Becker's Clinical Quality & Infection Control

47 Executive Briefing Sponsored by: Occupational exposure to hazardous drugs: Why the issue extends beyond pharmacy and what providers can do about it T he dangers associated with occupational exposure to hazardous drugs are well-documented. Protecting employees from this potential harm is good for business, the bottom line and brand reputation. Many healthcare systems have already taken extensive steps to protect pharmacy and nursing personnel from hazardous drugs during drug preparation and administration activities. Once a hazardous drug leaves the pharmacy, however, the number of staff potentially exposed increases and the types of exposure may be difficult to control. Becker's Hospital Review recently spoke with two experts from WorkingBuildings about hazardous drug exposure and risk management in patient care areas. Kurt Last, Principal, and Elaine Strauss, PharmD, Pharmacy Clinical Consultant, discussed USP <800> compliance and best practices that healthcare organizations can use to limit and eliminate staff exposure to hazardous drugs. Hazardous drugs and USP <800> The National Institute for Occupational Safety and Health maintains a list of hazardous drugs. According to NIOSH, a drug is considered hazardous if it meets at least one of the following characteristics in humans or animals: carcinogenicity, teratogenicity, reproductive toxicity, organ toxicity or genotoxicity. Individuals who need hazardous drugs for disease treatment take them under informed consent. They understand the risk-benefit calculation associated with taking them. Unintentional exposure to these drugs is undesirable. "Numerous studies have proven adverse effects as a result of staff having occupational exposure to Hazardous drugs," Dr. Strauss said. "These can include reproductive issues, skin rashes or hair loss." In response, the United States Pharmacopeia (USP) developed USP General Chapter <800> which focuses on handling of hazardous drugs in healthcare settings. This chapter defines processes intended to minimize exposure to hazardous drugs in healthcare organizations, with the goal of promoting safety and environmental protection for patients and workers. USP <800> will become official on Dec. 1, 2019. Although the chapter will not be enforceable until appeals related to USP <795>, <797>, and <825> are reviewed, healthcare systems should not halt their USP <800> compliance initiatives. "Since none of the appeals impacts the facilities or engineering aspects of USP <800>, healthcare organizations should stay the course on their work. "As soon as the pending appeals are resolved, USP <800> will be going into policy, procedure, and practice," noted Dr. Strauss. Hazardous drug exposure isn't limited to pharmacy and nursing units In health systems, the primary hazardous drug exposure point is the pharmacy where the drugs are manipulated. Fortunately, pharmacies are relatively small physical spaces, the staff are typically highly trained, and well-documented procedural and engineering controls are in place to limit exposure. Another common exposure route is in nursing units when hazardous drugs are administered or infused into patients. Most facilities have proactively implemented protocols, such as closed system engineering devices attached to the hazardous drug bags, to minimize nurses' exposure. "One problem is that there are many other areas of the hospital where hazardous drugs travel before they get to the pharmacy, " Mr. Last said. "The geography of these facilities is so large and there are so many people involved that the full range of HD exposure isn't well understood or controlled." In the receiving area of the hospital, warehouse or loading area employees may open boxes containing hazardous drugs. If the integrity of the packaging was compromised during shipment, those individuals could be accidentally exposed. Health systems must also consider how to protect employees from hazardous drug exposure during everyday environmental and patient care activities like cleaning patient bathrooms, changing linens and other patient care areas. "After a hazardous drug is administered to a patient, the downstream issues are considerable. In some cases, a substantial portion of the drug will pass through the patient either unmetabolized or partially metabolized. As result, the hazardous drug ends up in the patient's waste and body fluids," explained Mr. Last. Most HDs are excreted from patient's bodies within 48 hours after they have been administered, however some drugs can continue to present in patient body fluids for up to 7 days. Plans should also be developed for handling bed linens, towels and any other items from patient room that might have traces of hazardous drug contamination. Since exposure to hazardous drugs can happen in many areas of the hospital, limiting exposure requires a multifaceted approach. "Individual healthcare programs may have other treatment plans that involve acupuncture, massage therapy and perhaps others. The risk to the staff from working with and handling those patients must also be evaluated and mitigated," Mr. Last said. Hazardous drug surface contamination is a reality Surface residue from hazardous drugs is a reality in many healthcare settings. Implementing a four-step cleaning protocol is an effective way to address this issue through deactivation, decontamination, cleaning and disinfection. In addition to surfaces in patient rooms and bathrooms, employees must clean reusable equipment like IV poles,

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