Vincent A Armenio MD Nursing Policy & Procedure Manual Policy/Procedure Number: 4.

Effective Date: 10/01/04 Revised Date: ________ Version 1.0

Chemotherapy Preparation and Handling

Definition/Purpose: Appropriate care should be taken in all aspects of handling cytotoxic drugs to prevent exposure of personnel, patients, visitors, or the environment to hazardous drug contamination. The danger to health care personnel stems from a combination of the inherent toxicity and the extent to which workers are exposed to cytotoxic drugs. Three main routes of exposure are: inhalation of drug aerosols or droplets, absorption of drug through the skin or eyes, and ingestion through oral contact. Clinical personnel may inhale, absorb, or ingest cytotoxic drugs during preparation, administration, and/or disposal of contaminated materials. Personnel Responsible: Registered Nurses, Pharmacy Technicians and Pharmacists with specialized training in the handling of hazardous/cytotoxic drugs. Policy: 1. Chemotherapeutic agents are to be prepared and handled by pharmacists, pharmacy technicians, or registered professional nurses who have been specially trained and designated as qualified according to clinical policies and procedures. 2. To reduce exposure, personal protective clothing and equipment is to be used at all times when preparing or handling cytotoxic drugs. 3. Proper technique must be used in the administration and handling of antineoplastic drugs in order to protect the patient and the nurse. 4. All equipment used in the preparation and administration procedure and any unused drug(s) should be treated as hazardous waste and disposed of accordingly. 5. Eating, drinking, smoking, chewing gum or tobacco, applying cosmetics, and storing food is prohibited in areas where chemotherapy is used. Procedural Steps: A. Handling 1. Protect and secure unopened packages of hazardous drugs to prevent breakage or leakage.
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Inform and educate all involved personnel about hazardous drugs and safe handling procedures relevant to their responsibilities. Care should be taken to prevent drugs from escaping from containers when they are manipulated (ie, dissolved, transferred, administered, or discarded). Minimize the possibility of inadvertent ingestion or inhalation and direct skin or eye contact with the hazardous drugs through the use of personal protective clothing and equipment and a biological safety cabinet. Access to areas where hazardous drugs are stored should be limited to specific authorized staff. Personnel involved in shipping and receiving hazardous drugs should be trained in these procedures, including the proper use of protective garments and equipment. Damaged shipping cartons containing hazardous drugs should be received and opened in an isolated area, while wearing personal protective equipment (gown, gloves, eye protection) and disposed of accordingly. Methods for transporting hazardous drugs should be consistent with environmental protection. Hazardous drugs must be transported in appropriate containers (labeled CYTOTOXIC or CHEMOTHERAPY) and procedures should be used to prevent breakage and contain leakage. Syringes must be securely capped or sealed and properly packaged for transport. The containers should be secured and handled only by authorized personnel.

Note: Some studies have shown an increase in spontaneous abortions and fetal malformations in nurses who handle cytotoxic drugs without following current recommended OSHA guidelines for personal protective equipment. Employees who are pregnant, planning a pregnancy (male or female), or breastfeeding or who have other medical reasons prohibiting exposure to chemotherapy may elect to refrain from preparing or administering these agents or caring for patients during their treatment. Employees who wish to refrain from the work activities should discuss possible options with the leadership of their practice. B. Preparation 1. Personal protective equipment (PPE) should be used in the preparation of drugs. a) A lint-free, solid-front disposable gown with long sleeves and elastic or knit cuffs b) Powder-free latex gloves or chemo-gloves that extend over the cuffs of the gown. Gloves should be changed regularly every hour or if torn, punctured, or contaminated with a drug. c) Respiratory, eye, and face protection unless safety is provided by the use of biological safety cabinet (BSC)
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Only syringes and solution sets with luerlock fittings should be used for preparing and administering cytotoxic drugs, because the fittings are less likely to accidentally separate during handling and preparation procedures. Syringes should not be filled more than full to prevent spillage of the drug from accidental separation of the plunger and syringe barrel. Syringes and needles should not be clipped or otherwise destroyed, since drug aerosolization could result. Drug administration sets should be attached to IV solution bags and primed prior to the addition of the drug, using fluid that does not contain medication. When possible, all drug administration equipment should be assembled inside the BSC. The work surface within the BSC should be covered with a disposable plastic-backed absorbent pad. This pad should be treated as hazardous waste and disposed of properly upon removal from the BSC. Drug preparation: All chemotherapy/hazardous drugs should be prepared within a BSC. a) Ampules i. The contents should be gently tapped from the top and neck of the ampule. The neck of the ampule should be wiped off with alcohol. ii. A sterile gauze pad should be wrapped around neck of ampule when it is broken to protect from accidental cuts or exposure. iii. Break ampules away from individuals or self. iv. If the ampule contains dry material that needs to be reconstituted, the diluent should be added slowly down the side of the ampule to avoid splatter of drug powder. b) Vials must be handled carefully to avoid aerosolization resulting from pressure buildup. Only enough air should be added so that the drug can be aspirated easily. Excessive pressure in the vial may cause accidental aerosolization when the needle is removed from the vial. c) Chemo pins may also be used to prevent excessive pressure build-up when reconstituting or withdrawing cytotoxic drugs. d) The BSC work surface should be cleaned in accordance with the manufacturers directions daily, and immediately if large spills occur.

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C. Disposal 1. All contaminated materials used in the preparation of chemotherapy should be placed in a hazardous waste container (leak-proof, puncture-resistant) within the preparation area. 2. The Personal Protective Equipment (PPE) should be discarded in a hazardous waste container within the preparation area. The PPE should never be worn out of the preparation area. 3. Following chemotherapy administration, all contaminated materials should be placed in a hazardous waste container. Accidental Exposure 1. Accidental exposure to cytotoxic drugs or waste requires immediate intervention. 2. Remove contaminated gloves or gown and immediately clean the exposed skin with soap and water. 3. If eye exposure occurs, a five-minute eyewash with water or isotonic eyewash solution should be done. 4. Seek follow-up medical attention as necessary.

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