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Chemotherapy safety in the perioperative environment

Morandini, Sara MSN, RN

doi: 10.1097/01.NURSE.0000531004.17471.34
Department: PATIENT SAFETY
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Perioperative chemotherapy safety

Sara Morandini is a clinical scholar for perioperative services and a clinical nurse III in the inpatient OR at the University of Colorado Hospital in Aurora, Colo.

The author has disclosed no financial relationships related to this article.

INTRAOPERATIVE CHEMOTHERAPY administration is a critical procedure that requires staff competence and confidence. Perioperative staff members need to be equipped with the skills and knowledge necessary to provide safe patient care. The foundation of knowledge is the fact that chemotherapy is a cytotoxic agent that's excreted in all body fluids for 48 hours following administration.1-4

The purpose of this article is to identify educational needs to ensure safety for all involved. Through the research and analysis of evidence and best practice guidelines, this article breaks down chemotherapy education into three main factors: communication, risk of exposure, and disposal.

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Facets of communication

The Association of periOperative Registered Nurses identifies communication as an integral part of developing and maintaining a safe environment with communication that's “clear, accurate, [and] timely.”5 Communication in chemotherapy procedures begins with labeling surgical suite doorways, patient beds, urinary drainage bags, linen bags, disposal containers, and contaminated surgical instruments to convey the risk of exposure.1-4

Communication is also an important step in the six rights of medication administration.4,6 Performing an independent double check by the pharmacist and circulating nurse, as well as a chemotherapy time-out with the entire surgical team, will ensure that the right patient receives the right drug, at the right time, in the right dose, and by the right route of administration. Communication during the time-out allows staff members to stop and check their personal protective equipment (PPE) to minimize their risk of exposure.

Patient handoff at the bedside is essential when transferring care. Staff must accurately document the time of chemotherapy administration to determine when the 48-hour body fluid contamination period begins and ends.

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Exposure risks

The three types of fluids containing cytotoxic material in the perioperative environment are the chemotherapeutic agent, fluid containing the drug used as intended, and body fluids containing chemotherapy metabolites. (See What's “fluid containing drug used as intended”?) When assessing the risk of exposure, consider these body fluids: blood, urine, emesis, stool, sweat, and saliva.2

Intraoperative routes of chemotherapy administration include, but aren't limited to, intraperitoneal (chemotherapy administered directly into the peritoneal cavity) and intravesical (chemotherapy administered directly into the bladder). In these identified routes of administration, when the drug and diluent solution is drained, part of it will be drug while other parts may be body fluids or irrigant.2,4,7

Impervious drapes need to be applied to the surgical table under the linens, and absorbent pads need to be placed on top of the linens to help prevent the chemotherapeutic agent from contaminating beds or stretchers.2,3

An approved chemotherapy spill kit should be available wherever chemotherapy is located or contaminated patients' excreta are present.3 (See Looking into a hazardous drug spill kit.) When spills occur despite implementing appropriate safety measures, nurses need to don PPE correctly, cordon off the area, and work from the outside in.2 All spills and exposures must be acknowledged and addressed immediately and reported to leadership and pharmacy according to facility policy and procedure.1,3

In the event of an exposure, remove all contaminated items. Thoroughly clean contaminated skin with soap and water, and flush mucous membranes with water for 15 minutes.2,3

When an exposure risk is present, reducing that risk is a priority. PPE is mandatory for any staff member who assesses the need for protection due to a risk of exposure to fluids.2-4 PPE includes an impervious gown, double gloves, face shield or face mask with eye protection, and shoe covers.1,2,4,8 Shoe covers can decrease the risk of contaminants spreading to additional areas, and face shields are recommended over face masks with goggles because these protect more of the face.2,8 PPE is to be changed within 30 minutes of exposure, or immediately if torn or punctured, and hands must be cleaned with soap and water.2-4

Pregnant or breastfeeding healthcare providers face reproductive risks from exposure, but elimination of all risks can't be guaranteed despite the use of PPE and safe practice.3,9

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Disposal guidance

Chemotherapy-contaminated fluids are incinerated to destroy their hazardous components. Appropriately labeled, puncture-proof, tight-sealing hazardous drug (HD) waste containers must be present in all areas where chemotherapy fluids are present.2-4 HD waste containers are used to collect and dispose of trace amounts of drug, which is classified as 3% or less of the original total drug volume. Any amount greater than a trace amount of the original, nonadministered drug must be returned to the pharmacy and disposed of in a black Resource Conservation and Recovery Act hazardous waste container designed to segregate hazardous pharmaceutical waste.2 Follow facility policy and procedure for safe disposal of HD waste.

All single-use disposable items that are contaminated by any of the three fluid types must be placed in an approved HD waste container.2-4 Fluid-containing chemotherapeutic drug used as intended must be placed in an HD waste container.2,4,7

When handling fluid containing a chemotherapeutic drug used as intended, using a closed system reduces the risk of exposure. An example of a closed system is a urinary catheter connected to a urinary drainage collection bag.6,10 For disposal, allow the bladder to empty, then clamp both the urinary drainage bag and catheter and disconnect them from one another to allow the entire urinary drainage bag to be placed in an HD waste container. The catheter can then be connected to a new urinary bag.

Body fluids containing chemotherapy metabolites must be double flushed in a covered toilet. Absorbent pads may be used in place of a cover to contain splashes.3 Cleaning sweat, blood, urine, and other contaminants from the patient's skin with soap and water will help prevent skin irritation.3,6

Chemotherapy-contaminated metal surgical instruments should be soaked in a water detergent bath for 10 minutes before the standard cleaning and sterilization process based on the manufacturer's instructions for use.6 The sink must be thoroughly cleaned with water once the water detergent bath has completed draining.6

Linens must be collected and disposed of in the HD waste containers if they've been exposed to drug or fluid-containing drug used as intended.3 Linen contaminated with body fluids containing chemotherapy metabolites may be washed with detergent and water; however, labeling and double bagging is advised to contain the contaminants and to warn personnel of the risk of exposure.3,8

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Educational support

Support can be provided to staff through many different avenues. PPE carts can be created that contain all necessary protection items plus communication signs, a hazardous material spill kit, impervious drapes, and absorbent pads. A tip sheet can be created and attached to the PPE carts, with itemized requirements for patient care to help increase confidence and competence.

Access to on-demand educational classes is provided by the Oncology Nursing Society (ONS) for nononcology environments; ONS includes information on safe handling in the OR.10

Mock scenarios help educate staff members by supporting their practice of PPE donning and doffing procedures, improving interdisciplinary communication skills, and performing hazardous material spill cleanup in a safe environment.1,4

Additional support can be found in the Safety Data Sheets (SDS) that contain important information regarding chemotherapeutic agents administered in the perioperative environment.1,11 SDS provide access to safe handling practices and control measures to prevent emergency situations and are arranged in a format so that information can be gathered quickly.11 Taking the time to become familiar with SDS on the unit is advised for any team member who handles hazardous drugs.11

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Safety first

The perioperative environment is the scene for unique chemotherapy administrations. Extensive knowledge is needed for patient and staff safety. Supplementing clinical education with specialized classes, mock scenarios, and practice tip sheets can help staff learn and retain the practice guidelines and other important information. These steps can increase staff competence and confidence.

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What's “fluid containing drug used as intended”?2

This type of fluid contains a diluent and the chemotherapeutic drug such as a chemotherapeutic drug injected into the bladder. The urinary catheter is capped to prevent any drug or urine from being expelled. After a set period, the urinary catheter is uncapped, allowing all contents in the bladder to be drained. Although the fluid contains urine as well as drug that wasn't absorbed, the drug can't be distinguished from urine. The fluid contains drug and must be treated as hazardous.

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Looking into a hazardous drug spill kit

A hazardous drug spill kit should include the following contents:

  • enough supplies to absorb a spill of about 1,000 mL
  • appropriate PPE to protect the worker during clean-up, including two pairs of disposable chemotherapy gloves and nonpermeable, disposable protective garments (coveralls or gown and shoe covers), face shield, and respirator
  • absorbent, plastic-backed sheets or spill pads
  • disposable toweling
  • at least two sealable, thick plastic hazardous waste disposal bags (prelabeled with an appropriate warning label)
  • one disposable scoop for collecting glass fragments
  • one puncture-resistant container for glass fragments.

Source: U.S. Department of Labor. Controlling occupational exposure to hazardous drugs. www.osha.gov/SLTC/hazardousdrugs/controlling_occex_hazardousdrugs.html.

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REFERENCES

1. Kyriazanos I, Kalles V, Stefanopoulos A, Spiliotis J, Mohamed F. Operating personnel safety during the administration of Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Surg Oncol. 2016;25(3):308–314.
2. Polovich M, Olsen M. Safe Handling of Hazardous Drugs. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2017.
3. Polovich M, Whitford J, Olsen M. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 4th ed. Pittsburgh, PA: Oncology Nursing Society; 2014.
4. Small T. Introduction of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) to the surgery program. ORNAC J. 2013;31(2):12–17, 28-33.
5. Association of periOperative Registered Nurses. Position statement on a healthy perioperative practice environment. AORN. 2015:1–5. http://www.aorn.org/media/aorn/guidelines/position-statements/posstat-safety-healthy-practice.pdf.
6. Mellinger E, Skinker L, Sears D, Gardner D, Shult P. Safe handling of chemotherapy in the perioperative setting. AORN J. 2010;91(4):435–450; quiz 451-453.
7. Cianos R, LaFever S, Mills N. Heated intraperitoneal chemotherapy in appendiceal cancer treatment. Clin J Oncol Nurs. 2013;17(1):84–87, 90.
8. Burlingame BL. Clinical issues: intraoperative chemotherapy. AORN. 2007;86(6):1041–1049.
9. Gilani S, Giridharan S. Is it safe for pregnant health-care professionals to handle cytotoxic drugs? A review of the literature and recommendations. Ecancermedicalscience. 2014;8:418.
10. Oncology Nursing Society. Chemotherapy in non-oncology settings. ONS. 2015. http://www.ons.org/content/chemotherapy-non-oncology-settings.
11. United States Department of Labor. Hazard communication standard: safety data sheets. OSHA Brief. http://www.osha.gov/Publications/OSHA3514.html.
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