Chemotherapy health and safety

Re: Chemotherapy health and safety

Elisabeth Knappett — Fri, 27 Jun 2014 19:44:54 GMT

I agree that Martin's outline is great - the way I was told to create SOP's was to write it in plain english, step-by-step so if a brand new member of staff HAD to perform the task, they could do it exactly the same way as a current member of staff. So nothing is too simplified ie put gown on, put gloves on, put oversleeves on etc in bullet points is great. I second Chemopet and Cave referrals, Ian Grant is always very helpful and can provide dose by dose protective equipment and reconstituted drugs as well as advice about safe administration in practice, Is it possible for you to have one or two members of staff designated as chemotherapy guys? And ask your boss if you are going to be responsible for it, then you would like further official training, I'm sure there are some excellent chemo courses out there or a local centre would be happy to pass on their experience?

Re: Chemotherapy health and safety

Martin Atkinson — Fri, 27 Jun 2014 18:44:05 GMT

[quote user="Gerry Polton"]It's 10/10 and a gold star from me, Martin.[/quote]

[quote user="Gerry Polton"]Martin's policy is an excellent template, [/quote]

Re: Chemotherapy health and safety

Gerry Polton — Fri, 27 Jun 2014 18:37:48 GMT

It's 10/10 and a gold star from me, Martin.

The key thing, An On, is to have something that everybody involved is happy to work with. Bizarrely, you could get to be in some trouble with the HSE if you didn't have a policy but you would not be in (so much) trouble if you had a policy that said, 'chemotherapy can only be given by designated individuals in their swimwear'... so long as the rules were adhered to! I am being slightly childish here perhaps by trying to be humorous. However, legally you simply have to have a policy that everybody agrees to follow and indeed does follow. The HSE take great pains to state that your policy should take account of local limitations and concerns. That means, for instance, that you could designate a low traffic room in your practice that was best for chemo because of how your practice works. This same rule simply might not work in other practices. We have a policy that basically says all chemo must be done in the chemo room, unless the oncologist says otherwise because they always know what they're talking about. This is fine because everybody else in the practice has a simple rule to follow and the oncologists have the freedom to do other things when rare situations arise that would limit the effectiveness of treatment if the basic rules were applied.

Martin's policy is an excellent template, but don't be afraid to make it more personal to your practice to take account of the concerns of all staff, the georgraphy of the building, and the kinds of chemotherapy treatment you collectively feel confident and competent to perform.

Gerry

Re: Chemotherapy health and safety

Martin Atkinson — Fri, 27 Jun 2014 18:14:48 GMT

Here's mine - what do I get out of 10?

NURSING PROTOCOL FOR WORKING WITH CYTOTOXIC AGENTS

Cytotoxic agents are drugs used generally in the chemotherapy of tumours (cancer). They are all potentially toxic to human operatives. Accidental self injection or absorption through spillage on mucous membranes, i.e. eyes, nose and mouth is potentially serious and could result in permanent local damage, infertility, foetal abnormality, cancer or even death. It is therefore very important that great care is taken during handling, preparation and use. It is advisable that pregnant or sexually active women do not handle cytotoxic drugs or the excretions of animals to which they have been administered.

At all times, when handling liquid agents or reconstituting dry agents with liquids and during administration, operatives should wear protective clothing which should include: impervious gloves, a face mask, goggles and a plastic apron. It is also advisable to wear long sleeves. Tablets should never be broken and a mask and gloves should be worn even when dispensing tablets into bottles.

When drawing liquids from vials or bottles into syringes or using liquids to reconstitute powdered forms, to avoid blowback, care must be taken never to introduce positive pressure into the container containing the agent. Hypodermic needles used for withdrawing/transferring substances should be discarded and not re-sheathed. Syringes should be clearly marked and capped. Only someone who is experienced or has received comprehensive instruction should perform this process.

Agents should be prepared at the last practical moment over a sump (tub table) away from other unprotected staff and patients. Any spillages must be washed away immediately with copious quantities of water and any materials used for absorbing or cleaning spilled agents must be disposed of in cytotoxic waste (purple lid).

All disposable materials used during preparation and administration of chemotherpeutic agents: i.e. vials, syringes, needles, catheters, gloves etc should be disposed on in the cytoxic waste.

In the event of accidental self administration or spillage onto mucous membranes or skin wash the area immediately with copious quantities of water and seek immediate medical advise.

When using the agent Cisplatin, it is important to remember that it is excreted unchanged in the urine for at least 24 hours post administration and the same level of protection must be used when clearing urine as in the handling of the agent itself. All materials used for cleaning and contaminated bedding should be disposed of in the clinical waste.

For you information, cytotoxic agents used commonly, but not exclusively, in this practice are:

Vincristine (Oncovin) injectable

Vinblastine injectable

Cis-platin injectable

Actinomycin (Cosmogan Lysovar) injectable

Doxorubicin injectable

l-Asparaginase injectable

Melphalan (Alkeran) tablets

Cycolophosphamide (Endoxana) tablets

Chlorambucil (Leukeran) tablets

Re: Chemotherapy health and safety

Evelyn Barbour-Hill — Fri, 27 Jun 2014 17:59:00 GMT

[quote user="An On MRCVS"] but the plastic bin bags of waste - how often do you dispose of those?[/quote]

No substance is hazardous while in the proper container properly stored. So store it for ages if need be. The cytotoxic residues are not going to crawl out at night and lie in wait for the first nurse in in the morning.

But I don't think a plastic bag (however purple) stored in the kennel area quite counts as the proper container.

Re: Chemotherapy health and safety

Gerry Polton — Fri, 27 Jun 2014 17:53:10 GMT

In my opinion you are not over-thinking this. It's good to think about things. However, simple is always good in my opinion. I love your bullet points. The main thing is that the policy document is easy to understand and that it says what everybody wants it to say. It has to be agreed by all with a vested interest which is everybodfy who works in the practice, from the boss who never comes downstairs from his/her office to the cleaner who silently cleans up the mess that was left behind. I adivse that you think in terms of categories:

ordering, storage, administration, dispensing, disposal. Also injectable/oral

You only need to state what happens with potentially contentious issues. For example, you don't need to state that the normal paper packaging from a box in which a vial of chemotherapy was delivered can be disposed of in normal black bag waste. The policy document should be expected to evolve, so don't go printing 100 copies on high quality paper. Produce an electronic version if you can that only deisgnated people can modify (or delete!).

To sort of answer your question about frequency of waste disposal, I am concerned by how much waste you seem to be generating. I think, working in my two-person oncology only service, that I generate 60 litres of waste perhaps once every two weeks...

Gerry

Re: Chemotherapy health and safety

An On MRCVS — Fri, 27 Jun 2014 17:45:48 GMT

I guess this is generally what I wanted to know. How to other first opinion practices handle their chemo cases. I contacted a referral centre to find out how they did it This was part of their response -

'We vey rarely get spillages because of the system we use but the area would be thoroughly cleaned with trigene solution with doubling gloving and masks and putting all materials used to clean area into the special chemotherapy bins which we use to put all syringes, catheters, chemotherapy bottles, gloves, aprons and waste in. The bins are sealed and labelled, and collected about twice weekly by our designated disposal service.'

But they must see a lot of chemo cases so twice weekly collection is probably warranted. I accept what people are saying - keep hold of the sharps bins until full, but the plastic bin bags of waste - how often do you dispose of those? Or do you just wait until the freezer is full? One of my nurses worked at a referral type centre before so was shocked about how we are handling waste disposal here, but as I've said previously I have no previous experience to refer to!

Also I'm struggling with how to word a protocol? Does anyone have any examples for me? Do I just keep it basic and literally write it out bullet point as -

- No pregnant women allowed to be involved with chemotherapy administration

- Staff involved in administration must wear long sleeved aprons, double glove, goggles and masks

etc etc.

I may be over thinking this somewhat...

Re: Chemotherapy health and safety

Thomas Johnson — Wed, 25 Jun 2014 09:10:54 GMT

[quote user="Braden Collins"]

We ALWAYS use PhaSeal equipment for any injectable cytotoxics. It's a closed system and I thoroughtly recommend it. Never had a drop spilled yet.

[/quote]

I've started using this recently, it's available through Cave Referrals in the UK, and have been very impressed. It also means that I can get a nurse to help me place an i/v catheter and get everything connected, and then I can draw up and give the drug on my own.

Re: Chemotherapy health and safety

Martin Atkinson — Tue, 24 Jun 2014 16:45:28 GMT

I do have a written protocol for use of cytotoxics (including instructions for barrier nursing for stuff like doxorubicin). I have a purple lidded disposal container which is collected when full. I do make up cytotoxic drugs like cyclosphosphamide powder without a great song and dance, over a tub table wearing goggles, mask and gloves. Only I am allowed to handle cyctotoxics (locums can make their own risk assessment and are not forced to give chemo if they're not happy). All staff wear goggles, masks and gloves, long sleeves and disposable aprons if necessary when assisting with injections, cleaning cages etc where appropriate. This plus a great deal of common sense!

Re: Chemotherapy health and safety

Bob Russell — Tue, 24 Jun 2014 12:51:36 GMT

So much of the regulation seems to have been introduced for human clinical waste disposal at the convenience of the NHS.

What a shame good sense seems to have been (at least partially) replaced by overly strict rules.

Cytotoxics are nasty, dangerous drugs and should be treated with the utmost respect. An empty container of Alizin is not in the same category of danger! There is the real risk that the real nasties may be diluted by familiarity. Our purple lidded bins are treated with deep suspicion by all!!

Re: Chemotherapy health and safety

Claire Fisher — Mon, 23 Jun 2014 20:27:28 GMT

[quote user="bob lehner"]

(p.s I wonder how many people realise that hormone products such as Alizin etc fall into the same category?)

[/quote]

I didn't but will be updating our SOPs now that I do!

OP - if you don't do much chemotherapy then it might be worth looking at Iain Grant's chemopet website - he will send you individual doses of drugs as well as compounded lower mg cyclophosphamide, lomustine ect. They all come with Chemoclave administration systems.

If you are a BSAVA member there was a lecture at this years congress on this subject - you could listen to the podcast.

Re: Chemotherapy health and safety

Bob Russell — Mon, 23 Jun 2014 15:00:45 GMT

Seems strange that nowhere in the Alizin data sheet is there mention of any other form of disposal other than that required by any other injectable on the shelf.

As all pharmaceutical waste is handled under very strict conditions including high temperature incineration, I fail to see why a half decent risk assessment would require it to go into a purple lidded container with cytotoxics! That said I cannot see any reason why cytotoxics should be handled in a different way to pharmaceutical waste. It is all considered hazardous with all the legal requirements that go with it.

Pharmaceutical and cytotoxic waste should go down the same hazardous waste stream. We separate out the real cytotoxics to minimise the number of times things get placed in the bin. There is always the risk of a breaking bottle creating an aerosol!

Careful and sensible risk assessment is far more important to our safety!

I would still love to know what bright spark thought it would be OK for 'offensive waste' to go to landfill rather than incinerated as it was in the 'clinical waste' days!

Re: Chemotherapy health and safety

Braden Collins — Mon, 23 Jun 2014 14:47:48 GMT

Hello Anon.

We have dedicated cytotoxic bins, so everything goes straight into them.

We ALWAYS use PhaSeal equipment for any injectable cytotoxics. It's a closed system and I thoroughtly recommend it. Never had a drop spilled yet.

Is there a reason you chose injectable cyclophosphamide? Oral bioavailability is very good so this would be my normal route.

I think vets should really have a good think about doing chemotherapy without doing additional training. These drugs have higher risks to staff and animals, and IMHO do require extra training to work with safely and effectively.

Other things I will also insist on for safety - gloves, gowns, masks for all injections, Spill kit on hand when any handling of cytotoxics performed, informed consent of all staff involved with the case, only "trained" staff to handle the animal at all and clean any waste or bedding, storage of minimal amounts of drugs in tough containers away from all other drugs. There's a lot to think about.

Re: Chemotherapy health and safety

Utlendigur — Mon, 23 Jun 2014 14:47:13 GMT

[quote user="bob lehner"](p.s I wonder how many people realise that hormone products such as Alizin etc fall into the same category?)[/quote]

We do! Do we get a gold star. But one thing I'm not sure of is whether corticosteroids are classed as cytotoxic waste -ie what is meant by "certain hormones"? I think the full info says ones "that affect reproduction", but theoretically corticosteroids could.

Also does anyone know how to stop support staff filling the cytotoxic bin with empty vaccine vials, empty bottles of propofol etc - have tried plastering it with notes, writing out an SOP which they all signed to say they understood, asking them to leave the drugs in a tray for a vet or VN to sort ......conversely I found the cyclophoshamide tablets in the normal bin

Re: Chemotherapy health and safety

Gerry Polton — Mon, 23 Jun 2014 13:35:02 GMT

Dear Anon

To write your own cytotoxic substance polilcy is a very good idea, not least because the business is in breach of the Health and Safety at Work Act if one is not in existence and available to all staff to peruse and comment upon. I am sure that many of our readers will makle a mental note to adjust the lowly position of this policy document on their to-do list on reading this. You are not alone...

The Health and Safety at Work Act is very clear about what it says about handling substances hazardous to health. What it says is that all persons with an interest (=all staff) must be allowed to participate in the process of writing and revising this policy document. It makes it clear that there is a bidirectional responsibility; it is not just bosses who must be responsible for ensuring that a policy is written and adhered to, non-bosses also have a responsibility to express their opinions, to contribute to writing/revising the policy and must ensure that they follow the agreed plan. There is no single plan that fits all premises because all premises and businesses are different. There are generic truths though, such as the truth that the risk of accidental exposure is reduced with the use of suitable personal protective equipment.

The policy should also contain statements about considerations for the owners, their pets and the environment. This does not need to be complicated. The policy can say: 'it is acknowledged that there is a theoretical risk to owners and other people/animals through chemical transfer in urine/faeces of chemotherapy-treated animals. In order to manage this risk, owners are informed of the threat and the appended informatino sheets are given to all owners of pets who might be candidates for chemotherapy'. All you then have to do is to produce an owner information sheet, which I suspect you already have anyway.

So, to your specific questions:

I have cyotoxic waste collected weekly. My waste collector is happy to collect cytotoxic waste and will do so with every clinical waste collection if we have some. they only take full 'tubs' and I can imagine that it would not be economical to pay to have a rigid bin collected every week if you were not producing very much waste. I would contact your waste collector; you may find that they are happy to take anything to leave out for them, so long as it is appropriately presented (rigid purple-lidded bin). This may be less an issue of waste collection, more one of appropriate waste separation and storage. you don't need to freeze your waste. To answer the question about pedal bins, great idea, but you don't need one if you have designated chemo waste transfer bags. Look these up on Helapet's website; they are very cheap and you can then seal everything in small waste bags which can go in an 'open' waste bin and can be safely stored for a period of time.

Always use Luer lock syringes. This is non-negotiable. When someone gets spray in their face it is already too late to change your policy.

Take a look at the H&S website. It is actually very useful. There's a free booklet here: http://www.hse.gov.uk/pubns/priced/l5.pdf which will help.

Best wishes

Gerry

Re: Chemotherapy health and safety

bob lehner — Mon, 23 Jun 2014 13:29:16 GMT

BVA and BSAVA websites have quite a lot of information on disposal of chemotherapy agents - which are classed as Hazardous Waste.

e.g. This from the BSAVA resources:

'Cytotoxic and cytostatic drugs: This is a special category of medicines that has been introduced under the Disposal of Healthcare Waste Regulations. These medicines are deemed to be Hazardous Waste and will carry variable hazard codes. They all fall under the generic European Waste Catalogue (EWC) coding system of 18 02 07. This means that they must be segregated from all other pharmaceuticals and be disposed of by specialist contractors. The items for disposal include unused medicine, residue in used vials, contaminated syringes, needles, cannulae and contaminated protective clothing. It is important that the medicines are defined by their particular hazardous property (HP) code, which may include the following:

HP6 Toxic teratogenic
HP7 Carcinogenic
HP9 Infectious
HP10 Toxic for reproduction
HP11 Mutagenic.

The following classes of medicines should be included in this classification:

Cancer chemotherapeutics: including vincristine, pharmarubicin, methotrexate and all similar classes of tumour toxic medicines
Antiviral medicines: including aciclovir (Zovirax) ophthalmic ointment
Ciclosporin medicines in any form
Certain hormonal preparations: including prostaglandins and androgens (e.g. Tardak, Alizin and Mesalin).

These wastes must be segregated into purple flagged containers (i.e. the separate sharps bin should have a purple top, the separate pharmaceutical waste bin should have a purple lid or label and the yellow waste bag should be purple labelled). In addition, the EWC code and the HP codes must be clearly visible. The waste needs to be consigned to a specialist contractor and a fee is payable to the Environment Agency on disposal. Such waste items should not be moved between branch surgeries, unless specific dispensation is allowed (for example, there may be a local agreement with the Environmental Agency). Carriage of cytotoxic and cytostatic waste in unlicensed vehicles is illegal.'

Once you have the correct storage containers in place you can keep adding until ready for collection.

(p.s I wonder how many people realise that hormone products such as Alizin etc fall into the same category?)