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NIOSH: Monitor HCWs with chemo exposure
Recommends annual symptom questionnaire
Medical breakthroughs for patients can present new hazards for health care workers. With an ever-expanding range of hazardous drugs, hospitals must identify employees at risk and conduct medical surveillance at least annually, according to the National Institute for Occupational Safety and Health (NIOSH).
"There's been a real evolution of drugs to be increasingly toxic, but we've never ratcheted up an increasing responsibility to both communicate the hazard and protect health care workers," says Melissa McDiarmid, MD, MPH, professor of medicine and director of the occupational health program at the University of Maryland School of Medicine in Baltimore. She is a member of the NIOSH hazardous drug workgroup and a co-author of NIOSH's "Workplace Solutions" document on medical surveillance and hazardous drugs.
NIOSH advises employers to provide a symptom questionnaire to look for potential physical effects from the drugs, many of which are known carcinogens or reproductive hazards. The employees also should have a baseline CBC (complete blood count), urinalysis, and physical exam, and employers may want to consider other tests, such as liver function, NIOSH says. (See insert for a sample questionnaire.)
NIOSH has identified about 120 hazardous drugs used in health care settings, says Thomas Connor, PhD, research biologist at NIOSH in Cincinnati. "I don't know any other industry where you would have so many toxic chemicals," he says. "Nothing comes close. These are toxic because they work. They kill bacteria, yeast, fungi, and cancer cells. They have to be toxic."
Employees should have access to a Material Safety Data Sheet with information about each drug, he notes. But NIOSH isn't able to offer specifics on medical surveillance for each agent.
However, there are some basic measures that employers should have in place. "The first step is to identify who makes up that population [of potentially exposed employees] in your facility," Connor says.
Think broadly, advises Connor. Oncology nurses and pharmacists who prepare the drugs are obvious candidates for surveillance. But your list should include the housekeepers who change linens, the nursing assistants who empty bed pans, and the shipping and receiving workers who open boxes containing vials of the drugs, he says.
Studies show that the outside of the vials may be contaminated, he notes. "The people unpacking in the receiving department should be taking precautions," he says.
Look for rash, side effects
What should you be looking for in medical surveillance? That actually is a difficult question because the drugs are so varied and the effects may be gradual and long term.
Think about the side effects the drugs cause in your patients, such as an abnormally low white blood count or anemia, advises McDiarmid. For example, some of the drugs may have an effect on liver function.
Skin rashes also may indicate a problem. "Skin is going to be the route of exposure a lot of times," says McDiarmid, though she notes that drugs also become aerosolized in unexpected ways — for example, when a nursing assistant empties the bedpan of a chemotherapy patient into a toilet and flushes.
A significant exposure from a spill can cause acute effects, such as dizziness, rash, and profuse sweating, says Connor. Many of the antineoplastic drugs, such as cyclophosphamide, are known carcinogens. A NIOSH alert published in 2004 warns: "Health care workers who work with or near hazardous drugs may suffer from skin rashes, infertility, miscarriage, birth defects, and possibly leukemia or other cancers."1
Reproductive health issues may be difficult to evaluate. After all, miscarriage naturally occurs in about 25% of recognized pregnancies, McDiarmid notes. But it's important to look for reproductive health trends among staff handling the drugs.
Surveys of 4,393 nurses in the Netherlands found that nurses with dermal exposure to antineoplastic drugs took longer to conceive and were more likely to have premature delivery or low birth weight babies than a control group.2
Oncology nurses and others with potential exposure to hazardous drugs need to be aware of the potential reproductive hazards, says Marty Polovich, MN, RN, AOCN, oncology clinical nurse specialist at Southern Regional Medical Center in Riverdale, GA. If health changes occur, the hospital needs to take a closer look at the use of personal protective equipment and other measures to reduce exposure.
"Are the employees using appropriate precautions?" she says. "Is the safety cabinet working the way it's supposed to be working?"
Few offer surveillance
In its alert issued three years ago, NIOSH emphasized the need to assess the hazards and monitor employee exposures to antineoplastic agents. But few health care employers provide regular medical surveillance, according to a survey of 330 nurses by the Oncology Nurses Society, based in Pittsburgh.
About 47% of the nurses reported some type of surveillance, including a baseline physical exam. Only about 30% received an annual symptom questionnaire, and 22% had an annual physical exam as part of medical surveillance. Lab work was even rarer; 8% of nurses reported annual blood or urine tests.
The NIOSH guidance provides some momentum for surveillance, says Polovich. "Organizations will begin to appreciate the fact that people who handle hazardous drugs should be monitored in some way, even if it's only an annual questionnaire," she says.
Meanwhile, employers can take other steps to reduce exposure, advises Connor. Employees with potential exposure should receive periodic training on safe handling of the drugs. And hospitals should keep up on new protective technology as well as the addition of new drugs and novel uses of chemotherapeutic agents. For example, some of the agents are now being used in the operating room to flush the peritoneal cavity during surgery.
In the effort to create better outcomes for patients, make sure you're not putting health care workers at risk from exposure, he says.
(Editor's note: A copy of the Workplace Solutions document, Medical Surveillance for Health Care Workers Exposed to Hazardous Drugs, is available at www.cdc.gov/niosh/docs/wp-solutions/2007-117.)
1. National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention. Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Settings. DHHS (NIOSH) Publication Number 2004-165, Cincinnati; September 2004. Available at www.cdc.gov/niosh/docs/2004-165.
2. Fransman W, Roeleveld N, Peelen S, et al. Nurses with dermal exposure to antineoplastic drugs: Reproductive outcomes. Epidemiology 2007; 18:112-119.