Chemotherapy Standards for PPE

Chemotherapy Requirements for Healthcare Workers

Healthcare workers responsible for administering cancer treatments to patients are at risk of being exposed to toxic chemicals, including cytotoxic drugs, which must be handled, managed and disposed of with the greatest care. In Australia, recommended policies for best practice in performing chemotherapy and ensuring the safety of healthcare workers have been established in each state with the support of health organisations and government bodies.

According to the Clinical Oncology Society of Australia (COSA) (O’brien et al., 2017), there are several methods of treatment for patients with cancer, all of which require specialised care by qualified healthcare workers. With each distinctive route, such as oral and intravenous infusion, only healthcare workers who are trained to administer the treatment via that route can do so (O’brien et al., 2017). For example, a non-touch technique is required for oral administration to prevent direct drug contact (King Edward Memorial Hospital, 2014).

For the safe administration, handling and disposal of cancer treatments it is of vital importance to ensure that all healthcare professionals, including nurses, medical, pharmacy and ancillary employees, adhere to the standard operating procedures outlined in the management of cytotoxic drugs (The Royal Children’s Hospital, n.d). Reducing occupational exposure to cytotoxic agents can be applied through the guidance of Occupational Health and Safety Precautions.

Occupational Health and Safety Precautions

Continual training	• Informing staff and patients of the potential hazards of cytotoxic agents	• Equitable access to training for staff responsible for handling hazardous substances and related waste (Brown-West et al., 2017)
Personal protective equipment	• Training in PPE processes, including suitability, application and disposal	• Facial fit tests for respiratory protective equipment, such as face masks (Workplace Health & Safety QLD, 2017)
Quality assurance	• Random and frequent inspections to examine surfaces at risk of contamination from cytotoxic drugs (SA, 2015)	• Emergency spill procedure (King Edward Memorial Hospital, 2014) • Equipment checks and safety cabinet assessment (SA, 2015)
Up to date information	• Current information and evidence-based best practice resources for OH&S (Brown-West et al., 2017)

The safe disposal of cytotoxic waste and potentially contaminated materials or equipment is key to minimising the risk of exposure to healthcare workers. The Environment Protection Authority (EPA) Victoria have established strict guidelines for employers to implement a waste management strategy for all staff involved in the generation, handling and destruction of cytotoxic contaminated waste (WorkSafe Victoria, 2003). For best practice in healthcare facilities, there must be policies and procedures in place for identification, segregation, containment, storage, transportation, and disposal of cytotoxic waste.

Personal Protective Equipment Considerations

Personal protective equipment is a mandatory requirement for the safety of healthcare workers. When determining the appropriate choice of gowns and gloves for use with cytotoxic drugs, it is recommended that the apparel is tested against the following standards:

In Australia, there are very few non-sterile gowns that have been tested against cytotoxic drugs. Based on the selection considerations of medical gowns by Workplace Health and Safety Queensland (2017), healthcare workers should use impermeable gowns with a closed front and long sleeves with cuffs.

Having the choice of chemotherapy gowns to use when dealing with cytotoxic drugs presents an opportunity for healthcare facilities to minimise risks. For example, the PrimeOn AAMI Level 4 non-sterile procedure gown complies with ASTM F739 and is approved for use when administering, handling and disposing of chemotherapy drugs.

Glove colour, whether it be purple, blue or green, has been perceived in the past to be an important feature in choosing a glove for protection against chemotherapy drugs. However, the true determining factors for gloves deemed appropriate for dealing with cytotoxic drugs include: material, thickness and standard test results (i.e. ASTM D6978-05). According to SafeWork NSW (2017), the permeability of gloves to drug materials correlates with the drug’s chemical properties and the glove’s material and thickness. For instance, the minimum breakthrough detection time of nitrile gloves for protection against chemotherapy drugs reinforces that this glove material offers greater protection than vinyl and latex alternatives. The GloveOn nitrile range features many gloves that have been tested with a variety of commonly used chemotherapy drugs for their breakthrough detection times.

Minimum Breakthrough Detection Times (minutes)

Chemotherapy Drug

Concentration

Aegis

Alexa

Eureka

COATS Nitrile

Celeste

Matador

Maverick

Maverick LC

Paladin

Protect

Vigor LC

Carmustine (BCNU)

3.3mg/ml (3,300 ppm)

43.8

24.0

7.3

21.9

16.2

90.6

15.3

15.1

30.1

5.6

45.4

Cisplatin

1.0mg/ml (1,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Cyclophos- phamide (Cytoxan)

20.0mg/ml (20,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Dacarbazine (DTIC)

10.0mg/ml (10,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Doxorubicin Hydrochloride

2.0mg/ml (2,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Etoposide (Toposar)

20.0mg/ml (20,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Fluorouracil

50.0mg/ml (50,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Methotrexate

25.0mg/ml (25,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Mitomycin C

0.5mg/ml (500 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Paclitaxel (Taxol)

6.0mg/ml (6,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Thiotepa

10.0mg/ml (10,000 ppm)

97.8

56.9

20.6

36.0

28.4

165.8

46.3

30.8

57.0

38.2

30.9

Vincristine Sulfate

1.0mg/ml (1,000 ppm)

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

>240

Warning: Do not use gloves against drugs with breakthrough performance of less than 30 minutes. Gloves used for protection against chemotherapy drug exposure should be used specifically for the type of chemicals used. Due to the variety and concentration of chemotherapy drugs used in treatments, the resistance table shown does neither warrant nor imply the safe use of the gloves against chemotherapy drugs resistance in every case. The safe use of gloves in chemotherapy treatment is solely the decision of clinicians authorised to make such decision.

References

1. Brown-West, L, Siderov, J, Cancer Therapy Medication Safety Working Group 2017, What occupational health and safety precautions should be followed when providing cancer therapy?, Clinical Oncology Society of Australia, viewed 2 January 2019, <https://wiki.cancer.org.au/australia/Clinical_question:What_occupational_health_and_safety_precautions_should_be_followed_when_providing_cancer_therapy%3F>
2. King Edward Memorial Hospital 2014, Safe Handling of Cytotoxic Agents Clinical Guideline, viewed 2 January 2019, <https://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/Pharmacy/guidelines/Cytotoxic%20Agents%20Safe%20Handling%20of.pdf>
3. O’brien, C, O’Kane, C, Cancer Therapy Medication Safety Working Group 2017, How should chemotherapy be safely administered via different routes?, Clinical Oncology Society of Australia, viewed 2 January 2019, <https://wiki.cancer.org.au/australia/Clinical_question:How_should_chemotherapy_be_safely_administered_via_different_routes%3F>
4. SA Health 2015, Safe Handling Cytotoxic Drugs and Related Waste: A Risk Management Guide for South Australian Health Services, viewed 2 January 2019, <https://www.sahealth.sa.gov.au/wps/wcm/connect/f8aa68004b3f6cf6a340afe79043faf0/Safe+Handling+Cytotoxic+Guidelines.pdf>
5. SafeWork NSW 2017, Cytotoxic Drugs and Related Waste – Risk Management, viewed 3 January 2019, <http://www.safework.nsw.gov.au/__data/assets/pdf_file/0005/287042/SW08559-Cytotoxic-drugs-and-related-risk-management-guide.pdf>
6. The Royal Children’s Hospital n.d, Cytotoxic Drugs – The Management Of, Melbourne, Australia, viewed 3 January 2019, <https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Cytotoxic_Drugs_The_Management_Of/>
7. Workplace Health and Safety Queensland 2017, Guide for Handling Cytotoxic Drugs and Related Waste, viewed 7 January 2019, <https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0006/88710/guide-handling-cytoxic-drugs-related-waste.pdf>
8. WorkSafe Victoria 2003, Handling Cytotoxic Drugs in the Workplace, viewed 7 January 2019, <https://prod.wsvdigital.com.au/sites/default/files/2018-06/ISBN-Handling-cytotoxic-drugs-in-the-workplace-2003-01.pdf>