Hazardous drug spill management Reviewed: February 20, 2023 Il Introduction Nurses who prepare and administer hazardous drugs are at risk for occupational exposure, which in turn places them at risk for certain types of cancer, including leukemia; infertility and miscarriage; irritation of the skin or eyes; and allergic reactions.) Factors that affect the risk of exposure include preparation, administration, and disposal of hazardous drugs; the amount of drug prepared; the frequency and duration of drug handling: the potential for absorption; the use of ventilated cabinets; and work practices.2] The risk of experiencing adverse eff increases with the amount and frequency of exposure and poor work practices. Following good work practices and using proper personal protective equipment decrease the risk of such exposure. Facilities that store, transport, prepare, and administer hazardous drugs should have emergency procedures for handling spills and exposure as part of their overall health and safety program!) Hazardous drug spill kits should be available wherever chemotherapeutic agents and other hazardous drugs are stored, transported, prepared, or administered,4! ll health care facility personnel who handle hazardous drugs should be trained properly in spill cleanup. ll Equipment + Absorbent powder * Absorbent spill pads or absorbent plastic-backed sheets! * At least two large, heavy-duty, hazardous waste-labeled, sealable, disposable bags * Cleaning agent designed to remove chemicals from stainless steel * Disposable, low-permeability, back-closure, chemotherapy-resistant gown * Disposable scoop for collecting glass fragments + Disposable towels * Face shield « Facility-approved deactivating and decontaminating agents * Goggles * Hazardous drug precaution sign + Hazardous drug-resistant shoe covers + Heavy-duty utility gloves * Plastic sheeting* Puncture-proof container for glass fragments + Respirator mask, appropriate for the spilled agent, approved by the National Institute for Occupational Safety and Health (such as a fit-tested N95 or powered air-purifying respirator) * Safety data sheet (SDS) + Small, sealable plastic bag + Two pairs of hazardous drug-resistant gloves + Water * Optional: chemical cartridge-type respirator with full facepiece ll Preparation of Equipment Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility Spill kits that contain all the materials needed to clean up lous drug spills should be available wherever hazardous drugs are located. 4/2! Each kit should have sufficient supplies to absorb about 1,000 mL of hazardous drug. Assemble your own kit or use your facility's commercially prepared kit, as appropriat: Access the SDS for the spilled agent to determine whether use of a chemical deactivator is recommended. lll Implementation + Assess the size of the hazardous drug spill and call for trained assistance, if needed.) If the spill is large and can't be contained with two spill kits, call for additional help. + Immediately post a hazardous drug precaution sign (as shown below others of the presence of a hazardous drug spill and to limit access.+ Obtain and open a spill kit (as shown below’ + Put on gloves (inner and outer), a disposable gown, shoe covers, a face shield, goggles, and a respirator mask that's appropriate for the spilled agent.4] The Use of face shields with goggles is recommended because they offer added skin and eye protection. Don't use eyeglasses or safety glasses with side Shields because they don‘ offer adequate protection from splashes. Put on a chemical cartridge-type respirator with a full facepiece for a large spill 2/3+ Choose the appropriate items in the spill kit to contain the spill.21|3) Spills on hard surfaces + Pick up any broken glass fragments with the disposable scoop (as shown below) or by hand wearina heavy-duty tity gloves Place the fragments in 2 puncture-proof container.’ + Place an absorbent spill pad or absorbent plastic-backed sheet over the spill to pe up ligud. Use a damp disposable towel to wipe up ponder or Spills on soft surfaces + Pick up any broken glass fragments with the disposable scoop or by hand wearing heavy. duty utity loves Place the fragments in a puncture: proot container: 2/134] + Use an absorbent powder on the spill following the manufacturer's instructions. Don't use absorbent towels.« After the initial cleanup and containment, contact appropriately trained environmental services staff members to vacuum the area to remove the powder using a vacuum with a high: igency ‘particulate air (HEPA) filter reserved for hazardous drug cleanup.2| + Ensure that the soft surface is cleaned as directed by your facility!) Spills in a biological safety cabinet (BSC) * Remove any broken glass fragments by hand wearing heavy-duty utility gloves. Place the fragments in a puncture-proof container. Be careful not to damage the fixed-glove assembly in the isolator. 2/3] Clean up a liquid spill with absorbent spill pads. For a powder or solid spill, use posable towel. Include the drain spillage trough in washing + Thoroughly clean and decontaminate the involved area using a cleaning agent designed to remove chemicals from stainless steel. Refer to the SDS for the cleaning agent, as needed,21/4l If the HEPA filter has been contaminated by the spill, seal the op: BSC with plastic sheeting and label it as contaminated equipment. Schedule a BSC service technician to change the HEPA filter/4l Ensure that the BSC isn't used before the filter has been changed.21/4] Completing the procedure + Place the puncture-proof container holding the glass fragments and all other contaminated materials into a large, heavy-duty, hazardous waste-labeled, sealable, disposable bag. Then seal the bag. Place the sealed bag inside another properly labeled hazardous waste bag and leave the outer bag open + Rinse the contaminated area with water and then clean it with facility-approved deactivating and decontaminating agents following the manufacturers’ instructions for use, Rinse the contaminated area with water several more times. Place all materials used for cleanup and containment in disposable hazardous waste bags. 23] Seal the hazardous waste bags an final disposal as hazardous waste. \d put them in the appropriate container for Carefully remove all personal protective equipment while continuing to wear your inner gloves. Consider all personal protective equipment worn during hazardous drug spill cleanup to be-a east minimally contaminated with trace amounts of hazardous material.21[31|81 Put all disposable personal protective equipment in an appropriately labeled 2 hazardous waste disposable bag. Then seal the bag. Remove your inner gloves* Contain your inner gloves ina smal, sealable plastic bag Then place that bag in the final container to dispose of as hazardous waste.' * Dispose of personal protective equipment in the final hazardous waste contai trace- or bulk-contaminated waste, as determined by your + After the intial cleanup, contact your Facity's environmental services department to reclean the area,2//3] + Report and document the hazardous drug spill 4l I Special Considerations * When cleaning hazardous drug spills, move from the area of lowest contamination to the area of highest contamination. 2/3] * Before use, inspect your gloves for defects, such as hole: gloves that are permeation-resistant to hazardous agent: tears. Use only + If you have experienced direct skin or eye contact with a hazardous drug during a spill, immediately remove any contaminated clothing and wash the affected skin with soap and water or floed the affected eye with sotonic eyewash for at least 15 minutes, Then seek medical attention. + Send any nonemployee who has been exposed to a hazardous drug spill to your facility's emergency department for treatment or as directed by your facility. Then fill out your facility's incident or exposure form @ Complications Complications of Fayrous drug spill management may include exposure to the hazardous drug. I Documentation Documentation associated with hazardous drug spill management includes: + name of the hazardous drug * approximate volume of drug spilled + objective description of how the spill occurred + actions taken to manage the spill * procedure that was followed + names of health care facility personnel, patients, and anyone else who was exposed to the drug spill + names of facility personnel notified of the spill and the departments in which they work. @ Related Procedures+ Hazardous drug preparation and handling * Personal protective equipment (PPE), putting on * Personal protective equipment (PPE), putting on, ambulatory care + Personal protective equipment (PPE), putting_on, home care Ill References (Baling System for the Hierarchy of Evidence for Intervention/Treatment Questions) 1. National Institute for Occupational Safety and Health (NIOSH). (2004). MIOSH alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings. Retrieved January 2023 from hhttps://www,cde, gov/niosh/docs/2004-165/pdfs/2004-165,paf (Level VII) 2. Power, L. A., & Coyne, J, W. (2018). ASHP guidelines on handling hazardous drugs. American Journal of Health-System Pharmacy, 75(24), 1996-2031. Retrieved January 2023 from https://www.ashp.org/-/media/assets/policy- guidelines/docs/quidelines/handling-hazardous-drugs.ashx (Level VII) Abstract | Complete Reference | Ovid Full Text 3. Occupational Safety and Health Administration. (n.d.). Controlling occupational exposure to hazardous drugs. Retrieved January 2023 from hhttps://www.osha.gov/hazardous-drugs/controlling-occex (Level VII) 4, Olsen, M. M,, et al. (Eds.). (2019). Chemotherapy and immunotherapy guidelines and recommendations for practice. Oncology Nursing Society. 5, United States Pharmacopeial Convention (USP). (2016, revised 2020), USP general chapter <800>: Hazardous drugs—Handling in healthcare settings. Retrieved January 2023 from https://www.usp.org/compounding/general- chapter-hazardous-drugs-handling-healthcare (Level VII) 6. Lamerie, T. Q,, et al. (2013). Evaluation of decontamination efficacy of cleaning solutions on stainless steel and glass surfaces contaminated by 10 antineoplastic agents. Annals of Occupational Hygiene, 57(4), 456-469. Retrieved January 2023 from https://doi.org/10.1093/annhya/mes087 (Level v1) 7. Connor, T. H., et al. (2008). Personal protective equipment for health care workers who work with hazardous drugs. Workplace Solutions. Retrieved January 2023 from https://www.cdc. gov/niosh/docs/wp-solutions/2009- 106/pdfs/2009-106.pdf (Level 1) 8. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16), 1-45. Retrieved January 2023 from https://www.cdc. gov/mmur/paf/rr/r5116.pdf (Level II) 9. The Joint Commission. (2023). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. (Level VII) 10. World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care.Retrieved January 2023 from https://apps.who. int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf? sequence=1 (Level IV) 11. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Infection control. 42 CFR, § 482.42. 12. Accreditation Commission for Health Care. (2021), Standard 07.01.21, Healthcare Facilities Accreditation Program: Accreditation requirements for acute care hospitals. (Level VII) 13. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. MIAHO® accreditation requirements, interpretive guidelines and surveyor guidance — revision 20-1. (Level VII) 14. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Medical record services. 42 CER. § 482.24(b). 15. Accreditation Commission for Health Care. (2021). Standard 10.00.03. Healthcare Facilities Accreditation Program: Accreditation requirements for acute care hospitals. (Level VII) 16. The Joint Commission. (2023). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. (Level VII) 17. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. MIAHO® accreditation requirements, interpretive guidelines and surveyor guidance — revision 20-1. (Level VI) Il Additional References + American Society of Health-System Pharmacists. (2015). Discussion guide: An update on protecting health care practitioners and patients from hazardous drugs. Retrieved January 2023 from https: //www.ashpadvantagemedia.com/downloads/2015-USP800-discussion- guide. pdf (Level VII) * Bernabeu-Martinez, M. A., et al. (2018). Guidelines for safe handling of hazardous drugs: A systematic review. PLoS One, 13(5), Article e0197172. Retrieved January 2023 from https://doi.org/10,1371/journal.pone.0197172 * Oncology Nursing Society. (2018). Toolkit for safe handling of hazardous drugs for nurses in oncology. Retrieved January 2023 from https://www.ons.org/sites/default/files/2018- O6/ONS Safe Handling Toolkit O.pdf Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions The following leveling system is from Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice (2" ed.) by Bernadette Mazurek Melnyk and Ellen Fineout-Overholt. Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs)Level II: Evidence obtained from well-designed RCTs Level III: Evidence obtained from well-designed controlled trials without randomization Level IV: Evidence from well-designed case-control and cohort studies Level V: Evidence from systematic reviews of descriptive and qualitative studies Level VI: Evidence from single descriptive or qualitative studies Level VII: Evidence from the opinion of authorities and/or reports of expert committees Modified from Guyatt, G. & Rennie, D. (2002). Users’ Guides to the Medical Literature. Chicago, IL: American Medical Association; Harris, R.P, Hefland, M,, Woolf, S.H., Loh; K.N, ‘Mulrow, C.D, Teutsch, 5.M, et al. (2001). Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. American Journal of Preventive Medicine, 20, 21-35.