Adherence to safe handling guidelines by health care workers who administer antineoplastic drugs

Assessing floor contamination by antineoplastic agents in a Japanese medical institution specializing in cancer treatment

INTRODUCTION

This study investigated the extent of contamination with antineoplastic agents on floor surfaces of the ward and the outpatient chemotherapy center of a Japanese cancer center to evaluate healthcare workers' risk of occupational exposure to antineoplastic agents outside of the designated drug preparation areas.

METHODS

In this study conducted at Aichi Cancer Center, the amount of fluorouracil detected on various floor surfaces was measured using liquid chromatography-tandem quadrupole mass spectrometry. Areas around the toilets were cleaned with a surfactant two or three times a day, whereas other floor surfaces were cleaned only with dry and wet mops.

RESULTS

Fluorouracil was detected on all surveyed floor surfaces, with particularly high amounts detected around the toilet areas in the ward. Additionally, areas with more human traffic tended to have higher fluorouracil contamination.

CONCLUSIONS

This survey suggested that antineoplastic agent contamination occurring through patient excretions might spread throughout the hospital with human traffic. Therefore, controlling the spread of antineoplastic agent contamination in hospitals should include the review of measures to mitigate contamination around toilets and to implement effective cleaning methods for floor surfaces.

Characterization of education, technical practices and attitudes of Portuguese pharmacy technicians towards manipulation of cytotoxic drugs

Pharmacy professionals that manipulate cytotoxic drugs need to undergo educational programs, adopt the most convenient practices, and use appropriate equipment to avoid, as far as possible, occupational exposure to cytotoxic drugs. The main goal of this work is to characterize the education, technical practices, and attitudes towards cytotoxic drugs, of Portuguese pharmacy technicians. A questionnaire comprising eleven questions deemed pertinent was elaborated and subsequently validated by a pilot test. The anonymous, web-based survey was conducted between December 2022 and January 2023, by graduated pharmacy technicians that had manipulated cytotoxic drugs between 2017 and 2022. A total of 77 pharmacy technicians responded to the survey. Although sixty-six pharmacy technicians (86%) had been trained before beginning to manipulate cytotoxic drugs, the promotion of regular post-admission training by the institutions is sparse - only assumed by 53% of the pharmacy technicians (n = 41). All participants reported using gloves and gown during manipulation and the use of double gloves was common (99%; n = 76). Compliances with the recommended limit time for uninterrupted manipulation activity (82%; n = 63) and systematic double-checking (86%; n = 66) were high, but the regular use of sterile gauze around syringe connection sites 58% (n = 45), was less frequent. None of the surveyed pharmacy technicians used closed-system transfer devices (CSTD) and 41 (53%) of those who used spikes did not thoughtfully use these devices. The implementation of regular training programs in manipulating cytotoxic drugs should be fostered, to promote the more judicious use of engineering controls and transversal adoption of the safest technical practices.

Exposure Assessment and Monitoring of Antiblastic Drugs Preparation in Health Care Settings: A Systematic Review

Several antiblastic drugs (ADs) are classified as carcinogenic, mutagenic, and/or toxic for reproduction. Despite established guidelines and safe handling technologies, ADs contamination of the work environments could occur in healthcare settings, leading to potential exposure of healthcare staff. This systematic review aims to investigate the main techniques and practices for assessing ADs occupational exposure in healthcare settings. The reviewed studies unveil that workplace contamination by ADs appears to be a still-topical problem in healthcare settings. These issues are linked to difficulties in guaranteeing: (i) the adherence to standardized protocols when dealing with ADs, (ii) the effective use of personal protective equipment by operators involved in the administration or management of ADs, (iii) a comprehensive training of the healthcare personnel, and (iv) a thorough health surveillance of exposed workers. A "multi-parametric" approach emerges as a desirable strategy for exposure assessment. In parallel, exposure assessment should coincide with the introduction of novel technologies aimed at minimizing exposure (i.e., risk management). Assessment must consider various departments and health operators susceptible to ADs contamination, with a focus extended beyond worst-case scenarios, also considering activities like surface cleaning and logistical tasks related to ADs management. A comprehensive approach in ADs risk assessment enables the evaluation of distinct substance behaviors and subsequent exposure routes, affording a more holistic understanding of potential risks.

Psychometric properties of the Chinese version of the oncology nurses health behaviors determinants scale: a cross-sectional study

Objective

To test the validity and reliability of the Oncology Nurses Health Behaviors Determinants Scale (HBDS-ON) in oncology nurses, the Chinese version was developed.

Methods

The Brislin double translation-back translation approach was employed to forward translation, back translation, synthesis, cross-cultural adaptation, and pre-survey, resulting in the first Chinese version of the Oncology Nurses Health Behaviors Determinants Scale (HBDS-ON). A convenience sample technique was used to select 350 study participants in Liaoning, Shandong, and Jiangsu, China, who satisfied the inclusion and exclusion criteria, to assess the validity and reliability of the scale.

Results

The Chinese version of the Oncology Nurses Health Behaviors Determinants Scale (HBDS-ON) had six subscales (perceived threat, perceived benefits, perceived barriers, self-efficacy, cues to action, and personal protective equipment availability and accessibility), including 29 items. The average scale level was 0.931, and the content validity level of the items varied from 0.857 to 1.000. Each Cronbach's α coefficient had an acceptable internal consistency reliability range of 0.806 to 0.902. X2/df = 1.667, RMSEA = 0.044, RMR = 0.018, CFI = 0.959, NFI = 0.905, TLI = 0.954, and IFI = 0.960 were the model fit outcomes in the validation factor analysis. All of the model fit markers fell within reasonable bounds.

Conclusion

The Chinese version of the Oncology Nurses Health Behaviors Determinants Scale (HBDS-ON) has good reliability and validity and can be used as a tool to assess the influencing factors of chemotherapy exposure for oncology nurses in China.

Impact of lack of knowledge on risk perception and protective practices of home nurses handling antineoplastic drugs

Introduction: Health care workers handling antineoplastic drugs (ADs) are at risk of carcinogenic, mutagenic and reproductive toxic risks (CMR). The aim of this study was to assess the impact of the lack of knowledge (K) on risk perception (P) and on protective practices (PP) related to the handling of home-based chemotherapy (HC) by home nurses. Methods: This study was conducted in Normandy among home nurses. A questionnaire was developed to explore the K, P and PP related to handling ADs by home nurses working with four different providers from two hospitals. Results: Among the 28 home nurses included, 25.93% had received initial training on the specific treatment of ADs, 48.15% scored below average on risk management K, 52.00% scored below average on personal PP. Conclusion: This study reveals the importance of adapted and regular training on the handling of ADs. It will help develop a climate of safety and reinforce adherence to wearing personal protective equipment to protect health care workers from contamination.

Improvements in practising nurses' knowledge, skills, self-efficacy, confidence, and satisfaction after a simulated clinical experience of caring for a patient undergoing chemotherapy: a quasi-experimental study

BACKGROUND

The beneficial effect of simulation experience on nursing students is well established in the literature. However, an accurate simulation modality to help professional nurses enhance their clinical competence and expertise remains unexplored. The current study evaluated and contrasted the impact of two simulation modalities on nurses' knowledge, abilities, self-efficacy, confidence, and satisfaction following a simulated clinical experience caring for chemotherapy patients.

METHODS

A quasi-experimental research design was employed in this study. The participants were divided into group A, comprising nurses exposed to the high-fidelity simulation, and group B, comprising nurses exposed to the virtual simulation.

RESULTS

The study found that nurses exposed to high-fidelity simulation and virtual simulation gained a high standard of knowledge and skills. The nurses' post-test and post-objective structured clinical examination (OSCE) scores drastically increased after simulation exposure compared to their pre-test and pre-OSCE scores. For the group exposed to high-fidelity simulation, the mean differences were - 19.65 (pre- and post-test) and 23.85 (pre- and post-OSCE), while for the group exposed to virtual simulation, the mean differences were - 22.42 (pre- and post-test) and 20.63 (pre- and post-OSCE). All p-values indicated significant differences < 0.001. Moreover, both groups exhibited high self-efficacy, confidence, and satisfaction levels after the simulation experience. The outcomes of both simulation modalities regarding self-efficacy, confidence, and satisfaction levels indicate no significant difference, as supported by p-values of > 0.05.

CONCLUSION

High-fidelity simulation and virtual simulation training effectively and efficiently advance nurses' professional competence. The nurses exposed to high-fidelity simulation and virtual simulation gained high levels of knowledge and skills. Additionally, it increased their sense of happiness, self-worth, and self-efficacy. The simulation approach will be a potent instrument for improving nurses' competency and fully developing their sense of expertise. Therefore, developing policies adopting simulation as part of their professional development will ensure patient safety and improve health outcomes.

Perception, knowledge, practices and training regarding the risk of exposure to antineoplastic drugs in three French compounding units

INTRODUCTION

Healthcare workers are exposed to hazardous drugs such as antineoplastic drugs, which have potential carcinogenic, mutagenic and teratogenic effects. Protective measures must be taken after appropriate staff training to handle antineoplastic drugs in a safe way. The objective was to assess perception, knowledge, practices and training regarding the risk of exposure of healthcare workers in three French compounding units.

METHODS

This descriptive study was based on a questionnaire made of 33 questions divided into five sections related to the handling of antineoplastic drugs: perception of the risks, knowledge of the risks, protection practices, specific training and general questions.

RESULTS

Among the 39 participants, over half considered their overall risk of exposure to antineoplastic drugs not being very low. Inhalation was known to 69.2% of them as possible route of contamination. The breakroom was identified by 28.9% of them as a place of contamination. The procedure in case of accidental exposure to antineoplastic drugs was known by 69.2%, but only half could explain it. Only 38.5% said they changed their gloves every 30 min as recommended. Barely half said that they had been trained specifically for the handling of antineoplastic drugs during an initial training. Over half wished to be informed, trained and aware of the proper handling of antineoplastic drugs.

CONCLUSION

Although some of these results are encouraging, specifically when compared to the other settings where antineoplastic drugs are handled, there is still room for improvement. Efforts to build an adapted and impactful training program must pursue.

CLINICAL TRIAL REGISTRATION

Study CONTACT, ref. 19-504.

Knowledge and practices about safe handling regarding the risk of exposure to antineoplastic drugs for caregivers in compounding units and in operating rooms performing HIPEC/PIPAC

INTRODUCTION

Ever since the late 1970s, occupational exposure associated with the handling of antineoplastic drugs (ADs) in the healthcare environment has been highlighted and demonstrated. Contamination was detected in both operating rooms (OR) and compounding units (CU), where healthcare workers handle and are exposed to ADs in different ways. In the OR, the risk of exposure is higher and the staff receives less training in handling ADs than in the CU. This study aimed to assess and compare knowledge and practices about the safe handling of ADs by caregivers working in these two locations, namely the CU and OR.

METHODS

Two questionnaires (one each for the OR and CU) were created by two investigator pharmacists and were completed during a personal interview of 20 min. The questions were related to the following topics: training, knowledge about occupational exposure and questions related to protective practices. A scoring system was implemented to assess the knowledge and practices of each participant.

RESULTS

In total, 38 caregivers working in the OR and 39 in the CU were included in our study. Significantly more CU staff had specific initial training (p < 0.001) and ongoing training (p < 0.001) in handling ADs. Concerning the knowledge score, OR caregivers had a significantly lower median score for contamination routes (p < 0.001), contamination surfaces (p < 0.001), existing procedures (p < 0.001) and total knowledge (p < 0.001) than CU caregivers. Concerning protective handling practices of ADs, the two locations had nonsignificantly different median scores (p = 0.892).

CONCLUSION

This study suggests that there is still room for improvement in terms of knowledge and protection practices when handling ADs. An appropriate and tailored training program should be developed and provided to all caregivers who handle or come in contact with ADs.Clinical trial registrationStudy CONTACT, ref. 19-504.

Biosafety and biohazard considerations of HSV-1-based oncolytic viral immunotherapy

Oncolytic viral immunotherapies are agents which can directly kill tumor cells and activate an immune response. Oncolytic viruses (OVs) range from native/unmodified viruses to genetically modified, attenuated viruses with the capacity to preferentially replicate in and kill tumors, leaving normal tissue unharmed. Talimogene laherparepvec (T-VEC) is the only OV approved for patient use in the United States; however, during the last 20 years, there have been a substantial number of clinical trials using OV immunotherapies across a broad range of cancers. Like T-VEC, many OV immunotherapies in clinical development are based on the herpes simplex virus type 1 (HSV-1), with genetic modifications for tumor selectivity, safety, and immunogenicity. Despite these modifications, HSV-1 OV immunotherapies are often treated with the same biosafety guidelines as the wild-type virus, potentially leading to reduced patient access and logistical hurdles for treatment centers, including community treatment centers and small group or private practices, and healthcare workers. Despite the lack of real-world evidence documenting possible transmission to close contacts, and in the setting of shedding and biodistribution analyses for T-VEC demonstrating limited infectivity and low risk of spread to healthcare workers, barriers to treatment with OV immunotherapies remain. With comprehensive information and educational programs, our hope is that updated biosafety guidance on OV immunotherapies will reduce logistical hurdles to ensure that patients have access to these innovative and potentially life-saving medicines across treatment settings. This work reviews a comprehensive collection of data in conjunction with the opinions of the authors based on their clinical experience to provide the suggested framework and key considerations for implementing biosafety protocols for OV immunotherapies, namely T-VEC, the only approved agent to date.

Factors associated with internal contamination of nurses by antineoplastic drugs based on biomonitoring data from a previous study

Internal contamination of healthcare professionals by antineoplastic drugs (ADs) remains a current occupational health issue, particularly because these compounds are classified as dangerous to handle by the NIOSH. In order to improve preventive actions, a study of the factors associated with this internal contamination was conducted among nursing staff in health care institutions. This study is a statistical analysis of metadata from a cross-sectional observational study conducted among nurses in two French hospitals. The internal contamination of each nurse was assessed in a previous study and was defined by whether or not at least one studied AD was detected in at least one urine sample. Three urine samples and a self-questionnaire were collected for each participant. Analysis of five ADs (cyclophosphamide, ifosfamide, metabolite of 5-fluorouracil, methotrexate, doxorubicin) were performed by liquid chromatography coupled to tandem mass spectrometry. A multivariate stepwise descending regression model was used to determine factors associated with internal contamination by coupling data from a self-questionnaire with internal contamination data. A total of 74 nurses participated to the study and 68 were included for this work: 39 nurses with and 29 without detectable internal ADs contamination. Two protective factors of internal contamination could be identified: a high "glove wearing score" (OR: 0.957; 95%CI: 0.93-0.98; p < 0.01) and a high "total number of years handling ADs and/or caring for patients treated with ADs" (OR: 0.797; 95%CI: 0.67-0.91; p < 0.01). In addition, three factors contributing to internal contamination were identified, namely "feeling sufficiently informed about tasks exposing to ADs" (OR: 9.585; 95%CI: 2.23-57.05; p < 0.01), "disposal of a waste bin containing equipment used for administration of the ADs studied" (OR: 8.04; 95%CI: 1.87-46.08; p < 0.01) and "changing sheets and/or making bed of a patient treated by one of the ADs studied" (OR: 10.479; 95%CI: 1.43-133.30; p < 0.05). Thus, the use of gloves when handling ADs directly or indirectly and the contaminating nature of certain tasks should be taken into account when (1) implementing preventive actions in health care services and (2) training and informing exposed staff. Further studies would be desirable to confirm these results and extend them to other professional categories.

The meta-analysis of sister chromatid exchange as a biomarker in healthcare workers with occupational exposure to antineoplastic drugs

BACKGROUND

Sister chromatid exchange (SCE) can be used to identify early occupational health status in health care workers. Our aim is to comprehensively assess the relationship between long-term exposure to antineoplastic drugs (ADs) and SCE in health care workers via meta-analysis.

METHODS

Five databases were systematically searched for relevant articles published from inception to November 30, 2022. Literature data are expressed as mean difference and 95% confidence intervals (CI) or relative risk and 95% CI. For I2 > 50% trials, random effect model is used for statistical analysis, otherwise fixed effect model is used. This review was registered in the International Prospective Register of Systematic Reviews (identifier CRD42023399914).

RESULTS

Fourteen studies were included in this study. Results showed the level of SCE in healthcare workers exposed to ADs was significantly higher than in controls. The mean difference of the SCE trial was 0.53 (95% CI: 0.10-0.95, P = .01) under a random-effects model.

CONCLUSIONS

The findings suggested a significant correlation between occupational exposure to ADs in health care workers and SCE, requiring the attention of health care workers in general.

The Factors That Influence Chemotherapy Exposure Among Nurses: An Integrative Review

BACKGROUND

Exposure to chemotherapy is an occupational hazard predisposing nurses to severe health effects. The purpose of this integrative review was to identify the recent literature describing the risk factors for occupational exposure to chemotherapy among nurses.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was employed to conduct the review. The databases searched were Scopus, PubMed, and CINAHL using the search terms "chemotherapy," "drugs," "exposure," and "nurses." Included articles were published between January 2010 and February 2022, published in peer-reviewed journals for research conducted in the United States, and written in English language. Excluded articles were studies that did not involve nurses in their samples. Review articles, books, theses, and dissertations were excluded as well. The Johns Hopkins Nursing Evidence-Based Practice Model was used to assess the level of evidence from the reviewed studies.

FINDINGS

Fourteen studies were included in this review. Ten studies were rated on Evidence Level III, two on Evidence Level II, one on Evidence Level I, and one on Evidence Level V. The main risk factors for occupational exposure were nurses' knowledge of chemotherapy handling guidelines, nurses' adherence to using the personal protective equipment, nurses' health beliefs regarding chemotherapy exposure, and workplace-related factors such as workload and managerial support.

CONCLUSION

Addressing the identified risk factors would protect nurses from chemotherapy exposure. More research on nurses' health beliefs regarding chemotherapy exposure and the cues to adhere to chemotherapy handling guidelines in the work environment is needed.

Onco-pharmacist led evaluation of knowledge, attitude & practice (KAP) of safe handling cytotoxic drugs among health care professional's (HCP's) in tertiary care hospital: A hospital based interventional Study

BACKGROUND

Cytotoxic drugs (CDs) are hazardous in nature. But it is necessary for the treatment in cancer patients. The healthcare professionals (HCPs) act as a facilitator through which the manufactured CDs reach the patient. However, safe handling of CDs becomes a primary concern not only for the recipients but also for the HCPs.

METHODS

On Ethics committee approval, a prospective- interventional study was conducted among HCPs who are involved in handling of CDs in Oncology department of tertiary care hospital. The participants were screened for their eligibility criteria & 73 HCPs were recruited. The initial data was collected from the HCPs through interview & questionnaires. Later the participants were trained by oncology-pharmacist (7-8 months) for safe handling of CDs. After the training the participants were tested again through interview & questionnaires.

RESULTS

73 participants, (75%) nurses & (25%) physicians were included in the study. Among these participants, only 32.87% underwent training on reconstitution whereas 67.12% of the participants didn't undergo any training. The increase in mean score of KAP after the training was observed to be 3.44 ± 4.32, 1.23 ± 1.51 and 1.3 ± 1.01 respectively.

CONCLUSION

The study concludes that mandatory requirement of training for HCPs using SOP's by qualified oncology-pharmacist to minimize the hazardous effects of CDs. It also highlights the improvisation techniques for handling of CDs will enhance the safety profile of HCPs & the patients, which helps in refining the quality of pharmaceutical and health care services provided in the cancer care settings.

Effects of safe handling education on cognition, compliance and stress handling of antineoplastic drugs in clinical nurses

To evaluate the effects of safe-handling education on the cognition, practice and stress handling of antineoplastic drugs in clinical nurses. This study uses a quasi-experimental, non-equivalent control group pre-test and post-test design. The experimental and control groups had 30 nurses each, who handled antineoplastic drugs from three institutions. This study examines the safe handling of antineoplastic drugs six times, for two hours each over two weeks. To verify the homogeneity of the experimental and control groups and the effectiveness of safe-handling education about antineoplastic drugs, a chi-square test and independent samples t-test were performed. The results were statistically significant in both groups (cognition [t = 6.84, p < 0.001], practice [t = 5.86, p < 0.001], and the stress of handling antineoplastic drugs [t = 5.15, p < 0.001]). Education on ways to safely handle antineoplastic drugs improves cognition, practice and stress handling of these drugs; moreover, proper education minimizes exposure.

The Development and the Content Validation of the Oncology Nurses Health Behaviors Determinants Scale

OBJECTIVE

Chemotherapy exposure is an occupational hazard affecting oncology nurses. The adherence to chemotherapy-handling guidelines is essential to prevent exposure to these drugs. Oncology nurses' health beliefs and the cues in the environment are factors influencing the adherence to these guidelines. There is a lack of instruments with evidence of reliability and validity in the literature that address these factors. The purpose of this article is to describe the development and the content validation of the Oncology Nurses' Health Behaviors' Determinants Scale relative to adherence to chemotherapy-handling guidelines.

DATA SOURCES

This study was conducted in two phases: item development, then, content validation using a quantitative cross-sectional design with an exploratory part. A convenience sample of seven experts reviewed the items for relevance, wording, and comprehensiveness. The initial version of the scale that was sent to experts contained 65 items.

CONCLUSION

The Oncology Nurses' Health Behaviors Determinants' Scale has evidence of content validity. Twenty-eight items in the final instrument met the required level of content validity (item content validity index = 0.83). Four additional items were retained due to conceptual significance. Two items were added. The final scale contains 34 items with a total scale content validity index = 0.90.

IMPLICATIONS FOR NURSING PRACTICE

This newly developed instrument could be used to assess the factors that influence chemotherapy exposure among oncology nurses in the light of the Health Belief Model. Following that, interventions can be developed and implemented to foster greater adherence to safe chemotherapy handling guidelines.

Application of an Environmental Monitoring to Assess the Practices and Control the Risk of Occupational Exposure to Cyclophosphamide in Two Sites of a French Comprehensive Cancer Center

OBJECTIVES

The risk of chronic exposure to antineoplastic agents in hospitals, mainly by skin contact with contaminated surfaces, is well established. The aim of this study was to assess indirectly the risk of occupational exposure to antineoplastics drugs at two hospitals by using an environmental monitoring, and to suggest ways of improving the exposure to healthcare workers.

METHODS

An observational study of care practices on both sites was carried out. A wipe sampling campaign was then designed to study environmental contamination throughout the chemotherapy process: receipt, storage, compounding, transport, administration, and elimination areas. Samples were analyzed by a validated LC-MS/MS method allowing trace quantification of cyclophosphamide. A guidance 'safe value' of 0.10 ng/cm2 was considered.

RESULTS

A total of 293 samples were analyzed, of which 58% were found to be positive. In the compounding units, the drug vials were contaminated before [range = (non-quantifiable [NQ]-0.71) ng/cm2] and after cleaning procedure [(NQ-0.62) ng/cm2], particularly when the flip-off lid was removed during cleaning. The contamination found on manual preparations was operator-dependent: [non-detectable (ND)-3.51] ng/cm2 on infusion bag surfaces; (780.61-24 698.98) ng/cm2 on medication ports. In the case of automated preparations, the average contamination was higher on infusion bag surfaces [(2.43-36.86) ng/cm2] and lower on medication ports [(0.43-7.65) ng/cm2] than manual preparations. Contamination of the analytical control area was also highlighted. In the daily care unit, the contamination was located near the infusion area (armchairs, infusion stands, floor, and patient toilets), and varied somewhat between the two sites, especially on the floor with (0.46-27.32) compared to (ND-0.18) ng/cm2. We did not detect contamination on the transport boxes, on the door handles or in the disposal areas.

CONCLUSIONS

The variability of contamination observed between the two sites can be explained in part by the difference in routine practices, especially training of the staff, and cleaning procedures. Findings were communicated to healthcare workers, and news interventions were implemented based on wipe sampling results. This study demonstrated a method for routine environmental monitoring and worker education as a strategy to reduce occupational exposure.

3D Virtual Reality Smartphone Training for Chemotherapy Drug Administration by Non-oncology Nurses: A Randomized Controlled Trial

Chemotherapy agents are cytotoxic materials. Thus, there is a need for the operators to be familiar with the knowledge and procedures before operation. We conducted a randomized controlled trial investigating the effectiveness of an immersive 3D VR teaching of chemotherapy administration operated in a smartphone coupled with a visual and audio device. We adopted a two-arm single-blind design and recruited 83 nurses, and they were randomized using a cluster approach. The VR group learned chemotherapy administration through VR, while the controlled group learned through document reading. The Knowledge and Attitude of Chemotherapy Administration (KACA) was administrated before the intervention, while the Objective Structured Clinical Examination (OSCE) and the Checklist of Action Accomplishment (CAA) were administrated one month after the intervention. The VR group scored higher than the controlled group in the CAA (95.69 ± 5.37 vs. 91.98 ± 9.31, p = 0.02) and the OSCE (73.07 ± 10.99 vs. 67.44 ±10.65, p = 0.02). Stepwise regression demonstrated that service years, an education level of undergraduate or above, and VR exposure contributed positively to the OSCE score (adjusted R² = 0.194, p = 0.028). The use of VR improves the learning efficacy of chemotherapy administration in non-oncology nurses. We recommend using VR as a teaching tool for chemotherapy administration and other chemotherapy-related skills in a VR learning group with senior nurses with higher education levels as advisors. The study provides an approach to online training, especially during the COVID-19 pandemic. (CONSORT 2010 guidelines, registry number: NCT 04840732).

Perception, knowledge, and handling practice regarding the risk of exposure to antineoplastic drugs in oncology day hospitalization units and compounding unit staff

BACKGROUND

Antineoplastic drug exposure is a major problem in regard to caregivers' health. The aim of the present study was to assess the perception, knowledge, and handling practices of all occupation level categories of two oncology day hospitalization units and two compounding units regarding the risk of exposure to antineoplastic drugs.

METHODS

This descriptive study, performed through face-to-face interviews, concurrently assessed the perception, knowledge, and handling practices of antineoplastic drugs in five different job categories in four different settings. This work was part of a larger comprehensive project examining surface and blood contamination. Different scores were assigned to evaluate responses to a questionnaire about the perception, knowledge, and handling practices of healthcare workers, a risk global score including a risk perception score, and education/knowledge and handling practices scores.

RESULTS

In the survey, continuous training was associated with the global risk score (p = 0.03), particularly with the handling practices risk score (p = 0.01). Job category was also significantly associated with the global risk score (p < 0.001), particularly with the handling practices risk score (p < 0.001) and the education/knowledge score (p < 0.001). Pharmacy technicians had the highest score regarding risk perception (71.4%), indicating a higher perception of risk, and had a lower score regarding handling practices (25.0%) as well as a lower score (15.7%) regarding risk knowledge. Nurses and physicians had a high score (50%) regarding the risk of handling practices and a score of 57.1% regarding risk perception, indicating an increased perception of safety. Auxiliary caregivers had the highest global score (43.5%) and a score of 30.0% regarding handling practices.

CONCLUSIONS

This study identified significant differences among healthcare workers depending on job categories in the antineoplastic drug handling practices and in the knowledge of the risks associated with occupational exposure to antineoplastic drugs. These differences were particularly important between trained and untrained participants, revealing the importance of implementing a continuous training program.

Closed safety system for administration (CSSA): proposal for a new cytotoxic chemotherapy acronym

Exposure to cytotoxic chemotherapy can result in acute and chronic conditions including nausea, headaches, rashes, miscarriages, infertility and genetic aberrations. Surface contamination can occur during drug administration, and can subsequently spread throughout the healthcare environment. Dermal contact with contaminated surfaces can lead to drug absorption. Closed system drug-transfer devices (CSTDs) were initially developed to protect pharmacists during compounding. Components include a vial adapter to prevent pressurisation leakage and a syringe connector for transferring the drug to the intravenous infusion bag. Membrane-based CSTDs require a Luer adapter for drug administration whereas Luer system-based products do not. Most European nurses are familiar with needleless connectors. Unfortunately, these devices do not provide protection from chemotherapy exposure. To decrease confusion, CytoPrevent, a multi-national, primarily European organisation has proposed the term 'closed safety system for administration' (CSSA) for Luer based CSTDs. Along with education, the new term can help promote safety for nurses administering cytotoxic chemotherapy.

Perception, knowledge and protective practices for surgical staff handling antineoplastic drugs during HIPEC and PIPAC

Objectives

Two surgical techniques used for peritoneal metastasis involve a risk of exposure to antineoplastic drugs (ADs): hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). The objective of this study was to assess the differences in perception, training, and knowledge of the risks as well as in the protection practices and occupational exposures of all worker categories.

Methods

This descriptive study, led in two hospitals from two distant French regions, was performed through a face-to-face interview and assessed the perception, knowledge and handling practices of ADs by a questionnaire consisting of 52 questions.

Results

Fifty-one professionals participated in this survey. A total of 29.4% (n=15) professionals were afraid to handle ADs. Very few workers have been trained on handling ADs during initial training dedicated to all caregiver (5.9%; n=3). HIPEC is considered to involve a higher risk of exposure to ADs than PIPAC (81.6% (n=31) vs. 57.9% (n=22), respectively, p=0.022, agreement 65.8%). Protective equipment is considered to be less suitable for HIPEC than for PIPAC (29% (n=11) vs. 10.5% (n=4), respectively, p=0.016, agreement 81.6%). Concerning the potential AD contamination location, the participants identified a significant difference between these two practices. During HIPEC, 15.7% (n=6) of caregivers indicated that they had negative symptoms perceived in their practice vs. 2.6% (n=1) during PIPAC.

Conclusions

This study shows that perception, knowledge and protection practices are different between HIPEC and PIPAC. It also shows a difference between the worker categories. In view of the difficulties in making operating room staff available, the related training programmes must have an adapted format.

Health professionals’ practice to care cytotoxic drug handling and associated factors: The case of university of gondar specialized hospital

Background

Health care professionals are potential to be in contact with cytotoxic drugs during their daily work activ­ities. The study aimed to assess the practice of health professionals to care for cytotoxic drugs and associated factors in the University of Gondar Specialized Hospital.

Methods

Cross-sectional study design was employed. EPI Info 7 was used for data entry and then exported into SPSS 20 for statistical analysis. Frequencies and mean with standard deviation were computed. Logistic regression had been performed to find out associated factors. Crude’ and adjusted Odds’ ratio with 95% uncertainty interval was done. Variables with a p < 0.05 were declared as significant factors for practice of cytotoxic drug handling.

Results

The study used four-hundred and twelve health professionals took part in the study with 97.4% response rate. The mean age of study participants was 29.9 years ranging from 20–60 years and twenty (53.4%) participants were males. One hundred and fifty-five (37.6%) health professionals had good cytotoxic drug handling practice. Attending an average of 4–9 patients per day (AOR = 2.12, 95% CI: 1.05, 4.22), Medium work stress (AOR = 2.01, 95% CI: 1.04, 3.90), availability of cytotoxic drug handling manual (AOR = 2.51: 95% CI: 1.22, 5.12), and good knowledge (AOR = 4.09, 95% CI: 2.35, 7.11) were significantly associated with cytotoxic drug handling practice.

Conclusion

The practice of cytotoxic drug handling care was low. It demands the engagement of the health sector to avert such inadequate practice and has to focus on delivering knowledge and logistics for the practice of cytotoxic drug handling.

EQUIPAMENTOS DE PROTEÇÃO INDIVIDUAL NA ASSISTÊNCIA HOSPITALAR DE ENFERMAGEM: REVISÃO DE ESCOPO

RESUMO Objetivo: analisar a produção científica sobre o uso de equipamento de proteção individual pelos profissionais da enfermagem durante a assistência no âmbito hospitalar. Método: trata-se de uma revisão de escopo, baseada no Manual Institute Joanna Briggs de 2020 e norteado pelo PRISMA-PCR. Utilizou-se como base de dados PUBMED, EMBASE, CINAHL, LILACS, BDENF, SCOPUS e WEB of SCIENCE, sendo o período de busca escolhido nos últimos 20 anos. A coleta de dados ocorreu de setembro a outubro de 2021. Protocolo de estudo disponível em Framework: https://osf.io/7d8q9/files/. Foram incluídos estudos sobre o uso dos Equipamentos de Proteção Individual na assistência direta da equipe de enfermagem nos hospitais e excluídos aqueles que abordassem em outros cenários, revisões, teses, dissertações e estudos não disponíveis na íntegra. Resultados: a amostra foi composta por 26 documentos. O equipamento mais citado e com maior adesão nos estudos foram as luvas de procedimento, enquanto que o uso dos óculos foi o menor. Dos fatores que facilitam o uso dos EPIs pelos enfermeiros destacam-se as relações interpessoais, conhecimento, carga de trabalho, padronização das diretrizes e participação da equipe assistencial nas decisões gerenciais. Conclusão: a necessidade de educação dos profissionais utilizando como estratégia o conhecimento comportamental, a manutenção da comunicação nos setores para evitar a contaminação, a influência da carga de trabalho, a padronização das diretrizes são necessárias nos serviços de saúde hospitalar para aumentar o engajamento dos profissionais de saúde às práticas de biossegurança.

PERSONAL PROTECTIVE EQUIPMENT IN HOSPITAL NURSING CARE: A SCOPING REVIEW

ABSTRACT Objective: to analyze the scientific production on the use of Personal Protective Equipment by Nursing professionals during the care provided in the hospital environment. Method: this is a scoping review, based on the 2020 Joanna Briggs Institute Manual and guided by PRISMA-PCR. PUBMED, EMBASE, CINAHL, LILACS, BDENF, SCOPUS and WEB of SCIENCE were used as databases, choosing a search period corresponding to the last 20 years. Data collection took place from September to October 2021. The study protocol is available in the Open Science Framework: https://osf.io/7d8q9/files/. Studies on the use of Personal Protective Equipment in direct care provided by the Nursing team in hospitals were included; and those that addressed reviews, theses and dissertations in other settings were excluded, as well as studies not available in full. Results: the sample consisted of 26 documents. The items most cited and with the highest adherence in the studies were procedure gloves, while use of goggles was the least mentioned. The following stand out among the factors that facilitate PPE use by nurses: interpersonal relationships, knowledge, workload, standardization of guidelines, and participation of the care team in management decisions. Conclusion: the need to educate the professionals using behavioral knowledge as a strategy, as well as maintenance of communication in the sectors to avoid contamination, the influence of workload and the standardization of guidelines are necessary in the hospital health services to increase health professionals' engagement towards the biosafety practices.

Development and Proof of Concept of an Audit Toolkit for the Safe Handling of Cytotoxic Drugs in Low- and Middle-Income Countries

PURPOSE

Chemotherapies are considered high-risk drugs for patient and staff safety. Considering the rising burden of cancer and the increasing use of chemotherapy drugs in low- and middle-income countries (LMICs), promoting continuous improvements in the safety and quality of practices in these settings is essential. This paper describes the development and proof of concept of a toolkit to audit chemotherapy handling practices in the health care facilities of LMICs.

METHODS

A steering committee defined the audit method and the toolkit content. Several checklists were developed to facilitate the audit and data collection. Items included in checklists were derived from key reference works on safe handling. Different tools were validated using Delphi surveys and expert reviews. Audits of pilot sites were performed to test the toolkit's applicability and relevance.

RESULTS

The toolkit contains a 134-item global assessment tool for the different processes at each step of the medication pathway and three step-specific observation checklists to assess different health workers' practices during the prescription, preparation, and administration of chemotherapies. The toolkit also proposes using a surface-wipe sampling method to measure any cytotoxic contamination of the immediate environment. The toolkit was tested in three teaching hospitals in Africa.

CONCLUSION

The toolkit developed was successfully implemented in a variety of LMIC settings, providing a comprehensive evaluation of the quality and safety of the chemotherapy drug handling practices in participating health care facilities. This toolkit can help facilities in LMICs to implement a new approach to continuously improving the quality and safety of their practices and ultimately ensure patient and staff safety.

Barriers and facilitators for the safe handling of antineoplastic drugs

INTRODUCTION

Antineoplastic drugs are widely used in the treatment of cancer. However, some are known carcinogens and reproductive toxins, and incidental low-level exposure to workers is a health concern. CAREX Canada estimated that approximately 75,000 Canadians are exposed to antineoplastic drugs in workplace settings. While policies and guidelines on safe handling of antineoplastic drugs are available, evidence suggests that compliance is low. In this paper, we identify barriers and facilitators for safe handling of antineoplastic drugs in workplace settings.

METHODS

We utilized a unique method to study public policy which involved compiling policy levers, developing a logic model, conducting a literature review, and contextualizing data through a deliberative process with stakeholders to explore in-depth contextual factors and experiences for the safe handling of antineoplastic drugs.

RESULTS

The most common barriers identified in the literature were: poor training (46%), poor safety culture (41%), and inconsistent policies (36%). The most common facilitators were: adequate safety training (41%), leadership support (23%), and consistent policies (21%). Several of these factors are intertwined and while this means one barrier can cause other barriers, it also allows healthcare employers to mitigate these barriers by implementing small but meaningful changes in the workplace.

CONCLUSION

The combination of barriers and facilitators identified in our review highlight the importance of creating work environments where safety is a priority for the safe handling of antineoplastic drugs. The results of this study will assist policy makers and managers in identifying gaps and enhancing strategies that reduce occupational exposure to antineoplastic drugs.

Health professionals' attitude and associated factors toward cytotoxic drug handling in University of Gondar specialized hospital: Institution-based cross-sectional study

BACKGROUND

Studies have shown that cytotoxic drugs are dangerous to health care workers. Health care professionals' attitude to cytotoxic drugs is vital to apply safety protocols in the prevention of cytotoxicity. The current study aimed to assess health professionals' desirable attitude and associated factors toward cytotoxic drugs handling in the University of Gondar Specialized Hospital.

METHODS

An institution-based cross-sectional study was conducted on 412 health professionals from June to August 2019. Simple random sampling was used to select participants and a self-administered questionnaire was used to collect data. Epi Info and SPSS 20 were used for data entry and analysis, respectively. Variables with a p value < 0.05 were declared as determinants.

RESULTS

The number of health professionals included was approximately 412. The mean age of participants was 29.9 ± 5.4 years. The proportion of participants with desirable attitude toward cytotoxic drugs handling was 224 (54.4%) (95% confidence interval: 51.95-56.85). Male (adjusted odds ratio = 1.69, 95% confidence interval:[1.08-2.65]), work experience of 5-8 years (adjusted odds ratio = 1.92, 95% confidence interval: [1.10-3.34]), weekly working hours of 44-55 (adjusted odds ratio = 2.25, 95% confidence interval: [1.02-4.96]), medium work stress (adjusted odds ratio = 1.67, 95% confidence interval: [1.01-2.69]), and good practice of cytotoxic drug handling (adjusted odds ratio = 1.67, 95% confidence interval: [1.04-2.67]) were significantly associated with the attitude of health professionals.

CONCLUSION

A significant proportion of health care workers did not have desirable attitude to handle cytotoxic drugs. Thus, strategies are suggested to improve the positive attitude of health professionals to cytotoxic drug handling. Female health professionals, those who had work experience of less than 2 years and those with higher work stress demand special attention.

Safe Handling of Hazardous Drugs in Home Infusion

Chemotherapy agents used for cancer treatment are considered hazardous drugs (HDs). Guidelines and standards for handling HDs have been in place for several decades to protect oncology nurses working in hospitals and outpatient infusion areas. However, chemotherapy is frequently being administered in home settings, often by infusion nurses who do not necessarily have the requisite knowledge and training. Providing appropriate education for home infusion nurses is key to ensuring they are practicing in a manner that minimizes potential exposure to HDs.

Knowledge and Practices on the Safe Handling of Cytotoxic Drugs Among Oncology Nurses Working at Tertiary Teaching Hospitals in Addis Ababa, Ethiopia

Background

Cytotoxic drugs (CDs) administration and occupational exposure is a worldwide concern. Inappropriate handling may cause toxic residues to infiltrate hospital environments and patient care areas, and can even be traced to patients’ homes. Hence, the study sought to assess knowledge and practices on the safe handling of cytotoxic drugs Among Oncology Nurses at Tertiary Teaching Hospitals in Addis Ababa, Ethiopia.

Methods

The researchers conducted a hospital-based cross-sectional study among 77 nurses from April 1–30, 2019. Purposive sampling was used in recruiting the respondents. Structured questionnaires were filled through self-administered interviewing. Data were analyzed using SPSS version 23 software. Multiple linear regression was performed to see the association between dependent variables and independent variables at a p-value of less than 0.05.

Results

Mean score of knowledge and practice of nurses was 7.82±2.22 out of 15 and 22.1±5.50 out of 40 respectively. Nearly 69% of nurses reported the lack of training program on the handling of CDs at their workplaces and the use of Personal Protective Equipment (PPE) remains suboptimal as none used all of PPE. Nurses who had not heard about CDs had an average knowledge score of 0.33 points lower than nurses who had heard about CDs (p ≤ 0.01). Nurses who have scored higher knowledge points had 0.33 points more practice score of safe CD handling than those who had lower knowledge score (p < 0.05) and also married nurses had average safe CDs handling practice score 0.27 points lower than their counterparts (p < 0.05).

Conclusion

Nurses’ knowledge and practice of safe handling of cytotoxic drugs are inadequate. Nurses who have scored higher knowledge points and are married were more likely to practice safe CD handling. Provision of proper PPE and training regarding the handling of CDs for Oncology Nurses are recommended and chemotherapy safety protocol and guidelines should be established.

Chemical risk in hospital settings: Overview on monitoring strategies and international regulatory aspects

Chemical risk in hospital settings is a growing concern that health professionals and supervisory authorities must deal with daily. Exposure to chemical risk is quite different depending on the hospital department involved and might origin from multiple sources, such as the use of sterilizing agents, disinfectants, detergents, solvents, heavy metals, dangerous drugs, and anesthetic gases. Improving prevention procedures and constantly monitoring the presence and level of potentially toxic substances, both in workers (biological monitoring) and in working environments (environmental monitoring), might significantly reduce the risk of exposure and contaminations. The purpose of this article is to present an overview on this subject, which includes the current international regulations, the chemical pollutants to which medical and paramedical personnel are mainly exposed, and the strategies developed to improve safety conditions for all healthcare workers.

Virtual reality teaching in chemotherapy administration: Randomised controlled trial

AIMS AND OBJECTIVES

This study examined the effect of virtual reality (VR)-based documents (VRdocs) on knowledge and attitude towards chemotherapy administration in nursing students.

BACKGROUND

Chemotherapeutic drugs in cancer patients are a complicated and dangerous process. However, despite the high toxicity of the chemotherapeutic drugs, the compulsory or internship courses in nursing schools do not include training in operational chemotherapeutics and its associated safety measures.

DESIGN

A randomised controlled trial based on the CONSORT 2010 guidelines (registry number: NCT03707210).

METHOD

A total of 77 students were randomised to an experimental (VRdocs, n = 38) or a control group (n = 39). Pre- and posttest data were collected. After the pretest, the control group received the education documents, whereas, the experimental group used VR software consisting of an application about chemotherapy administration. Finally, the effectiveness of the intervention was self-evaluated using questionnaires after 7 days.

RESULTS

The posttest scores for knowledge (F = 6.412, p = .013) and attitude in the experimental group were significantly different from those in the control group (F = 8.469, p = .005). Compared with the control group, a significant number of students in the experimental group indicated their higher recommendation score for the VRdocs (p = .0001).

CONCLUSION

Schools must provide a variety of handouts and teaching methods to educate nursing students about high-risk nursing techniques. Methods using VR can address the shortcomings of the traditional documents, and the use of both methods simultaneously can produce better learning results.

RELEVANCE TO CLINICAL PRACTICE

Virtual reality based documents were provided to the participants to understand the preparation, implementation, and safety of chemotherapy. VRdocs allow students to re-learn high-risk care techniques without the influence of time and space and may prove useful for other nursing courses.

Availability, Accessibility and Proper Use of Personal Protective Equipment in Wards at Queen Elizabeth Central Hospital (QECH) Blantyre, Malawi: An Observational Study

Background

The purpose of this study was to evaluate the availability, accessibility and proper use of personal protective equipment (PPE) in the wards at Queen Elizabeth Central Hospital (QECH).

Methods

We conducted an observational study with a cross-section design. Convenience sampling method was used for selection of healthcare workers (HCWs) in wards. HCWs filled a checklist on accessibility of PPEs and they were observed on proper use of PPE while conducting clinical procedures. Nurse ward in-charge was asked to fill out a checklist on availability of PPE in their ward.

Results

PPE was available in 75.8% of wards, not available in 12.5%. Goggles were absent in 70.8% of wards. PPEs were 71.4% accessible and 28.6% inaccessible to healthcare workers in the wards. The most inaccessible PPEs were goggles (83.2%) and footwear (73.7%) while facemasks, sterile and non-sterile gloves and aprons were readily accessible. Non sterile gloves were 100% available and accessible. Only 13.5% of the HCWs had good compliance with PPE standard procedures. The average PPE compliance score of those who had been trained was 6 % greater than those who were not trained.

Conclusion

This study identified areas of improvement in healthcare system delivery regarding standard precautions with emphasis on PPE. Improvements in training during professional college education and in-service refresher training could improve compliance with appropriate use of PPE for relatively low cost. Management support could improve availability and accessibility of PPE in the wards at QECH, with active supervision to improve adherence levels to personal protective equipment usage. The study can also help in the development of policies and guidelines regarding PPE usage by showing that most HCWs need to be trained in proper PPE usage.

Predictors of Chemotherapy Safe-Handling Precautions and Knowledge Among a Sample of Jordanian Oncology Nurses: A Model-Building Approach

BACKGROUND

There are adverse side effects associated with handling chemotherapy; however, using safe-handling precautions can minimize or prevent these potential effects. Despite availability of international guidelines for chemotherapy handling, adherence to precautions is below expectations. This study examined knowledge of safe-handling precautions among a sample of oncology nurses in Jordon.

METHODS

A cross-sectional study was employed that included a convenience sample of 153 oncology nurses. Oncology nurses from two hospitals completed the Chemotherapy Handling Questionnaire. Descriptive analysis, Spearman rank correlation coefficients, and regression analyses were performed to determine the predictors of precaution use when handling hazardous drugs among participants.

FINDINGS

We observed that age, number of patients for whom the worker administered chemotherapy per day, the number of patients receiving chemotherapy per day in the participant's work unit, nurses' knowledge about safe-handling precautions, perceived risk, perceived barriers, self-efficacy, organization influence/workplace safety climate, conflict of interest, and interpersonal influences were predictors of use of safe-handling precautions (adjusted R² = .66, p < .001).

CONCLUSION/APPLICATION FOR PRACTICE

Several predictors for using safe-handling precautions were identified. Clinically, chemotherapy handling procedures should be evaluated frequently to identify barriers to safe practices and to improve worker safety.

Prepregnancy handling of antineoplastic drugs and risk of miscarriage in female nurses

PURPOSE

To examine the association betweenantineoplastic drug (AD) handling and risk of miscarriage.

METHODS

Nurses' Health Study-3 participants self-reported AD administration and engineering controls (ECs) and personal protective equipment (PPE) use at baseline. We estimated the hazard ratio (HR) of miscarriage in relation to baseline AD handling using multivariable Cox proportional regression.

RESULTS

Overall, 2440 nurses reported 3327 pregnancies, with 550 (17%) ended in miscarriages. Twelve percent of nurses self-reported currently handling AD and 28% previously handling AD. Compared with nurses who never handled AD, nurses who handled AD at baseline had an adjusted HR of miscarriage of 1.26 (95% confidence interval [CI], 0.97-1.64). This association was stronger after 12-weeks gestation (HR=2.39 [95% CI, 1.13-5.07]). Nurses who did not always use gloves had HR of 1.51 (95% CI, 0.91-2.51) compared with 1.19 (95% CI, 0.89-1.60) for those always using gloves; nurses who did not always use gowns had HR of 1.32 (95% CI, 0.95-1.83) compared with 1.19 (95% CI, 0.81-1.75) for nurses always using gowns.

CONCLUSIONS

We observed a suggestive association between AD handling and miscarriage, particularly among nurses who did not consistently use PPE and EC with stronger associations for second trimester losses.

Environmental Risk Factors: The role of oncology nurses in assessing and reducing the risk for exposure

BACKGROUND

The multifaceted origins of cancer are related to the dynamic interface between the human body and the environment. It is estimated that as many as 60% of cancers arise from environmental exposures.

OBJECTIVES

This article describes potential risks for exposure to radon, arsenic, pesticides, and antineoplastic agents, which can lead to the development of cancer.

METHODS

The authors performed a review of the literature on environmental exposures and their relationship to the development of cancer.

FINDINGS

Environmental factors are abundant in the home, workplace, and environment. Nurses can lead campaigns to educate the public about environmental risk factors and their effects on the development of cancer.

Knowledge and associated factors towards cytotoxic drug handling among University of Gondar Comprehensive Specialized Hospital health professionals, institutional-based cross-sectional study

BACKGROUND

Currently, cancer is among the leading causes of morbidity and mortality in the world. Exposure to CDs may occur during drug preparation and mixing, during drug administration, during transport, and cleaning spills and waste disposal. Healthcare workers who prepare or administer antineoplastic drugs, or who work in areas where these drugs are used, can be exposed to these agents. This also affects the public around the exposed area if appropriate disposal system is not known. Several studies reported increased risks of leukemia and breast cancer among nurses handling CDs and not following safety guidelines. Because of the absence of studies in Ethiopia, the current study was conducted to determine the knowledge level of cytotoxic drug handling and associated factors among health professionals in the University of Gondar Comprehensive Specialized Hospital.

METHODS

The institutional-based cross-sectional study was conducted from June to August 2019. Epi info 7.1 was used for data entry and then exported into SPSS version 20 for computing, recording, and statistical analysis. Logistic regression was used to explain the relationship with independent variables.

RESULTS

Four hundred and twelve health professionals participated in the study with 53.4% males. The participants' mean age was 29.9 (± 5.43) years ranging from 20-60. Two hundred and twenty-three (54.1%) health professionals heard about cytotoxic drugs, and 52.7% (95% UI 47.8-57.8%) had good knowledge of cytotoxic drug handling. Being male sex (AOR = 1.84, 95% CI (1.13-3.00)), age of 29-31 (AOR = 1.99, 95% CI (1.03-3.84)), hearing information about cytotoxic drug handling (AOR = 2.53, 95% CI (1.43-4.47)), ever attended training on cytotoxic drug handling (AOR = 3.15, 95% CI (1.13-8.79)), ever taking courses related to cytotoxic drugs (AOR = 2.03, 95% CI (1.15-3.59)), and good practice (AOR = 3.24, 95% CI (1.95-5.37)) were significantly associated with knowledge towards cytotoxic drug handling. It is therefore imperative to train health professionals and to incorporate CDs handling related course contents while revising curricula to raise the knowledge of health professionals about proper cytotoxic drug handling.

CONCLUSION

Above half of the study participants scored higher than the median of the cytotoxic drug handling knowledge questions. Sex, age, information about cytotoxic drug handling, training, taking courses related to cytotoxic drugs, and good practice were significantly associated with knowledge towards cytotoxic drugs handling.

Environmental assessment of cytotoxic drugs in the Oncology Center of Cyprus

Background

Cytotoxic drugs constitute an important workplace hazard in the hospital environment. Our aim was to conduct an environmental assessment of hazardous drugs in the Oncology Center of Cyprus.

Methods

Wipe samples were obtained from 42 workplace areas of the Oncology Center including two pairs of gloves in an initial assessment, while 10 samples were obtained at follow-up 3 years later. Potential contamination with cyclophosphamide (CP), ifosphamide (IF) and 5-fluorouracil (5-FU) and other cytotoxic medications was examined using the GC-MSMS system (CP, IF) and the HPLC system with UV detection (5-FU) method, respectively.

Results

Wipe sample contamination was detected at 11.9% and 15% in the initial and follow-up assessment, respectively. Both pairs of gloves assessed were free from contamination. The results showed contamination with cyclophosphamide on the work space inside the isolator, on a day-care office phone and on the central pharmacy bench. Ifosphamide was only detected on the floor of a patient’s room. Contamination with 5-fluorouracil was found only on the surface of a prepared IV infusion bag. The levels of contamination in the positive samples ranged from 0.05 to 10.12 ng/cm².

Conclusions

The overall percentage of sample contamination at the Oncology Center was very low compared to other centers around the world. In addition, the detected levels of contamination with cytotoxic drugs were relatively low with the exception of the workspace inside the biological safety cabinet. These results in both assessments may reflect the implementation of comprehensive control measures including employee training, technological equipment and effective cleaning procedures.

Surgical Smoke-Hazard Perceptions and Protective Measures in German Operating Rooms

(1) Background: Hazardous substances in surgical smoke that is generated during laser or electrosurgery pose a potential health hazard. In Germany, the Technical Rules for Hazardous Substances (TRGS 525) have included recommendations for appropriate protective measures since 2014. Up to now, no empirical data has been available on the extent to which recommendations have been implemented in practice. (2) Methods: In 2018, 7089 surgeons in hospitals and outpatient practices were invited by email to participate in an online survey. In addition, 219 technical assistants were interviewed. The questionnaire dealt with knowledge of, and attitudes toward, the hazard potential of surgical smoke, as well as the availability and actual use of protective measures. Furthermore, manufacturers and distributors of smoke extraction devices were asked to give their assessment of the development of prevention in recent years. (3) Results: The survey response rate was 5% (surgeons) and 65% (technical assistant staff). Half of all surgeons assumed that there were high health hazards of surgical smoke without taking protective measures. Operating room nurses were more often concerned (88%). Only a few felt properly informed about the topic. The TRGS recommendations had been read by a minority of the respondents. In total, 52% of hospital respondents and 65% of the respondents in outpatient facilities reported any type of special suction system to capture surgical smoke. One-fifth of respondents from hospitals reported that technical measures had improved since the introduction of the TRGS 525. Fifty-one percent of the surgeons in hospitals and 70% of the surgeons in outpatient facilities "mostly" or "always" paid attention to avoiding surgical smoke. The most important reason for non-compliance with recommendations was a lack of problem awareness or thoughtlessness. Twelve industrial interviewees who assessed the situation and the development of prevention in practice largely confirmed the prevention gaps observed; only slight developments were observed in recent years. (4) Conclusions: The low response rate among surgeons and the survey results both indicate a major lack of interest and knowledge. Among other measures, team interventions with advanced training are needed in the future.

Hazardous Drug Residues in the Home Setting: Worker Safety Concerns

Safety concerns have existed for more than 40 years about how hazardous drug (HD) exposure contributes to adverse health outcomes in health care workers. Careless handling causes toxic HD residues to infiltrate hospital and ambulatory care settings and can even be tracked to patient homes. Little is known about the adverse health outcomes experienced by exposed caregivers. The December 1, 2019, release of new regulations will enforce health care organizations to minimize risk to all health care workers by implementing the US Pharmacopeia (USP) General Chapter<800>Hazardous Drugs-Handling in Healthcare Settings safety standards. Worker safety measures include wearing personal protective equipment, even in home care settings.

Assessing variability of antineoplastic drugs handling practices in clinical settings

The United States Pharmacopeia (USP) Chapter <800> guidelines will be adopted in the U.S. and Canada in 2019, requiring regular surface sampling for antineoplastic drug (AD) surface contamination as a means of environmental surveillance. USP Chapter <800> does not provide guidance on when and where to sample. Research to support the development of such guidance within a broader sampling strategy is limited. This study was conducted to help address some of the underlying information gaps by identifying surfaces pharmacy and nursing staff are likely to contact, presenting a potential dermal exposure risk. Observations were conducted at one regional and one urban clinic, providing insight into inter- and intra-worker variability and between-clinic differences based on size and patient load. Thirteen surfaces in the compounding pharmacies and 14 surfaces in the patient administration were initially selected for video observations. Following a preliminary assessment to eliminate surfaces that were touched infrequently or not at all, five commonly touched surfaces in the compounding pharmacy areas (vials, syringes, IV lines, IV bags, waste bags) and six commonly touched surfaces in the patient administration area (yellow containment bag, IV bag, IV line, patient port, computer workstation) were assessed further. Variability between healthcare staff and clinics in pharmacy staff was low for both the mean frequency and duration of touch to surfaces. Differences between clinics in frequency of contact among nursing staff in patient administration areas were significant (two-way ANOVA) for five of the six surfaces. Duration of contact was not significantly different except for duration of touching the IV pump. These insights will be used to give guidance in selecting locations for a longitudinal surveillance study and help tailor worker training to reduce exposure risks.

CE: Original Research: Antineoplastic Drug Administration by Pregnant and Nonpregnant Nurses: An Exploration of the Use of Protective Gloves and Gowns

: Background: Many antineoplastic (chemotherapeutic) drugs are known or probable human carcinogens, and many have been shown to be reproductive toxicants in cancer patients. Evidence from occupational exposure studies suggests that health care workers who have long-term, low-level occupational exposure to antineoplastic drugs have an increased risk of adverse reproductive outcomes. It's recommended that, at minimum, nurses who handle or administer such drugs should wear double gloves and a nonabsorbent gown to protect themselves. But it's unclear to what extent nurses do.

PURPOSE

This study assessed glove and gown use by female pregnant and nonpregnant nurses who administer antineoplastic drugs in the United States and Canada.

METHODS

We used data collected from more than 40,000 nurses participating in the Nurses' Health Study 3. The use of gloves and gowns and administration of antineoplastic drugs within the past month (among nonpregnant nurses) or within the first 20 weeks of pregnancy (among pregnant nurses) were self-reported via questionnaire.

RESULTS

Administration of antineoplastic drugs at any time during their career was reported by 36% of nonpregnant nurses, including 27% who reported administering these drugs within the past month. Seven percent of pregnant nurses reported administering antineoplastic drugs during the first 20 weeks of pregnancy. Twelve percent of nonpregnant nurses and 9% of pregnant nurses indicated that they never wore gloves when administering antineoplastic drugs, and 42% of nonpregnant nurses and 38% of pregnant nurses reported never using a gown. The percentage of nonpregnant nurses who reported not wearing gloves varied by type of administration: 32% of those who administered antineoplastic drugs only as crushed pills never wore gloves, compared with 5% of those who administered such drugs only via infusion.

CONCLUSION

Despite longstanding recommendations for the safe handling of antineoplastic and other hazardous drugs, many nurses-including those who are pregnant-reported not wearing protective gloves and gowns, which are considered the minimum protective equipment when administering such drugs. These findings underscore the need for further education and training to ensure that both employers and nurses understand the risks involved and know which precautionary measures will minimize such exposures.

Application of an innovative high-throughput liquid chromatography-tandem mass spectrometry method for simultaneous analysis of 18 hazardous drugs to rule out accidental acute chemotherapy exposures in health care workers

OBJECTIVES

Despite safe handling guidelines published by several groups, health care worker exposure to hazardous drugs continues to occur due to suboptimal engineering controls and low use of protective equipment. Simple, multi-target and specific analytical methods are needed so that acute exposures to these drugs in the workplace can be assessed rapidly. Our aim was to develop an analytical method for simultaneous detection and quantification of widely used cancer drugs to rule out accidental acute chemotherapy exposures in health care workers.

METHODS

We examined the feasibility of alternate high-performance liquid chromatographic-tandem mass spectrometry methods to simultaneously detect eighteen chemotherapy analytes in plasma and urine. The linear concentration ranges tested during assay development were 0.1-50 ng/mL. After development of a multi-analyte assay protocol, plasma samples (n = 743) from a multi-center cluster-randomized clinical trial (n = 12 sites) of an hazardous drug educational intervention were assayed. Confirmatory assays were performed based on the individual acute-spill case-histories.

RESULTS

An innovative HPLC-multiple reaction monitoring-information dependent acquisition-enhanced production ion (MRM-IDA-EPI) analytical method was developed to simultaneously detect: cytarabine, gemcitabine, dacarbazine, methotrexate, topotecan, mitomycin, pemetrexed, irinotecan, doxorubicin, vincristine, vinblastine, ifosamide, cyclophosphamide, vinorelbine, bendamustine, etoposide, docetaxel, and paclitaxel. The retention times ranged from 4 min to 13 min for the analytical run. The limit of detection (MRM-IDA-EPI) and limit of quantitation (MRM) was 0.25 ng/mL and 0.1 ng/mL, respectively for most analytes. No detectable plasma concentrations were measured at baseline, post-intervention and in cases of documented acute spills. Use of a secondary tandem mass spectrometry approach was able to successfully rule out false positive results.

CONCLUSIONS

Development of a sensitive high-throughput multi-analyte cancer chemotherapy assay is feasible using an MRM-IDA-EPI method. This method can be used to rapidly rule out systemic exposure to accidental acute chemotherapy spills in health care workers.

Urine tropenol ester levels in workers handling tiotropium bromide synthesis: implications for exposure prevention and biomonitoring

Tropenol ester is a highly toxic anticholinergic substance and an intermediate used in industrial production of the bronchodilator tiotropium bromide. The aim of this study was to systematically test workers involved in its production for tropenol ester in urine to identify any exposure pathways and define additional preventive measures. Twelve workers performing tasks involving potential exposure to tropenol ester were repeatedly monitored at the end of each production cycle. Medical exams revealed no symptoms of acute poisoning with tropenol ester, but biological monitoring of urine showed 36 positive findings in 79 samples, with tropenol ester concentrations ranging between the detection limit of 54 pg/mL and 2160 pg/mL. We managed to establish the cause of only one positive finding, which was a hole in a protective glove, whereas the rest most likely occurred due to human error. Because of this, the plant decided to modify the production process by replacing tropenol ester with a safer intermediate. While it is the safest course of action, there where it cannot be taken, biological monitoring can be very helpful in raising awareness about exposure to toxic substances, including the new ones that have not been studied for their adverse potential.

Current evidence of education and safety requirements for the nursing administration of chemotherapy: An integrative review

PURPOSE

The administration of chemotherapy is a complex task which has many safety issues. Safe administration of chemotherapy by nurses should be evidence-based. The aim of this integrative review was to synthesise the evidence about education and practice requirements for safe administration of chemotherapy by nurses.

METHOD

A systematic search of four databases identified 17 studies for inclusion in this review. Key words: Nurse, chemotherapy, cytotoxic drug, administration, safety, education. Data extracted from the studies included author, year, aims, design, sample, outcome measures and findings. After screening the articles, extracting study data and completing a summary table, critical appraisal of the studies was completed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

All the studies focused on strategies to promote patient and nurse safety during nursing administration of chemotherapy. Content analysis identified five themes: governance, process safeguards, communication, interdisciplinary collaboration and education. Key strategies or interventions that increased patient and/or nurse safety identified were standardised computer-generated chemotherapy orders, barcodes, medication safety procedures, education and simulated learning.

CONCLUSIONS

This review found low-level evidence exists about the education and safety requirements for nursing administration of chemotherapy. High-level research is needed to assist healthcare services to select evidence-based educational and safety strategies and provide appropriately resourced work environments to support the safe nursing administration of chemotherapy and deliver the best possible patient outcomes.

Korean nurses' adherence to safety guidelines for chemotherapy administration

PURPOSE

Nurses are at risk from handling chemotherapeutic agents. This study aimed to determine adherence to safety guidelines for chemotherapy administration by Korean nurses and to examine the relationship between the hospital safety climate and nurses' adherence to safety guidelines.

METHOD

A descriptive, correlational design with a cross-sectional survey using data from the Korea Nurses' Health Study. For this study, participants included 872 female nurses who had administered chemotherapeutic agents to patients in the last 30 days.

RESULTS

Only a quarter of the participants had high adherence to the safety guidelines, while the majority had moderate to low adherence. The absence of job hindrances and feedback/training - two sub-factors of the hospital safety climate - enhanced the likeliness for nurses to comply with the safety guidelines by almost 1.3 and 1.7 times, respectively.

CONCLUSION

The results imply that the hospital safety climate, particularly feedback/training, and the absence of job hindrances are significantly correlated with adherence to the safety guidelines for chemotherapy administration. Therefore, organisational and policy support is needed to improve the hospital safety climate.

Occupational exposure to cytotoxic drugs: the importance of surface cleaning to prevent or minimise exposure

Healthcare workers who prepare or administer cytotoxic agents run the risk of exposure, and the risks for health are real even at doses lower than those applied in cancer patients, because, in theory, no dose is safe. The most common and problematic route of exposure is through the skin, especially as work surfaces can remain contaminated even after cleaning. This pilot study aimed to demonstrate the importance of having an effective surface decontamination protocol by determining surface contamination with cyclophosphamide, 5-fluorouracil, and paclitaxel as the most common cytotoxic drugs in an oncology day service. Samples were collected before and after drug handling and analysed with high performance liquid chromatography with diode array detection (HPLC-DAD). Of the 29 samples collected before drug handling 23 were contaminated, five of which with more than one drug. Of the 30 samples collected after drug handling 25 were contaminated, eight of which with more than one drug. The two time points did not significantly differ, which evidences a widespread contamination and ineffective cleaning. This calls for revising the cleaning protocol and handling procedure to place contamination under control as much as possible.