugs increases from hazardous drugs increases with the amount and frequency of with the amount and frequency of exposure and the lack of proper exposure and the lack of proper work practiceswork practices

Work activities with the Work activities with the potential for exposurepotential for exposure Preparation, administration, and/or Preparation, administration, and/or

disposal of hazardous drugs disposal of hazardous drugs Handling body fluids Handling body fluids Handling/transporting contaminated Handling/transporting contaminated

wastewaste Decontamination and clean-upDecontamination and clean-up Removal and disposal of PPE after Removal and disposal of PPE after

exposure to contaminated wasteexposure to contaminated waste Performing specialized procedures i.e.: Performing specialized procedures i.e.:

in OR, at the bedsidein OR, at the bedside

Routes of exposureRoutes of exposure

InhalationInhalation– Mixing liquids, expelling air from syringes, crushing Mixing liquids, expelling air from syringes, crushing

pills, spills, priming an IVpills, spills, priming an IV InjectionInjection

– Needlestick or sharps injuryNeedlestick or sharps injury IngestionIngestion

– Hand to mouth contact: eating/drinking in the work Hand to mouth contact: eating/drinking in the work environment, handling food with contaminated environment, handling food with contaminated handshands

Absorption Absorption – Skin contact/absorption, handling contaminated Skin contact/absorption, handling contaminated

materialsmaterials

Current state of Current state of practice practice Often inconsistentOften inconsistent May contain some of the program May contain some of the program

elements, but not allelements, but not all May address some of the workers, May address some of the workers,

but not allbut not all May not be implemented and May not be implemented and

carried outcarried out

MNA Survey: Hazardous MNA Survey: Hazardous Drug Information FormDrug Information Form 20062006 2000 nurses surveyed at 3 facilities2000 nurses surveyed at 3 facilities 400 responses400 responses 87% reported handling/administering 87% reported handling/administering

hazardous drugshazardous drugs Only 54% aware of programs re: safe Only 54% aware of programs re: safe

handling of hazardous drugs and traininghandling of hazardous drugs and training Only 30% read programsOnly 30% read programs Only 12% had classroom trainingOnly 12% had classroom training Only 6% had hands-on-trainingOnly 6% had hands-on-training

Survey results cont.Survey results cont.

Nurses do not identify many drugs Nurses do not identify many drugs they administer as hazardousthey administer as hazardous

Continue to handle in same mannerContinue to handle in same manner Not aware of changes in controlsNot aware of changes in controls 70% use personal protective 70% use personal protective

equipment, likely glovesequipment, likely gloves Use of face shields, and gowns or lab Use of face shields, and gowns or lab

coats much less likelycoats much less likely 10% do not use any PPE10% do not use any PPE

Some conclusions of Some conclusions of MNA SurveyMNA Survey Gap between NIOSH Alert and practiceGap between NIOSH Alert and practice Many nurses are unaware of issues of Many nurses are unaware of issues of

hazardous drug exposure and hazardous drug exposure and prevention programsprevention programs

Nurses who were aware of and had Nurses who were aware of and had read hazardous drug programs were read hazardous drug programs were much more likely (85.6%) to use PPEmuch more likely (85.6%) to use PPE

Protecting nurses and Protecting nurses and other workersother workers As required byAs required by

– OSHA Hazard Communication OSHA Hazard Communication Standard – 1910.1200Standard – 1910.1200

Education – Education – – product information and MSDS for the product information and MSDS for the

drugs that are specific to work setting drugs that are specific to work setting – recognize the sources of exposurerecognize the sources of exposure– apply appropriate work practicesapply appropriate work practices

Protecting nurses and Protecting nurses and other workersother workers Training – Training –

– equipment and procedures for equipment and procedures for preventionprevention

Administrative controls Administrative controls – – work setting designed to protect work setting designed to protect

workers workers

providing appropriate PPEproviding appropriate PPE

medical surveillance medical surveillance

provide safe areas for staff to eatprovide safe areas for staff to eat

NIOSH suggests:NIOSH suggests:

Follow recommendations that are Follow recommendations that are presented in the ALERTpresented in the ALERT– Assess hazardsAssess hazards– Evaluate workplaceEvaluate workplace– Review inventory of hazardous drugsReview inventory of hazardous drugs– Seek input of workers with potential Seek input of workers with potential

for exposurefor exposure– Conduct training and evaluate practiceConduct training and evaluate practice– Reassess annuallyReassess annually

Training includes:Training includes:

Safe handlingSafe handling Spill proceduresSpill procedures Equipment and PPE useEquipment and PPE use Reporting spills, exposures and Reporting spills, exposures and

symptomssymptoms– Who, how and whereWho, how and where

Work practices Work practices – No eating or drinking in workplaceNo eating or drinking in workplace

Medical surveillanceMedical surveillance

Depending on exposureDepending on exposure– Physical examPhysical exam– CBC CBC – Monitoring urine Monitoring urine

dipstick or microscopic examdipstick or microscopic exam

– Monitoring the work area Monitoring the work area air and surface contaminationair and surface contamination

Incorporating all the Incorporating all the requirements can be requirements can be overwhelming!!!overwhelming!!! HowHow WhenWhen WhereWhere WhoWho

– Is responsibleIs responsible– Must be trainedMust be trained

Developing a Developing a Comprehensive Model for Comprehensive Model for Prevention and Prevention and ImplementationImplementation Identify problemIdentify problem Seek resources, support, expertsSeek resources, support, experts Start or join group-enlist colleagues, other Start or join group-enlist colleagues, other

stakeholdersstakeholders Investigate what is being doneInvestigate what is being done Set goals/timelineSet goals/timeline What are the barriers to preventionWhat are the barriers to prevention Who is responsible/needs to be?Who is responsible/needs to be? Develop process to assess prevention Develop process to assess prevention

effectivenesseffectiveness Collaborate! Don’t reinvent the wheel.Collaborate! Don’t reinvent the wheel.