Dr. Yukiko Kudo,
Assistant Professor of Public Health and Basic Nursing Studies,
Akita University Graduate School of Medicine and Faculty of Medicine
III-1 Environmental Maintenance When Handling Anticancer Drugs
When preparing anticancer drugs and preparing to administer them in a hospital ward, there is a risk of exposure not only for the nurse performing the work directly, but also for medical personnel in the surrounding area unless the work environment is adequately maintained. The guidelines of the Occupational Safety and Health Administration (OSHA) in the United States recommend the installation of biological safety cabinets (hereinafter referred to as “safety cabinets”) as the most important element in exposure prevention. There are three types of safety cabinet: Class I, II, and III. However, the Class II Type B2 safety cabinet, which enables the maintenance of a high-level of cleaning functions of the interior and the release of 100% of the air outside of the room, is recommended (Fig. 1). In recent years, a closed-system negative pressure isolator for the sterile preparation of antineoplastic agents is now being used to ensure that aerosol is not also discharged inside the preparation room.
If a safety cabinet cannot be used, stricter maintenance of the environment and superior techniques are required to prevent exposure by aerosol. The following are important for the workplace: 1) it has ventilation equipment, 2) it is separated from tables on which other drugs are prepared, and 3) a place unfrequented by people is selected. A label warning indicating danger (“Danger!”, etc.) must be posted in areas where anticancer drugs are prepared and people in the surrounding area must be made aware of the danger.
Fig. 1 Airflow Inside of the Safety Cabinet (Provided by: Nikka Micron Co., Ltd.)
III-2-1 Mixing and Preparation in the Safety Cabinet
Protective equipment (two pairs of gloves, a mask, a gown, protective glasses or face shield, and cap), absorbent sheets, drugs and syringe / syringe needle to be used for mixing and preparing, IV drip bag, and waste containers (such as puncture-resistant containers and sealable plastic bags).
After washing hands, put on the protective equipment. Spread an absorbent sheet on the work table, and then place the supplies to be used in the preparation of the drugs on top of it. Prepare the anticancer drugs inside of the safety cabinet.
After finishing, place the used syringe needle and any shards of glass in a puncture-resistant waste container; place all other supplies that have been used along with the outer gloves in a sealable plastic bag and seal it. Discard all trash in a waste container dedicated to hazardous drugs. Discard the protective equipment including the gown, remaining gloves, mask, and cap in a waste container dedicated to hazardous drugs (Fig. 2), and then wash hands.
Fig. 2 Anticancer drug (hazardous drugs) dedicated, puncture-resistant waste container (box) (BD™ Chemotherapy Collector: Imported and sold by: Nippon Becton Dickinson Company, Ltd.)
III-2-2 Mixing and Preparation Without a Safety Cabinet
The same as when a safety cabinet is used, and in addition, a spill kit (see III-4 Methods of dealing with spilled anticancer drugs).
Post a label warning indicating danger in areas where anticancer drugs are prepared and do not allow people outside the department to enter. After washing hands, put on protective equipment, spread an absorbent sheet on top of the work table, and arrange the supplies so that they are easy to use. Mix and prepare the anticancer drugs (see III-3 Preparation, Administration, and Processing After Ending Treatment of Anticancer Drugs).
After finishing, place the used syringe needle and any shards of glass in a puncture-resistant waste container; place all other supplies that have been used along with the outer gloves in a sealable plastic bag and seal it. Discard all trash in a waste container dedicated to hazardous drugs. Discard the protective gear including the gown, remaining gloves, mask, and cap in a waste container dedicated to hazardous drugs. In addition to washing hands, the worker must also gargle sufficiently.
III-2-3 Cleaning inside the safety cabinet and work table
Use sodium hypochlorite (bleach) to deactivate the anticancer drugs in the cleaning of inside of the safety cabinet and work table. Because sodium hypochlorite has a corrosive effect on metals, also wipe down with a sodium thiosulfate solution (sodium thiosulfate hyposulfite) to neutralize it.
2% sodium hypochlorite, 1% sodium thiosulfate solution, gauze, sealable plastic bag for waste, and protective equipment (thick gloves, a mask, a gown, protective glasses or a face shield, and a cap)
Cleaners put on protective equipment. For a safety cabinet, keep it ventilated. Clean the inner surfaces and side walls with a gauze containing 2% sodium hypochlorite, moving from the top with the least amount of contamination toward the bottom, which is more contaminated. Next, wipe with a gauze containing 1% sodium thiosulfate solution from the top to the bottom. For a work table, wipe the surface of the work table with 2% sodium hypochlorite and with 1% sodium thiosulfate solution in that order. Place the gauze and gloves used in cleaning into a sealable plastic bag, and discard the protective equipment worn in a harmful waste container.
III-2-4 Use of Protective Equipment
Put on protective equipment, such a gloves, masks, hair caps, gowns, and protective glasses / face shields, to prevent contact with drugs for work handling anticancer drugs (Fig. 3).
Use thick, powder-free gloves without any visible tears. Gloves made of nitrile are recommended 3)
. Prepare two pairs of gloves, and put them on so that the inner pair of gloves is under the sleeves of the gown, and the outer pair of gloves is over the sleeves of the gown.
Fig. 3 State of Donned Protective Equipment
Masks that handle microparticles conforming to N95 and N99 standards are preferable because surgical masks cannot prevent the inhalation of aerosol and vaporized substances.
(3) Protective Glasses / Face Shields
Use disposable protective glasses or a plastic face shield to protect eyes from anticancer drug splash.
Put on a disposable gown to prevent contamination of clothing due to anticancer drug splash. Use the gown that is made of polyethylene or a material with low permeability such as one with a plastic coating that closes in the back and has long sleeves with elastic at the sleeve opening.
(5) Hair Cap
Put on a disposable hair cap to prevent contamination of hair due to anticancer drug splash. Use a hair cap made from a material with low permeability and that can cover hair on the head entirely.
(6) Removing Protective Gear and Methods of Disposal
Place the protective gear described above in a sealable plastic bag, seal, and then place in a waste container dedicated to hazardous drugs. When removing the protective equipment, first remove the outer pair of double-layered gloves, turn any area that may have anticancer drugs deposited on them inward. Next, gather so that any area of the gown that may have anticancer drugs deposited on it is folded inward and dispose of it. Remove the hair cap, mask, and protective glasses so as not to contact surfaces that may have anticancer drugs deposited on them, and dispose of them. Finally, remove and dispose of the inner gloves.
- Noriko Ishii, Ed.: The Handling-Manual of Antineoplastic Drugs for Nurses, 2nd Edition, Yuushobou, p. 32, 2013
- Noriko Ishii, Ed.: The Handling-Manual of Antineoplastic Drugs for Nurses, 2nd Edition, Yuushobou, p. 25, 2013
- Oncology Nursing Society: Safe Handling of Hazardous Drugs, second edition, Pittsburgh: ONS, 2011; p39