Q&A with
Seth Eisenberg, RN, OCN

Pharmacy Purchasing & Products: What are some of the exposure risks that are often overlooked in the hazardous drug handling process?
Seth Eisenberg: Exposure to hazardous drugs (HDs) can occur at numerous points throughout the handling and administration processes. In many facilities, pharmacy has focused on creating a safe compounding environment, following the guidance of USP <797> and NIOSH for hazardous drug handling. Too often, in those same facilities, nursing has not benefited from an equal focus on HD safety. This creates an opportunity for pharmacy to share their expertise in communicating the risks posed by improper HD handling and creating safe practices to reduce nurses’ risk of exposure.

Just as we have learned that HDs often arrive at the hospital’s loading dock with hazardous residue on the containers and packaging, nursing faces that same risk when they receive compounded doses from pharmacy: residue can be found on the outside of the bag or the syringe, depending on how the drugs are being compounded. As such, policies and procedures (P&Ps) must be developed to ensure nurses and any other staff members coming into contact with HDs are appropriately protected. This includes the use of gloves for those who are delivering and receiving these products on the nursing unit. 

Nurses also face a high risk of exposure when required to manipulate the tubing. One method of reducing exposure is to have pharmacy prime the IV tubing as part of the compounding process, rather than having nurses prime at the bedside. Needleless systems should also be used. It is important for both pharmacy and nursing to understand how tubing can impact the potential for exposure at the bedside. Using a single, primary system is cost-effective, but typically requires pharmacy to have the entire length of tubing in the BSC. Unless specifically designed to do so, primary tubing does not allow for flushing residual drug from the tubing (beginning with the drip chamber). Should the bag and tubing run partially dry, it also is difficult to remove air without risking exposure. Requiring pharmacy staff to pre-prime the tubing with a neutral solution prior to compounding also introduces a significant workload. On the other hand, secondary tubing requires less work for pharmacy staff, although in most situations the shorter secondary tubing still needs to be primed with neutral solution in the pharmacy unless it is back-primed at the bedside. Yet another option is dispensing the bag without any tubing, and instead use CSTDs in both the pharmacy and at the bedside.

An often-overlooked area of possible hazardous drug exposure occurs with the handling of patient excreta. Body fluids from patients receiving chemotherapy may contain traces of these medications and their active metabolites. All excreta from patients undergoing chemotherapy should be treated as contaminated; the length of time is dependent upon the agent, ranging from 48 hours to seven days following drug administration.¹ Gloves, face protection, and a non-permeable gown should be required when handling excreta from patients who have received chemotherapy, and housekeeping staff should wear PPE when cleaning bathrooms used by patients receiving chemotherapy. A small study in Japan recently found significant hazardous drug contamination in the bathrooms at the homes of patients who received outpatient chemotherapy.² This raises the question as to how much contamination would be found in hospital and clinic bathrooms. In addition to establishing rigorous P&Ps, it is important to ensure that PPE is easily accessible by those required to use it. In general, PPE should be kept in a convenient location, based on standard workflow. Keeping gowns in a storage closet far from the patient care area will severely limit their use. 

Data indicate that despite following recommended safe-handling practices, measurable levels of surface contamination with antineoplastic drugs occurs in pharmacy and nursing areas.³ Therefore, it is critical to investigate every conceivable area where staff may come into contact with hazardous drug residue, both on the units and in patient rooms. 

PP&P: Getting nursing to buy in to the need to update hazardous drug administration practices can be difficult. How do you recommend approaching nursing with new safety initiatives? 
Eisenberg: Engage nursing early on in the process when initiating any safety improvement project. Enlisting the assistance of a nurse safety champion is extremely effective to gain buy-in to safe practices. When identifying a safety champion, choose clinically based nurses who work with chemotherapy on a regular basis, such as an oncology clinical nurse educator or a clinical nurse specialist. If directly involved in the clinical program, the nursing manager may also be an appropriate choice; however, if the nursing manager performs a largely non-clinical role and is not familiar with workflow details, it may be prudent to identify another champion. Nurses are most likely to embrace safety initiatives when directives are made by a peer rather than a staff member who is not directly involved in clinical work and is not familiar with daily workflow practices.

One effective tool to gain nurse buy-in for safe administration of hazardous drugs is conducting wipe testing and discussing the results with staff. Recently I worked with the pharmacy manager and conducted wipe testing in our pharmacy and nursing units to evaluate contamination levels. Wipe testing provides evidence that hazardous drug practices should be adhered to more stringently, and will help convince skeptical staff members that safety is a serious concern. The results of wipe testing are difficult to refute—contamination is either present or not present. For example, wipe testing that identifies hazardous drug residue on computer keyboards or on phones is extremely effective in convincing staff of the importance of safe hazardous drug practices. Fortunately, wipe testing is easy to conduct and quite a few laboratories now provide wipe kits with easy-to-follow instructions. 

PP&P: Should pharmacy and nursing collaborate to choose a closed system transfer device (CSTD)?
Eisenberg: Using a CSTD is the best available option to prevent health care workers from being exposed to hazardous drugs. Because both pharmacy and nursing must use the device, it is vitally important that choosing a CSTD be a joint endeavor. A thorough understanding of the workflow considerations for both departments is necessary to choose the CSTD that is most effective and easy to use for pharmacists and nurses. Furthermore, when evaluating CSTDs be sure to consider their compatibility with other technologies. 

For example, a CSTD may not be designed to work with a particular IV pump. Be sure to verify the CSTD’s compatibility with all existing equipment prior to signing a contract. 

There are four main factors to consider when choosing a CSTD: 

• Effectiveness: Clearly, the most important consideration is how effectively the CSTD prevents exposure to hazardous drugs. Evaluating the published literature will provide guidance on the effectiveness of the available CSTDs. However, it is not always easy to interpret the results of these publications. In some studies, surrogates for chemotherapy have been used in place of the actual drug, which may or may not accurately simulate actual use. Comparison studies are useful, provided there is no inherent bias in how the study was conducted. And as we often see in oncology, there may be conflicting information from different studies. Therefore, the primary consideration should be evidence that a device works as advertised. 
• Ease of use: Remember that if a device is not used correctly, the safety benefits are bypassed and the chance of a spill or residual contamination increases. Therefore, ease of use should be considered in conjunction with effectiveness. If you choose a device that is extremely effective but difficult to use, nurses may use it improperly or discard it altogether. Balancing effectiveness and ease of use when selecting a CSTD will ensure nurses use the device. 
• Workflow: Consider the number of pieces required to use the CSTD. When numerous pieces are needed, this reduces the likelihood that the device will be used. If an adapter is required, it is important to ensure it is easily accessible—not stored in the medication room down the hall—or again, nursing may decide not to use the CSTD. Ensuring that required equipment is easily accessible improves compliance. CSTD manufacturers are now producing tubing sets and extensions that can work with existing equipment and reduce the number of individual pieces. 
• Cost: Finally, consider the cost of the CSTD. For an effective evaluation, be sure to consider the total cost of use—not only the price of the actual device, but the cost of any additional pieces or adapters that must be purchased as well. When a vendor quotes a price, be sure to inquire if the cost quoted includes every component or if some must be purchased separately. Additional pieces may be required depending on vial size or pieces required to work with existing pumps and tubing. However, some vendors are developing devices that can be used with various vial sizes, which will eliminate the need to stock multiple sizes in the pharmacy. 

When evaluating CSTDs, it is useful to conduct trials in real-world situations. Although this type of trial requires staff training, expense, and time, it is the most effective method of identifying which device best suits the needs of your hospital. Evaluate at least two CSTDs in common clinical situations to identify the pros and cons of each device. While sales representatives generally have a good understanding of how to operate their devices, they may tend to emphasize the positives of their device while downplaying the negatives. Using the devices in typical situations in your practice will provide the most accurate assessment of the utility of each CSTD. 

Should pharmacy and nursing come to separate conclusions as to which product best suits their needs, consider adopting a hybrid approach. Many facilities have successfully adopted one CSTD in pharmacy, while nursing uses a different CSTD for administration. Collaboration is key to the success of this hybrid approach.

References

1. ISOPP Standards of Practice. Section 15 – Waste handling and patient excreta. J Oncol Pharm Pract. 2007;13:66-69.
2. Yuki M, Sekines S, Takase K, et al. Exposure of family members to antineoplastic drugs via excreta of treated cancer patients. J Oncol Pharm Pract. 2013;19(3):208-217.  
3. Connor TH, DeBord G, Pretty JR, et al. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer hospitals. JOEM. 2010;52(10):1019-1027.

Seth Eisenberg, RN, OCN, professional practice coordinator for infusion services at the Seattle Cancer Care Alliance Ambulatory Clinic, has been practicing in the field of oncology since 1983. His experience includes 26 years in hematopoietic stem cell transplantation at the Fred Hutchinson Cancer Research Center. 

SIDEBAR
Simplifying HD Wasting
At the Seattle Cancer Care Alliance Ambulatory Clinic, chemotherapy waste bins are located in each infusion bay. Because each bin is on a trolley, they can easily be moved closer to the waste site rather than requiring staff to walk across the room to dispose of hazardous waste. The bins are operated using a foot pedal, which slides the lid open; allows the bag, tubing, and PPE to be dropped in; and then shuts like a trap door. This mechanism helps minimize hazardous drug aerosolization and prevents the nurse from having to touch the lid with gloved or ungloved hands. Environmental services checks the bins every morning, and they are replaced regularly.