A Milligram of Prevention: Chemotherapy Safety for Technicians

If we have learned anything from the pandemic, it is that it is better to take significant precautions than to suffer grievous consequences. Risks and hazards surround us every day, so the precautions we take make a difference to our health and survival. This article describes the key things technicians should know about safety around chemotherapy drugs.

Veterinary technicians have the highest potential for exposure to chemotherapy since they perform most, if not all, of the duties listed.

by Diana Smith, BS, CVT, VTS (Oncology)

If we have learned anything from the pandemic, it is that it is better to take significant precautions than to suffer grievous consequences. Risks and hazards surround us every day, so the precautions we take make a difference to our health and survival.

In the veterinary workplace, implementing protective safety measures when working with hazards can prevent injury and disease. Who wouldn’t want to do that? If eating blueberries every day was proven to prevent cancer by 90–100%, we would all be eating blueberries every day.

Veterinary hospitals with a safety-minded culture are ahead of the curve. When a hospital’s management team fosters the implementation of safety protocols, employees will be empowered with more knowledge about the reasons behind the safety measures, and be more amenable to utilizing them. Having safety as a state of mind is just as important as the equipment and protocols put in place to protect people and animals from hazards.

Hazards such as working with antineoplastic (chemotherapeutic) drugs.

Let’s First Discuss the Hazard

The National Institute for Occupational Safety and Health (NIOSH) defines hazardous drugs (HDs) as a health hazard that exhibits one or more of the following toxicity criteria in humans, animal models, or in vitro systems:

  • carcinogenicity
  • developmental toxicity (including teratogenicity)
  • reproductive toxicity
  • genotoxicity
  • organ toxicity at low doses

structure and toxicity profile that mimics those of existing drugs determined hazardous by exhibiting any one of the previous five toxicity types, unless the drug also exhibits a molecular property that may limit the potential for adverse health effects in healthcare workers from exposure to the drug

HDs encompass the following classifications:

  • antineoplastic medications used to treat cancer and neoplasms (e.g., chemotherapy, targeted therapies)
  • nonantineoplastic medications used to treat diseases or conditions such as autoimmune diseases, nonmalignant diseases, and some cancers (e.g., antifungals, hormone agents, bisphosphonates, bioengineered drugs)

NIOSH created the List of Hazardous Drugs in Healthcare Settings to provide an advisory and informational document on the list of HDs. The most recent version is from 2016, but a 2020 version is pending.

Note that the NIOSH HD list does not include veterinary-specific HDs. Thus, the veterinary hospital must perform an assessment of veterinary drugs suspected of being hazardous (because of package insert information, chemical or molecular composition, classification of drug, etc.) to determine whether they are indeed hazardous. For example, toceranib phosphate is a veterinary-specific, antineoplastic agent that is a tyrosine kinase inhibitor, which classifies this drug as hazardous. The NIOSH HD list contains other small-molecule inhibitors approved for human therapies.

The Occupational Safety and Health Administration (OSHA) has published Controlling Occupational Exposure to Hazardous Drugs, which provides a comprehensive outline and description of mandatory standards, regulations, and recommendations. The United States Pharmacopeia (USP) has also published information in various chapters of standards for safe handling of HDs. The most pertinent USP chapter that best applies to the veterinary hospital environment is the 2017 USP chapter <800>: Hazardous Drugs—Handling in Healthcare Settings, which was released to provide safety guidance for healthcare workers who handle and administer HDs.

Pets are family, and veterinary staff want to do everything they can to improve and extend the lives of those pets. Even though chemo can be a beneficial therapy for patients with cancer and other diseases, these drugs pose a significant occupational hazard. Many chemotherapeutic drugs are known to be cytotoxic and can check off multiple NIOSH toxicity criteria.

The CDC/NIOSH states that “about 8 million US healthcare workers are potentially exposed to hazardous drugs.” In a veterinary hospital, veterinary technicians are the employees who most commonly handle, prepare, and administer these drugs and are especially at risk for exposure.

HDs can enter the body via various routes, including:

  • dermal and mucosal absorption
  • inhalation
  • ingestion
  • injection

Situational examples of exposure can include chemo spills, aerosolization of HDs, leakage or splashing of chemo during administration, and cross-contamination with food and beverages.

The CDC/NIOSH states, “Published studies have shown that workplace exposures to hazardous drugs can cause both acute and chronic health effects such as skin rashes, adverse reproductive outcomes (including infertility, spontaneous abortions, and congenital malformations), and possibly leukemia and other cancers.” Other symptoms can include lightheadedness, headache, nausea, hair loss, and leukopenia.

Whom Does This Affect on Our Veterinary Team?

Veterinary personnel (veterinarians, veterinary technicians, assistants, pharmacy and inventory personnel, etc.) who risk exposure to chemotherapy include those who are involved in:

  • receiving/inventory
  • dispensing
  • administration
  • handling, preparing, and transporting HDs
  • handling bodily fluids of patients who have received chemo within a certain timeframe
    cleaning and decontaminating
  • HD areas
  • handling chemo spills
  • preparing chemo waste for disposal

Veterinary technicians have the highest potential for exposure to chemotherapy since they perform most, if not all, of the duties listed. It is crucial that veterinary staff fully protect themselves to prevent exposure to chemotherapeutic drugs. Yes, fully—and it’s not as difficult or cumbersome as one may think.

What Can Staff Do to Protect Themselves and Prevent Exposure?

There are various practices to utilize and implement to prevent exposure to chemotherapy. A multitiered, tandem approach must be used to provide the ultimate protection for personnel. The NIOSH Hierarchy of Controls is as follows (in this order):

  1. Elimination of hazard
  2. Substitution of hazard
  3. Engineering controls
  4. Administrative controls
  5. Personal protective equipment (PPE)

Commonly, elimination and substitution of the hazard cannot be avoided since chemotherapy is the main therapy for treating certain diseases.

Engineering Controls

Engineering controls reduce or eliminate exposure to chemical or physical hazards using equipment or devices that provide containment of HD liquids and gases or vapors. These controls should be used, regardless of whether the hospital treats 1 patient or 1,000 patients per year. Engineering controls include:

  • biological safety cabinet (BSC)
  • closed-system transfer device (CSTD)
  • dedicated room for the BSC and HD preparation area
  • negative-pressure rooms or areas

A biological safety cabinet (a.k.a. chemo hood) is a ventilated device that provides primary containment of chemotherapy drugs during handling and preparation. It protects the worker and environment by removing airborne vapors and gases from the work area and keeping liquids isolated to within the BSC. Certain BSCs will also protect the product against microbial ingress.

A BSC should be:

  • a Class II BSC (Type A2, B1, or B2; a B2 is best for containing vapors and gases)
  • vented to the outside of the building via dedicated ducting (exhaust canopy may be needed)
  • cleaned and decontaminated by staff on a regular basis (HD cleaning and deactivation wipes can be ideal for this and other areas)
  • serviced and certified by a professional company immediately after installation and at least annually thereafter 
  • professionally decontaminated before decommissioning or moving the BSC

A closed-system transfer device is a supplemental system of components that work together to provide a closed, contained system for injectable chemotherapy and other HDs. Some also provide protection against microbial ingress into the vial for a period of time. It mechanically prohibits the leakage of gases or vapors and fluid by containing those contaminants within the system during preparation and mixing of injectable chemotherapy as well as administration.

Since not all CSTDs are alike, hospitals should choose a CSTD brand wisely. A product that has proven, peer-reviewed performance claims for 100% containment of liquids and vapors, is FDA approved or cleared, and is not cumbersome to use is an ideal choice. A CSTD is an excellent layer of protection and should be used in conjunction with a BSC and PPE, but must not replace them.

Additional controls to guide movement of air and ventilation in the oncology suite can help contain any potentially HD-contaminated air to the rooms where chemo is stored, prepared, and administered. Then, that air is ventilated to the outside of the building. The following can be considered for the oncology suite:

  • isolating the BSC and HD preparation area to a dedicated room
  • providing negative-pressure rooms with dedicated ventilation

Administrative Controls

Administrative controls aim to reduce or limit the exposure to a hazard by changing the behavior of employees in how they perform their jobs. These controls can help foster the safety culture by providing training or education, reference materials, alerts or reminders, and guidance. For chemotherapy safety, they include:

  • HD safety training (per OSHA regulation, safety training must be performed before staff work with chemo, annually thereafter, and when new chemo drugs or equipment are introduced)
  • manuals
  • standard operating procedures
  • policies and rules
  • signage and alerts
  • supervision (to ensure employees are correctly protecting themselves)

Personal Protective Equipment

PPE consists of garments designed to prevent exposure to hazards, thus providing the worker protection. PPE is the final line of defense against hazards. PPE must be donned before handling chemo. When handling chemotherapy drugs, the following PPE must be worn:

  • chemotherapy gloves
    • must meet ASTM standard D6978
    • made of nitrile, neoprene, or latex
    • two pairs worn when preparing or administering chemotherapy drugs, handling chemo waste, and cleaning chemo spills
  • chemotherapy gown
    • other laminate materials shown to resist permeability by HDs
  • eye and face protection
    • goggles or a face shield (glasses do not protect against splashes)
  • foot protection when handling chemotherapy spills (impervious material)
  • respiratory protection when unavoidable exposure to chemotherapy drugs is anticipated (e.g., during cleanup of a chemo spill when not using a BSC and CSTD)—employees must be medically evaluated and fit-tested in order to wear a respirator
    • N95 respirator—used for filtering particulates, dust, and powders only
    • air-purifying respirator—used for filtering toxic gases and vapors (and particulates with certain cartridges)

Still, There’s Limited Time, Nowhere to Put These Things, and Then There’s the Cost!

Cost, time, and space are the main concerns that veterinary hospital staff express when considering the various protective measures for chemotherapy safety. It is important to consider the safety equipment and PPE as an investment in the employees and their health as well as part of the administration plan.

Cost. Just as the chemotherapy drug, IV catheter, administration sets, pill vials, and other supplies are part of the cost of treatment, so is the use of the BSC, CSTD components, PPE, and other safety supplies. A typical BSC, if maintained properly, will last decades. Shortchanging safety because of cost is bad practice. OSHA requires employers to provide PPE and other safety supplies to their employees.

Time. The donning and doffing of PPE and use of a CSTD takes barely any time at all, usually a couple of minutes altogether.

Space. This can be a bit trickier. Sometimes, reorganization of spaces and rooms in the hospital is all that is warranted. Sometimes, construction of a new space is needed. Storing small amounts of supplies in the oncology suite can save space there, and then backstock can be stored elsewhere.

Let’s step back for a moment and look at a comparison. If the hospital wants to provide radiographic imaging for patients, multiple things are needed: physicist surveys, appropriate wall construction, the X-ray machine, state registration fees, inspection fees, maintenance and repairs, dosimeters for employees, lead gowns, gloves, thyroid shields, software, radiation safety training, and so on. All of these components are part of the entire process of providing radiographic imaging. Cost, time, and space are factors that are accepted. If any of the safety measures are not utilized or followed, then employees working in radiology can be seriously harmed.

Protection against chemotherapy exposure is no different. If any of the safety measures are not utilized or followed, then employees working with chemotherapy can be seriously harmed by hazard exposure.

Supply Shortage of PPE During a Pandemic Situation

The world has been living through unprecedented times during the COVID-19 pandemic. This pandemic has also revealed the issues that supply chains have had in keeping up with the demand. If the standard PPE options are unavailable, then conservation measures and alternative PPE options are still needed. The Oncology Nursing Society provides great guidance on this topic in ONS Interim Guidelines During the COVID-19 pandemic, as do guidelines posted on the CDC website.

Conclusion

Safe handling of chemotherapy has come a long way since the inception of chemotherapy drugs and especially since the first documented occupational exposure to chemotherapy in the 1970s. There are now multiple protective options available and resources to help guide hospitals to compliance. As a dedicated veterinary community, we have a moral and legal obligation to protect our employees, our colleagues, and ourselves from occupational hazards like chemotherapy. We are worth it!

A Note from an AAHA Practice Consultant

Environmental safety is incredibly important for handling chemotherapeutic drugs. As practice consultants, we recommend having a quiet, low-traffic room that is dedicated only to chemotherapy purposes. Preparation for a spill is just as important as PPE or storage of HDs. Chemotherapy spill mats should always be used when preparing and administering HDs. Spill kits can be purchased premade, and typically include a fit-tested NIOSH-certified N95 respirator mask. It is recommended to have spill kits in any rooms where HDs are used, and in areas where patients are treated with them. Staff training should include knowing where all spill kits are located throughout the hospital.

Having a detailed, written protocol is key to ensuring consistency among staff when handling chemotherapeutic agents. Many hospitals violate safety guidelines the moment HDs are delivered to the practice. Protocols for storage, handling, preparing, and dispensing HDs can be broken down into a step-by-step guide to aid in preventing safety errors. It is a great idea to do safety refreshers at staff meetings at least once a month. USP General Chapter <800>, NIOSH, and CDC are all great resources that can be used to update chemotherapy protocols.

Reach out to your AAHA accreditation team with questions about creating protocols or training opportunities. Contact us at 800-252-2242 or practice.accreditation@aaha.org.

Beth Armstrong, CVT, RVT, CFE, CCFP, CTP, is the AAHA practice consultant for Illinois, Wisconsin, Iowa, and Missouri.

Diana Smith
Diana Smith, BS, CVT, VTS (Oncology), has worked in the veterinary industry for 27 years. She earned her Bachelor of Science in animal science at Rutgers University, and obtained her veterinary technician specialist (VTS) certification in oncology. Smith was a member of the AAHA task force that created the 2016 AAHA Oncology Guidelines for Dogs and Cats. She is currently a regional safety coordinator for Compassion-First Pet Hospitals. She lives in central New Jersey with her canine companion, Merlin, an amazing pit bull. She is also an avid artist, a budding photographer, and a singer in a band called the Docs of Rock that donates all performances to local fundraising events.

 

Photo credits: Photos courtesy of Iowa State University

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