Walking into your place of work, opening a door and handling equipment should not carry a degree of danger. But for healthcare professionals (HCPs), working directly with hazardous drugs, this is the day-to-day reality. Skin rashes, allergies, hair loss and, in some cases, infertility, can happen.
HCPs working with these drugs in oncology departments are especially at risk as chemotherapy drugs are often hazardous when handled incorrectly.
“Many nurses dedicate their whole career to nursing patients with cancer, which can ultimately mean they spend decades potentially risking their own health by working with hazardous drugs,” says Clare Cobbett, clinical nurse consultant at BD.
“Hazardous drugs are substances with therapeutic properties,” she says. “But they can cause unwanted effects in those who handle the drug during preparation, administration or disposal.”
Cytotoxic drugs, for instance, which are frequently used to treat cancer, are medicines containing chemicals that are toxic to cells. These drugs are used in chemotherapy because they stop cells replicating or growing, but often they do not discriminate between cancerous and healthy cells. As a result, such properties – essential for treating cancer – make them extremely toxic in other circumstances.
Spillages, leaks, vapours and aerosols can cause contamination, with these drugs spreading widely because of the way that they are administered. They spread across worktops, doorknobs, chairs, floors, and between healthcare workers whether or not they are administering the drugs. People can get it on their skin, they can ingest it, or they can breathe in the vapour. These drugs may be delivered in hospitals or in the community.
According to Cheryl Rogers, also a clinical nurse consultant at BD, the method of administering chemotherapy also puts the nurses at risk.
“When these medications are prepared in a pharmacy, isolators are in place to protect the pharmacist. Injections are manufactured in a sealed unit to protect the operator from the chemotherapy and to prevent contamination of the product. Whereas in contrast, on the ward, the nurses administering it wear gloves and an apron,” says Rogers.
At the minimum, nurses working in chemotherapy should wear appropriate personal protective equipment (PPE). “There is a hierarchy of best practice in terms of protection and [an apron and gloves] is the lowest-ranked level,” says Cobbett. PPE ought to also include eye protection, long disposable sleeves and ideally a closed system to transfer the treatment from one device to the other, reducing the risk of nurses being exposed to hazardous/toxic drugs.
“When chemotherapy nurses are training, there is a lot of teaching emphasis placed on the nature of the drugs and what they will do to the patient, including how to manage the side effects,” she says. However, she considers that there has not been enough focus on what these powerful drugs can do to nurses.
“When there is a need to change the drug that is given, or clean the line, the previous drug needs to be disconnected. Traditional techniques put nurses at a 100% chance of exposure,” says Rogers. With each removal of an IV bag from the IV tubing device, there can be an aerosol effect and environmental contamination – therefore the removal of an IV bag containing a hazardous drug from an IV spike is inherently unsafe and should be avoided.
As a result, nurses working in oncology units are at constant risk from low-level exposure to chemotherapy drugs and many are well aware of the need for a safe system. The first article to describe these risks was published in 1979; further research since has detailed the occupational risks of working with these drugs, and the health conditions that can ensue.
The introduction of closed-system drug transfer devices (CSTD) has, however, made chemotherapy much safer for those who administer it. The CSTDs prevent any drug, vapour, or aerosols escaping because there is no more spiking and unspiking. As the drugs are administered within a closed device (which lets nothing in or out), it is mechanically impossible for vapour to escape.
Clare Norris is ward manager at Castle Hill hospital, Hull University teaching trust. She has been instrumental in driving forward the use of closed systems within oncology at her hospital. “Prior to implementing the closed system, we were at risk of exposure to chemotherapy. We mitigated this by using best practice,” she says.
“[Implementation] started in the day unit – in a busy week, there could be 80-90 patients a day,” she says. This was a change in practice but trainers from BD were there to help. Subsequently, two inpatient wards started to use closed systems, too.
A nurse’s mindset is focused on helping others. However, nobody wants to go to work thinking they may be at risk. “Nurses are a scarce resource for hospitals so they have more power than they might think,” says Rogers. “I know of one nurse who took a job in an oncology unit which implemented closed systems, because she was allergic to the medications being administered. Using closed systems protects her, and others, from exposure and gives them confidence that their employer is taking their occupational health and safety seriously.”
