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Protect HCWs from hazardous drugs
NIOSH, OSHA, TJC align on message
Make sure your health care workers are handling hazardous drugs safely. That is the key message to hospitals in a joint letter from three leading safety agencies: the U.S. Occupational Safety and Health Administration, the Joint Commission accrediting body, and the National Institute for Occupational Safety and Health.
The letter, which was to be mailed to all U.S. hospitals, does not add any new information or regulatory action. Instead, it underscores the importance of the 2004 NIOSH alert (http://1.usa.gov/ierb5Q) and the 2010 updated list of antineoplastics and other hazardous drugs (http://1.usa.gov/ddQ3IC).
Recent research demonstrates the continuing hazard to health care workers, even when they use protective equipment and safe work practices, such as biological safety cabinets. A study by NIOSH research biologist Thomas Connor, PhD, found that 60% of wipe samples in work areas tested positive for contamination with antineoplastic drugs, including carts, trays, countertops, IV bags, and even floors in patient rooms.1
In a companion study, Melissa A. McDiarmid, MD, MPH, DABT, director of the Occupational Health Program at the University of Maryland School of Medicine in Baltimore, found that nurses and pharmacists were 20% more likely to have a chromosomal abnormality than a control group if they had 100 or more chemotherapeutic drug-handling events. The likelihood of chromosomal abnormalities rose with greater exposure.2
Meanwhile, Washington became the first state in the nation to enforce protections for health care workers working with hazardous drugs. In April, Gov. Chris Gregoire signed a law that requires health care facilities to comply with the NIOSH alert and 2010 update and to protect health care workers from exposure.
The Washington legislature passed the law unanimously after a series of stories in the Seattle Times told of health care workers who had handled chemotherapy drugs and later developed cancer. The Department of Labor & Industries will draft regulations that are "consistent with and [do] not exceed provisions" of the NIOSH recommendations. The regulations also can be updated to incorporate any future changes by NIOSH.
"There is strong and convincing evidence that these drugs pose a significant risk to health-care workers," Michael Silverstein, assistant director, L&I's Division of Occupational Safety and Health, said in a statement. "This legislation ensures workers who provide lifesaving treatment for others aren't placed at risk themselves."
Research into links between cancer and health care occupations has been difficult because cancer registries typically don't include occupation. The Washington legislature also passed a law requiring the Washington State Cancer Registry to collect information on occupation.
"It's a start at connecting employee exposures to adverse health outcomes," says Marty Polovich, PhD, RN, AOCN, associate director of clinical practice at the Duke Oncology Network in Durham, NC. "I wish some other states would do the same."
No new national regulations
Nationally, there has been no movement beyond voluntary guidelines and recommendations, despite the known toxicity of many hazardous drugs. NIOSH has defined hazardous drugs as those that have been shown to have one or more of six effects on humans or animals: carcinogenicity, teratogenicity or other developmental toxicity, reproductive toxicity, organ toxicity at low doses and genotoxicity. There are currently 157 drugs on the list. NIOSH continues to review drugs for a future update.
"Chemicals like this are regulated in other industries. They're not regulated in health care," notes Connor.
OSHA's Director of Occupational Medicine, Rosemary Sokas, MD, MOH, notes that OSHA can use the "general duty clause" that requires employers to maintain a workplace free of serious hazards, and the agency is working toward an Injury and Illness Prevention Program standard that would require employers to find and fix hazards. While chemotherapy presents both risks and benefits to patients, workers experience only the risks, Sokas said in an emailed response to HEH. "This is why worker protection is so important," she said.
Connor and McDiarmid welcomed the joint letter as a way to increase awareness and spur better compliance with the recommendations. "I certainly would like to see this alert enforceable in the other 49 states," says McDiarmid. "It's evidence-based. The standard of practice is there."
Although hospitals have made progress in protecting workers from hazardous drugs, concerns remain. Even when containment isolators are used to prepare hazardous drugs, for example, contamination can spread once the items are removed, says Connor. "You're generating contamination inside the isolator. You're contaminating everything that goes in and everything that goes out," he says. "The products themselves can be contaminated."
Further research is needed to determine the safest practices, he says. Meanwhile, the 2004 NIOSH alert details procedures for reducing exposures. For example, the alert cautions workers to use appropriate personal protective equipment and safe work practices even when they are using a closed-system device to transfer hazardous drugs from their original packaging to dosing equipment. "Remember that a closed-system transfer device is not an acceptable substitute for a ventilated cabinet and should be used only within a ventilated cabinet," the alert states.
It's important to maintain vigilant adherence to the recommendations to reduce the risk of exposure, says Connor. "The study we did showed that even when people think they're doing a good job, they're still not entirely protecting their workers. There still is potential for exposure," he says.
By turning the NIOSH recommendations into requirements, Washington state is likely boosting compliance, says McDiarmid. "A lot of organizations find the resources they didn't think they had [to provide worker protections] when it's a standard as opposed to a guideline," she says. "I would at a minimum want the regulated community to know that the science is quite good as to what the hazards are and what the solutions and strategies are."
1. Connor TH, DeBord DG, Pretty JR et al. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. J Occup Environ Med 2010; 52:1019-1028.
2. McDiarmid MA, Oliver MS, Roth TS et al. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. J Occup Environ Med 2010; 52:1028-1034.