Hazardous Drug Spills
Aside from compounding, chemotherapy spill represents the biggest opportunity for HD exposure. It is not known how many spills occur each year as there is no centralized database for this information and institutions typically do not make the data public. Instead, we rely upon published surveys and anecdotal evidence.
The largest survey to date was published by Boiano and colleagues in 2014 and included 1,954 nurses. 12% reported experiencing a spill or leak within the week prior to the survey. Almost 10% stated that spills had not been properly cleaned. No data is available for the number of spills that occurred during the prior 6 or 12 months, although multiple spills during the 7 day period were reported (Boiano, Steege & Sweeney, 2014, Journal of Occupational and Environmental Hygiene, 11.)
A study published in 2017 by He et al, which included nurses from California, Michigan and Georgia (n=252), indicated that 26% had experienced a spill within 6 months. Only 17 nurses reported using a CSTD; however, 62% cited a device malfunction. (See discussion on CSTDs for more information.) Also of interest, only 57% used chemotherapy tested gloves and only 39% used double-gloves (He, Mendelshon-Victor, McCullagh, & Friese, Oncology Nursing Forum, 2017, 44(1).
In 2015, Chris Freise and colleagues reported on a pilot study (n=40) in an ambulatory infusion center. During a 6 month period, 9 employees were involved in 4 spills. More significantly, HD was detected in the urine of employees who did not report or were not involved with a spill, indicating likely environmental contamination. This study resulted in changes being made to spill cleaning procedures (Friese, McArdle, Zhao, Sun, Spasojevik, Polovich and McCullagh, 2015. Cancer Nursing, 38(2).
The primary route of HD absorption is dermal (Fransman, Roeleveld, Peelen, de Kort, Kromhout, & Heederik, 2007, Epidemiology, 18.) and dermal contact in the environment can lead to absorption. This is one rationale for performing regular surface wipe testing. Considerably less information is available about inhalation of vapors. (See section on respiratory protection.) And despite the use of components to prevent spills (e.g., Luer Lok connections and CSTDs), spills still occur. So while we must do everything possible to prevent them, the reality is that at some point a spill will happen.
Just as organizations do everything possible to prevent fires, drills and safety protocols are a normal part of the healthcare workplace. This same approach must apply to spills, and is discussed throughout USP <800>.
USP <800> does not specifically discuss how nurses should clean a spill at the bedside, but information is included in the section I authored in the ONS Safe Handling of Hazardous Drugs (2018). Readers are encouraged to review this material.
USP <800> also does not specify who should respond to spills, but section 16 requires that they must be trained. As with fires and code blue events, it might be years before someone has to respond to a spill, thus providing the rationale and requirement for annual training.
A number of manufacturers offer HD spill kits. Nurses should be familiar with what is in their kit (similar to knowing what's in the crash cart), and with the institution's spill policy. It should be recognized that not everything in a kit may be useful or effective as there are no regulations requiring manufacturers to test the items in their kits. Many contain surgical masks or N95 respirators that are completely useless for vapors, and may not provide an airtight fit against the employee's face. (OSHA 29 CFR 1910.134(f) requires fit testing for respirators.) Shoe covers in some kits may not be impervious to HDs, providing a false sense of security.
At a minimum, a kit should contain*: (in addition to HD-resistant gown and ASTM 6978-05 chemotherapy gloves)
Absorbent pads or pillows
Equipment for glass cleanup if glass is used in the setting
Signage alerting staff and visitors to avoid the area
HD-designated bags (large and small sizes)
PPE if not immediately available in the area
Eye and face protection (goggles and face shield)
*Polovich M, Olsen M. Safe Handling of Hazardous Drugs. 3rd Ed. Pittsburgh, PA: Oncology Nursing Society; 2017
** Fit testing required for N95 or N100 respirators but not for PAPRs
If building a custom kit, here are specific recommended vendor/part numbers to consider. I have personally tested these products for HD spills of various sizes. The pads are exceptionally absorbent, and the booties are impervious to a long list of hazardous chemicals and acids.
Fisher Scientific Hazmat pads (2 sizes; yellow and blue) (pictured above
Medline disposable face shield #NONFS300Z
Lakeland ChemMax C5903 yellow chemical resistant booties (pictured above)
On the right is chemical testing for the ChemMax boot covers. While HDs are not included, these 'booties do offer considerably more protection than standard shoe covers found in most spill kits.
Other useful supplies include documentation forms, a copy of the policy & procedure, and a neutralizing agent. For a discussion on neutralizing, click here. If glass IV bottles are used for HD administration, a scoop and brush are recommended, and glass must be placed in a puncture-proof container (not the yellow HD bags).
Staff must know where the kits are located, and a system must be in place to ensure that kits are regularly inspected to ensure that it has not been opened and items removed.
Spills on patients or staff
Since dermal contact is believed to be the primary method of HD absorption, a spill that results in direct skin contact should be considered an emergency--particularly if the drug is a vesicant. Detailed information describing specific interventions can be found in the 3rd edition of the ONS Safe Handling of Hazardous Drugs (2018).
Staff who have direct dermal contact should followup with their medical provider as this is best practice for biologic monitoring within the scope of medical surveillance.