SAFE MANAGEMENT OF CYTOTOXIC SPILLS

GONG Cancer Care Guidelines

Next Review Date: Feb 2010 Responsibility: Gippsland Oncology Nurses Group. Purpose: Provide comprehensive, current, evidence based guidelines for

management of cytotoxic spills to inform standardized policy and procedure development across Gippsland. This guideline gives a brief overview of the principles for safe management of cytotoxic spills and follows the WorkSafe Victoria guide (see references). Desired Outcome: Raise awareness of the topic of management of cytotoxic spills in everyday assessment of cancer care and thereby promote best practice.

1. DEFINITION OF CYTOTOXIC WASTE

The GONG Guideline Safe Handling of Cytotoxic Substances should be read in conjunction with this guideline. www.gha.net.au/GRICS

Spillage of cytotoxic medications or any body fluids of a patient which are still deemed to be contaminated with the cytotoxic medication or less active metabolites of treatment. Cytotoxic medications are primarily eliminated from the patient by renal and hepatic excretion. All body substances may be contaminated with either the unchanged drug or active drug metabolites. Exposure to cytotoxic waste can occur through handling vomitus, blood excreta and fluid drained from body cavities; handling bedpans, urinals, emptying urinary catheter bags, colostomy/urosotomy bags and vomitus bowls; handling bed linen or clothing soiled with patient waste, or potentially contaminated with unchanged drug metabolites; cleaning spills. Any person handling cytotoxic medications and related waste might be involved in dealing with a spill, which may occur: When preparing, storing and transporting packaged drugs. During administration or transport of patients with chemotherapy in-situ. Handling patient body substances contaminated with cytotoxic medications. Any time any cytotoxic waste is handled.

2. RISK POTENTIAL
The period during which body substances may be contaminated with cytotoxic medications WILL DIFFER for individual drugs and patients. See appendix 1 for excretion times of cytotoxic medications.

3. HEALTH SERVICE POLICY

Health services should develop a spill policy and procedure for in-patient and home visits, that is understood, implemented and maintained by all personnel who handle cytotoxic medications and waste, and those who may be involved in managing spills. Employers should ensure that all employees who handle cytotoxic medications and waste have received appropriate training, and have obtained the required level of proficiency for spill management. Those personnel deemed safe to provide appropriate spill containment include: all hospital staff that may deal with the potential risk listed in point 2 Risk Potential. Patients and carers should be provided with written health and safety information such as the GRICS Chemotherapy Safety at Home patient information brochure available on www.gha.net.au/GRICS

4. STAFF EDUCATION

5. PATIENT EDUCATION - SPILL MANAGEMENT AT HOME

SAFE MANAGEMENT OF CYTOTOXIC SPILLS

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6. SPILL EQUIPMENT - HOSPITAL SETTING

All areas where cytotoxic medications and related waste are handled should have the following readily available: Spill kit containing (minimum) instructions for use, personal protective equipment, disposable gown, head covering, over-shoes, protective gloves, protective eyewear, respiratory protective device. Adequate supplies of disposable absorbent material. Cleansing material including strong alkaline detergent pH>10 (eg. Decon). Disposable mop head. Approved container for cytotoxic spill waste. Approved container for sharps where required. A disposable brush and shovel should be available in case a glass container has been broken. Spill pillows may be necessary for larger spills.

7. LAUNDERING - HOSPITAL SETTING

Special precautions are required for the laundering of nondisposable personal protective equipment and linen contaminated with cytotoxic waste. This is to protect the laundry personnel from cytotoxic waste. This is achieved by: Preventing contamination of the materials being laundered. Contaminated linen should be placed in plastic bags appropriately labelled with cytotoxic labels at the point of contamination for subsequent laundering. Alginate bags may be used. Bed mattresses should be cleaned after a spill with a cleansing material including strong alkaline detergent pH>10 (eg. Decon).

8. EQUIPMENT - HOME SETTING

For patients receiving a continuous infusion of chemotherapy at home, the equipment available for the visiting nurse should include: Spill kit containing (minimum) instructions for use, personal protective equipment, disposable gown, head covering, over-shoes, protective gloves, protective eyewear, respiratory protective device. Adequate supplies of absorbent material. Cleansing material including strong alkaline detergent pH>10 (eg. Decon). Approved container for sharps where required. Appropriate cytotoxic waste containers.

Patients who experience a cytotoxic spill at home should refer to their GRICS Chemotherapy Safety at Home Patient information brochure.

SAFE MANAGEMENT OF CYTOTOXIC SPILLS

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9. STAFF OR PATIENT CONTAMINATION

Use a spill kit. Wash area with copious amounts of water or shower if possible. Notify medical officer. Notify manager. Fill out appropriate health service documentation. Complete relevant Health Service incident reporting, eg. Spill registry where appropriate. Notify treating doctor if spill was associated with interruption to treatment or loss of chemotherapy dosage. Document event in patients medical record.

10.

DOCUMENTATION

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. American Society of Health-System Pharmacists. (2002). ASHP guidelines on preventing medication errors with antineoplastic medications. Am J Health-Syst Pharm. 59:1648-68. Austin Health. (2004). Procedure for cytotoxic chemotherapy spill management. Austin Health. British Columbia Cancer Agency. (2006). Policy: Chemotherapy process. British Columbia Cancer Agency. Cancer Nurses Society of Australia ( 2006) Position statement on the minimum education and safety requirements for nurses involved in the administration of cytotoxic drugs Bayside Health. (2005). Guidelines for safe handling of cytotoxic drugs. Bayside Health. Cancer Institute NSW. (2005). Cytotoxic spill management. http://www.cancerinstitute.org.au/ Cancer Institute NSW. (2005). Excretion Times of Cytotoxic Medications. http://www.cancerinstitute.org.au/ Cancer Nurses Society of Australia. (2003). Chemotherapy Position Statement on the minimum education and safety requirements for nurses involved in the administration of cytotoxic drugs. CNSA. Latrobe Regional Hospital. (2006). Cytotoxic substances-safe handling policy. Latrobe Regional Hospital.

10. Peter MacCallum Cancer Centre. (2004). Management of cytotoxic spill. Peter MacCallum Cancer Centre. 11. SHPA Committee of Specialty Practice in Oncology. (2005). SHPA Standards of practice for the safe handling of cytotoxic drugs in pharmacy departments. Journal of Pharmacy Practice and Research. Vol 35 (1): 44-52. 12. WorkSafe Victoria. (2003). Handling cytotoxic drugs in the workplace. WorkSafe Victoria. Website: http://www.worksafe.vic.gov.au

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APPENDIX 1 - EXCRETION TIMES OF CYTOTOXIC MEDICATIONS

Clinical Summary Length of time that safe handling precautions should be taken with urine and stools after the administration of cytotoxic medication. These excretion times are a guide for when to wear the appropriate Personal Protective Equipment. Standard Universal Precautions will suffice at all other times. Source: Cancer Institute NSW. (2005). Excretion Times of Cytotoxic Medications. http://www.cancer institute.org.au/

DRUG
Amsacrine Asparaginase Bleomycin Busulphan Capecitebine Carboplatin Carmustine Chlorambucil Cisplatin Cyclophospha mide Cytarabine Dacarbazine Dactinomycin Daunorubicin Docetaxel Doxorubicin Epirubicin Etoposide phosphate Etoposide Fludarabine Fluorouracil Fotemustine Gemcitabine Hydroxyurea Idarubicin Ifosfamide Irinotecan Liposomal Doxorubicin Lomustine Melphalan Mercatopurine Methotrexate Mitomycin Mitoxantrone Oxaliplatin Paclitaxel Pemetrexed Procarbazine Temozolomide Teniposide Thioguanine Thiotepa Topotecan Vinblastine Vincristine Vindesine Vinorelbine

URINE
2 days Trace amounts 3 days 12-24hrs 1 day 1-2 days 4 days 2 days 7 days 3 days (IV) 1 1 5 2 7 6 7 4 day day days days days days days days

STOOL

Notes

Trace amounts

10% as C0 > 10% excreted in bile In sweat and saliva for 3 days

5 days after PO dose

7 days 7 days 7 7 5 7 days days days days

20% elimination via gall bladder in first 24hrs

4 days 2 days 2 days 4 days 7 days 2 days 4 days 2 days 2 days Extended elimination 4 days 2 days 2-3 days 3 days 1 day 6 days 3 days 1 day 3 days 2 days Unknown 5 days 1 day 3 days 2 days 4 days 4 days 4 days 4 days

7 days

7 days

Biphasic elimination; half life of 5hr & 55hrs. 7 days 5 days 7 days Small amount in bile 7 days 5 days

2 days

7 7 7 7

days days days days

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