Evaluation of the risk of occupational exposure to antineoplastic drugs in healthcare sector: part II - the application of the FMECA method to compare manual vs automated preparation

Healthcare workers handling antineoplastic drugs (ADs) in preparation units run the risk of occupational exposure to contaminated surfaces and associated mutagenic, teratogenic, and oncogenic effects of those drugs. To minimise this risk, automated compounding systems, mainly robots, have been replacing manual preparation of intravenous drugs for the last 20 years now, and their number is on the rise. To evaluate contamination risk and the quality of the working environment for healthcare workers preparing ADs, we applied the Failure Mode Effects and Criticality Analysis (FMECA) method to compare the acceptable risk level (ARL), based on the risk priority number (RPN) calculated from five identified failure modes, with the measured risk level (MRL). The model has shown higher risk of exposure with powdered ADs and containers not protected by external plastic shrink film, but we found no clear difference in contamination risk between manual and automated preparation. This approach could be useful to assess and prevent the risk of occupational exposure for healthcare workers coming from residual cytotoxic contamination both for current handling procedures and the newly designed ones. At the same time, contamination monitoring data can be used to keep track of the quality of working conditions by comparing the observed risk profiles with the proposed ARL. Our study has shown that automated preparation may have an upper hand in terms of safety but still leaves room for improvement, at least in our four hospitals.

Developing wipe sampling strategy guidance for assessing environmental contamination of antineoplastic drugs

Surveillance for environmental contamination of antineoplastic drugs has been recommended by authoritative bodies such as the United States Pharmacopeia and the National Association of Pharmacy Regulatory Authorities. Clear guidance is needed on how to develop sampling strategies that align with surveillance objectives efficiently and effectively. We conducted a series of simulations using previously collected surveillance data from nine cancer treatment centers to evaluate different sampling strategies. We evaluated the impact of sampling 2, 5, 10, or 20 surfaces, at monthly, quarterly, semi-annual, and annual frequencies, while employing either a random or sentinel surface selection strategy to assess contamination by a single antineoplastic drug (AD) or by a panel of three ADs. We applied two different benchmarks: a binary benchmark of above or below the limit of detection and AD-specific hygienic guidance values, based on 90th percentile values as quantitative benchmarks. The use of sentinel surfaces to evaluate a three-drug panel relative to 90th percentile hygienic guidance values (HGVs) resulted in the most efficient and effective surveillance strategy.

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.

Quantitative comparison of anticancer drug dispersal before and after introducing appropriate preparation procedures during anticancer drug preparation

Background

In Japan, engineering controls for preparing injectable anticancer drugs are inadequate and compliance with appropriate preparation procedures is vital. In this study, we evaluated the effects of adherence to appropriate anticancer drug formulation and packaging procedures on reducing anticancer drug dispersal in clinical practice, especially in Japan.

Methods

We quantitatively evaluated the effectiveness of implementing procedures that were experimentally verified to help reduce the amount of anticancer drug dispersed during preparation based on procedures described in the “Anticancer Drug Preparation Manual.” The target facilities were four regional hub hospitals in the Kanto area. Contamination of sheets and gloves with 5-fluorouracil (5-FU) and gemcitabine (GEM) in a safety cabinet during formulation was evaluated using wipe tests. Subsequently, the proper preparation procedure was shown on a video, training was provided, and the wipe tests were repeated.

Results

Forty-one and 39 pharmacists were engaged in drug preparation before and after intervention, respectively. 5-FU had the highest dispersal per prepared vial on the sheet before intervention. The dispersal amount per prepared vial decreased significantly (P = 0.01) after intervention. The amount of GEM dispersed before and after intervention did not differ significantly. However, the percentage of sheets below the detection limit after intervention was 62%, increasing from 46% before intervention. The amount dispersed on gloves was not significantly reduced by proper preparation technique. Although not explicitly noticeable and quantifiable, pharmacists must consider that a significant amount of anticancer drug is dispersed on gloves despite following appropriate preparation procedures.

Conclusions

Quantitative amounts of anticancer drugs dispersed in the preparations of 5-FU and GEM were found in our study. The difference in the amount of contamination before and after intervention was significantly reduced only for the contamination of sheets with 5-FU. There was no decrease in the amount of glove contamination. There was also no difference between medical facilities. Despite following appropriate preparation procedures, dispersed amounts cannot be maintained below the detection limit, indicating the need for a combination of education and engineering controls.

Evaluation of three barrier-type closed system transfer devices using the 2015 NIOSH vapor containment performance draft protocol

Background

Closed System Transfer Devices (CSTD) have been developed to reduce healthcare worker exposure to hazardous drugs during medication handling. To evaluate CSTD performance in preventing the escape of drug vapors, the National Institute for Occupational Safety and Health (NIOSH) developed a 2015 draft testing protocol incorporating two compounding tasks utilizing 70% isopropyl alcohol (IPA) as a medication surrogate.

Purpose

The objective of this study was to evaluate the performance of three CSTDs (Chemolock [ICU Medical Inc., San Clemente, CA], PhaSeal [BD, Franklin Lakes, NJ], and Equashield [Equashield, Port Washington, NY]) in preventing the escape of drug vapor in accordance with the 2015 NIOSH draft protocol during simulated compounding and administration tasks.

Methods

The protocol was modified for the CSTDs to be used in accordance with manufacturer instructions for use and to represent clinical practice through repeated CSTD connections. Tasks were executed with each of the three CSTDs using 70% IPA as the medication surrogate to simulate compounding of a lyophilized drug, intravenous (IV) bag preparation (task 1), and bolus administration through an IV set (task 2). A positive control was performed by completing both tasks in duplicate, utilizing a needle and syringe instead of the CSTD to simulate preparation and injection through luer connectors. Differences in time to complete each simulated task was also evaluated.

Results

The three CSTDs had statistically equivalent performance and maintained IPA vapor levels below the limit of detection (LOD) of 1.0 ppm. Positive controls had mean vapor release of 17.40 ppm and 23.45 ppm for tasks 1 and 2, respectively. Positive controls also required statistically longer mean time to complete both tasks, followed in decreasing order by PhaSeal, Equashield, and Chemolock.

Conclusions

This study suggests that when evaluated in accordance with the 2015 NIOSH draft protocol, the three CSTDs are equivalent in their ability to prevent IPA vapor release while differences in time required for task completion may exist.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40267-022-00905-x.

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.

Oral Chemotherapy: An Evidence-Based Practice Change for Safe Handling of Patient Waste

BACKGROUND

Safe handling practices for patient waste have focused on patients receiving IV chemotherapy, but these practices do not address safe handling for patients receiving oral chemotherapy.

OBJECTIVES

The aim of this article is to evaluate evidence and formulate best practice recommendations for handling and disposing waste from patients receiving oral chemotherapy.

METHODS

A literature search established a framework for the project. For healthcare providers and staff, procedures were established to access biohazard supplies and to follow safe handling of patient waste post-oral chemotherapy administration. Supply cost utilization was evaluated pre- and postimplementation. Staff perceptions were assessed six months after project implementation.

FINDINGS

The cost of supplies per patient day increased minimally. Staff self-reported use of biohazard precautions when handling patients' waste increased. The majority of staff reported that they had access to supplies and were knowledgeable regarding safe handling procedures six months after this practice change.

Blood contamination of the pharmaceutical staff by irinotecan and its two major metabolites inside and outside a compounding unit

BACKGROUND

Caregivers in healthcare settings are exposed to a risk of antineoplastic drug contamination which can lead to adverse health effects. Biological monitoring is necessary to estimate the actual level of exposure of these workers. This study was conducted with the aim of assessing blood contamination levels by irinotecan and its metabolites of pharmaceutical staff operating inside and outside a compounding unit.

METHODS

The study took place within the pharmaceutical unit of a French comprehensive cancer centre. Blood samples were collected from the pharmacy workers operating inside and outside the compounding unit, and analysed by UHPLC-MS/MS. Plasma and red blood cell irinotecan and its metabolites (SN-38; APC) were determined with a validated analytical method detection test.

RESULTS

A total of 17/78 (21.8%) plasma and red blood cell-based assays were found to be contaminated among staff. Overall, the total number of positive assays was significantly higher for staff members working outside the compounding unit than for workers working inside it (P = 0.022), with respectively 5/42 (11.9%) and 12/36 (33.3%) positive assays. For plasma dosages, the "outside" group had a significantly higher number of positive assays (P = 0.014). For red blood cell-based assays, no significant difference was found (P = 0.309).

CONCLUSIONS

This study reveals that pharmaceutical staff serving in health care settings are exposed to a risk of antineoplastic drug contamination, not only inside the compounding room but also in adjacent rooms. The results would help to raise awareness and potentially establish protective measures for caregivers working in areas close to the compounding room as well.

The efficiency of antineoplastic drug contamination removal by widely used disinfectants-laboratory and hospital studies

OBJECTIVE

Antineoplastic drugs (ADs) pose risks to healthcare staff. Surface disinfectants are used in hospitals to prevent microbial contamination but the efficiency of disinfectants to degrade ADs is not known. We studied nine disinfectants on ten ADs in the standardized laboratory and realistic in situ hospital conditions.

METHODS

A survey in 43 hospitals prioritized nine most commonly used disinfections based on different ingredients. These were tested on inert stainless steel and in situ on contaminated hospital flooring. The effects against ten ADs were studied by LC-MS/MS (Cyclophosphamide CP; Ifosfamide IF; Capecitabine CAP; Sunitinib SUN; Methotrexate MET; Doxorubicin DOX; Irinotecan IRI; Paclitaxel PX; 5-Fluorouracil FU) and ICP-MS (Pt as a marker of platinum-based ADs).

RESULTS

Monitoring of the floor contamination in 26 hospitals showed that the most contaminated are the outpatient clinics that suffer from a large turnover of staff and patients and have limited preventive measures. The most frequent ADs were Pt, PX, FU and CP with maxima exceeding the recommended 1 ng/cm² limit by up to 140 times. IRI, FU, MET, DOX and SUN were efficiently removed by hydrolysis in clean water and present thus lower occupational risk. Disinfectants based on hydrogen peroxide were efficient against PX and FU (> 70% degradation) but less against other ADs, such as carcinogenic CP or IF, IRI and CAP. The most efficient were the active chlorine and peracetic acid-based products, which however release irritating toxic vapors. The innovative in situ testing of ADs previously accumulated in hospital flooring showed highly problematic removal of carcinogenic CP and showed that alcohol-based disinfectants may mobilize persistent ADs contamination from deeper floor layers.

CONCLUSION

Agents based on hydrogen peroxide, peracetic acid, quaternary ammonium salts, glutaraldehyde, glucoprotamine or detergents can be recommended for daily use for both disinfection and AD decontamination. However, they have variable efficiencies and should be supplemented by periodic use of strong chlorine-based disinfectants efficient also against the carcinogenic and persistent CP.

Chemical Decontamination of Hazardous Drugs: A Comparison of Solution Performances

OBJECTIVES

Over the past 40 years, numerous actions have been undertaken to decrease the contamination of hospital facilities by intravenous conventional antineoplastic drugs (ICADs) such as centralizing compounding in pharmacies, using personal protective equipment, specific compounding, or infusion devices. As recently proposed in the <USP800> monograph, an additional specific decontamination step must be envisaged. A recent literature review analysed and discussed the different solutions tested in terms of decontamination efficacy. This article aims to discuss the performance of these solutions in the framework of aseptic compounding.

METHODS

The same dataset used in the previous literature review was reanalysed according to other parameters so as to select decontamination solutions: overall decontamination efficiency (EffQ), tested contaminants, and the risks of use in daily practice.

RESULTS

Using an EffQ threshold of 90% resulted in discarding 26 out of the 59 solutions. Solutions were tested differently: 8 on 1 contaminant, 11 on 2 contaminants, and 14 solutions on between 3 and 11 contaminants. Three risks were identified to help make choices in routine practice: the mutagenicity of degradation products, the safety of operators and facilities, and respect for the aseptic environment.

CONCLUSIONS

From the results, performance is discussed according to specific situations: a one-time incident or the basic chemical contamination due to daily practice. Accordingly, the decontamination solution selected then required a risk analysis and an evaluation before implementing it in the daily practice of a compounding unit.

Evaluating Six Commercially Available Closed-System Drug-Transfer Devices Against NIOSH's 2015 Draft Vapor Protocol

Purpose: In 2015, the National Institute for Occupational Safety and Health (NIOSH) published a draft vapor containment protocol to quantitatively evaluate combined liquid, aerosol, and vapor containment performance of commercially available closed-system drug-transfer devices (CSTDs) that claim to be effective for gas/vapor containment within a controlled test environment. Until the release of this proposed protocol, no standard method for evaluating airtightness of CSTDs existed. The aim of this study was to evaluate six commercially available CSTDs utilizing NIOSH draft protocol methodology to evaluate vapor containment under a robust vapor challenge. Methods: In this study, six commercially available CSTDs were tested utilizing draft NIOSH vapor containment protocol methodology to simulate drug compounding and administration using 70% isopropyl alcohol (IPA) as the challenge agent. All device manipulations were carried out in an enclosed test chamber. A Miran sapphIRe gas analyzer was used to detect IPA vapor levels that escaped the device. Study test included the two tasks designated by the NIOSH protocol, with additional steps added to the evaluation. Tasks were repeated 10 times for each device. Results: Only three of the six tested CSTDs (Equashield®, HALO®, and PhaSealTM) had an average IPA vapor release below the quantifiable performance threshold (1.0 ppm) for all tasks performed. This value was selected by NIOSH to represent the performance threshold for successful containment. The remaining three CSTDs had vapor release above 1 ppm at various times during the IPA manipulation process. Conclusion: Equashield®, HALO®, and PhaSealTM devices tested met the 2015 NIOSH protocol quantifiable performance threshold, functioning as a truly closed system. Quantifiable effective data may be useful in product selection.

Evaluation of bioabsorbable calcium sulfate hemihydrate beads for local delivery of carboplatin

The objectives of this study were to evaluate a novel kit of resorbable calcium sulfate beads marketed specifically for use in veterinary medicine and generally used for local delivery of antimicrobials as carboplatin-delivery system. The study characterized the elution of carboplatin in vitro, and investigated whether the initial dose and formulation of carboplatin, or the bead size significantly influences carboplatin elution in vitro. Calcium sulfate hemihydrate beads of 3- and 5-mm diameter were prepared. Five doses and two formulations of carboplatin (20, 50, 100, and 500 mg carboplatin per kit in powder formulation; 20 mg in liquid formulation) were tested in triplicates for each diameter beads. Beads were placed in 37°C phosphate buffered saline for 72 hours. Carboplatin concentrations in the eluent were measured by high-performance liquid chromatography at 11 time points with a modified United States Pharmacopeia assay. Concentrations of carboplatin in the eluent proportionally increased with the initial dose and peaked between 13 and 52 hours, ranging from 42.1% to 79.3% of the incorporated load. Higher peak concentrations, percentages released, and elution rates were observed with the liquid formulation and with higher carboplatin doses. There was no significant difference in maximum carboplatin concentrations between 3- and 5-mm diameter beads, but 5-mm diameter beads had slower elution rates. The novel kit can be used for preparation of carboplatin-impregnated resorbable calcium sulfate beads at variable doses, sizes and formulations. Further study is warranted to define the in vivo requirements and effective carboplatin dose, spatial diffusion and desired duration of elution.

Healthcare failure mode and effect analysis in the chemotherapy preparation process

PURPOSE

To conduct a Health Care Failure Mode and Effects Analysis (HFMEA) of the chemotherapy preparation process to identify the steps with the potential to cause errors, and to develop further strategies to improve the process and thus minimize the risk of errors.

METHODS

An HFMEA was conducted to identify and reduce preparation errors during the chemotherapy preparation process. A multidisciplinary team mapped the preparation process, formally identified all the steps, and then conducted a brainstorming session to determine potential failure modes and their potential effects. A severity and probability score for each failure mode, a hazard score (HS) and a total HS were calculated. A hazard analysis was conducted for each HS equal to or more than 8. Finally, an action plan was identified for each failure mode. After the action plan was implemented, failure modes were revaluated and a new HS score was calculated as well as the percentage decrease in risk.

RESULTS

The team identified five main steps in the chemotherapy preparation process and nine potential failure modes. After implementing the control measures, all the HSs decreased. The total HS associated with the chemotherapy preparation process decreased from 54 to 26 (-52%). This reduction in the total HS was mainly achieved by updating the Standard Operating Procedures (SOPs) and implementing bar code and gravimetric control system.

CONCLUSION

The application of HFMEA to the chemotherapy preparation process in centralized chemotherapy units can be very useful in identifying actions aimed at reducing errors in the healthcare setting.

Environmental Contamination and Occupational Exposure of Algerian Hospital Workers

Guidelines are in place to assure limited occupational exposure to cytostatic drugs. Even though this has led to a reduction in exposure, several studies reported quantifiable concentrations of these compounds in healthcare workers. In this study, we evaluated occupational exposure to cytostatic drugs in hospital workers from the University Hospital in Tlemcen, Algeria. Monitoring was performed by collecting wipe samples from surfaces, objects, personal protective equipment (gloves and masks) and from the skin of employees at an Algerian university hospital. Wipe samples were analyzed with ultra-performance liquid chromatography coupled to a mass spectrometer. Concentrations ranged from below the limit of quantification up to 208.85, 23.45, 10.49, and 22.22 ng/cm² for cyclophosphamide, ifosfamide, methotrexate and 5-fluorouracil, respectively. The highest values were observed in the oncology department. Nowadays, there are still no safe threshold limit values for occupational exposure to cytostatic agents. Therefore, contamination levels should be kept as low as reasonably achievable. Yet, healthcare workers in this hospital are still exposed to cytostatic agents, despite the numerous guidelines, and recommendations. Consequently, actions should be taken to reduce the presence of harmful agents in the work environment.

Efficiency of four solutions in removing 23 conventional antineoplastic drugs from contaminated surfaces

BACKGROUND

Residual contamination by intravenous conventional antineoplastic drugs (ICAD) is still a daily issue in hospital facilities. This study aimed to compare the efficiency (EffQ) of 4 different solutions to remove 23 widely used ICADs from surfaces.

METHOD AND FINDINGS

A solution containing 23 ICADs (4 alkylating agents, 8 antimetabolites, 2 topo-I inhibitors, 6 topo-II inhibitors and 3 spindle poisons) was spread over 100 cm2 stainless steel. After drying, decontamination was carried out using 10×10 cm wipes moistened with 300 μL of one of the following solutions: 70% isopropanol (S1); ethanol-hydrogen peroxide 91.6-50.0 mg/g (S2); 10-2 M sodium dodecyl sulphate/isopropanol 80/20 (S3) or 0.5% sodium hypochlorite (S4). Six tests were performed for each decontamination solution. Two modalities were tested: a single wipe motion from top to bottom or vigorous wiping (n = 6 for each modality). Residual contamination was measured with a validated liquid chromatography with tandem mass spectrometry detection method. Solution efficiency (in %) was computed as follows: EffQ = 1-(quantity after decontamination/quantity before decontamination), as median (min-max) for the 23 ICADs. The overall decontamination efficiency (EffQ) of the 4 solutions was compared by a Kruskall-Wallis test. Decontamination modalities were compared for each solution and per ICAD with a Mann-Whitney test (p<0.05). EffQ were significantly different from one solution to the next for single wipe motion decontamination: 79.9% (69.3-100), 86.5% (13.0-100), 85.4% (56.5-100) and 100% (52.9-100) for S1, S2, S3 and S4 (p<0.0001), respectively. Differences were also significant for vigorous decontamination: EffQ of 84.3% (66.0-100), 92.3% (68.7-100), 99.6% (84.8-100) and 100% (82.9-100) for S1, S2, S3 and S4, respectively (p<0.0001). Generally, vigorous decontamination increased EffQ for all tested solutions and more significantly for the surfactant.

CONCLUSION

Decontamination efficiency depended on the solution used but also on the application modality. An SDS admixture seems to be a good alternative to sodium hypochlorite, notably after vigorous chemical decontamination with no hazard either to materials or workers.

Evaluation of handling, storage, and disposal practices of oral anticancer medications among cancer patients and their caregivers at home setting in the Princess Noorah Oncology Center

BACKGROUD

Oral medications are commonly prescribed for many cancer patients. Unfortunately, most of them are dispensed without proper counseling about handling practices. We aimed to evaluate the handling, storage, and disposal practices of oral anticancer medications among cancer patients and their caregivers at home.

METHODS

A cross-sectional questionnaire was filled in by adult cancer patients or caregivers who received oral anticancers and/or visited an outpatient pharmacy over two months.

RESULTS

A total of 201 participants were interviewed, 67% were female, and nearly 44% were between 40 and 60 years of age. The majority of participants were educated (78%). The top five medications involved were: tamoxifen, capecitabine, letrozole, dasatinib, and imatinib. More than 95% of participants reported that medications were kept away from children and pets in the original container and stored away from extreme heat, cold, and humidity. Hand washing and wearing gloves were not consistently practiced. Only 5% reported "Always" wearing gloves, while 24% reported "Always" washing hands after handling anticancer medications. The participants reported that they had been informed about safe handling and storage by their physician (39%) and pharmacist (25%), while 34% had not been informed. In terms of disposal practices, 66% of patients have not had any unused or expired medications, 29% disposed them in the trash, and 27% returned them.

CONCLUSIONS

Our findings suggest that patients and caregivers' handling practices of oral anticancer medications are inconsistent with the published recommendations. Hence, appropriate and comprehensive education is needed to mitigate the risk of exposure to these agents in the home setting.

Cytostatic drugs and risk of genotoxicity in health workers. A literature review

OBJECTIVE

To analyse the genotoxic risk of cytostatic drugs in health professionals after occupational exposure.

METHOD

Literature was searched for the databases PubMed, Lilacs, The Cochrane Library and Scopus with free and controlled language (MeSH terms) using boolean operators AND and OR. The research was limited to articles published between 2005-2016.

RESULTS

11 articles were selected depending on their relevancy to this review's aim. Nine of the 11 articles proved the existence of damage to genetic material (DNA) of health workers, who were exposed to cytostatics. Furthermore, current security practices do not eliminate the chance of exposure completely. Therefore, the creation of new clinical trials is required.

CONCLUSIONS

Handling cytostatic drugs can cause a genotoxic risk to health workers who are exposed to these substances. This exposure may cause damage on the workers' DNA. There are not enough data to prove a cause-effect relationship between the genotoxic risk and adverse reactions on individuals. Health education will be the main way to raise the awareness and prevention this problem.

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.

Cystostatic drugs and risk of genotoxicity in health workers. A literature review

OBJECTIVE

To analyse the genotoxic risk of cytostatic drugs in health professionals after occupational exposure.

METHOD

The literature was searched using the databases PubMed, Lilacs, The Cochrane Library and Scopus with free and controlled language (MeSH terms) using Boolean operators AND and OR. The research was limited to articles published between 2005-2016.

RESULTS

11 articles were selected depending on their relevancy to this review's aim. Nine of the 11 articles proved the existence of damage to genetic material (DNA) of health workers, who were exposed to cytostatics. Furthermore, current security practices do not fully eliminate the chance of exposure. Therefore, new clinical trials are required.

CONCLUSIONS

Handling cytostatic drugs can cause a genotoxic risk to health workers who are exposed to these substances. This exposure may cause damage to the workers' DNA. There are not enough data to prove a cause-effect relationship between the genotoxic risk and adverse reactions in individuals. Health education will be the main way to raise awareness of and prevent this problem.

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.

Development and Implementation of a Standardized Sterile Compounding Training Program

Purpose: The purpose of the study is to develop and implement a standardized sterile compounding training program in a multihospital system that incorporates sterile compounding best practice recommendations and ensures compliance with United States Pharmacopeia (USP) Chapters 797 and 800 standards. Methods: Baseline sterile compounding training data were collected and reviewed for sterile compounding facilities across a multihospital health system, which included 37 distinct sterile compounding operations. Current sterile compounding personnel across the system completed preintervention assessments consisting of a written, knowledge-based exam; media-fill challenge test; and an observed assessment of aseptic technique. The personnel then completed refresher training of sterile compounding concepts by completing online and in-person courses. A postintervention assessment was then conducted to evaluate training methods and topics. Based on the intervention data, a training program for new sterile compounding personnel was developed and implemented. A program to provide annual, ongoing training to existing sterile compounding personnel was also developed and implemented. Results: There was a statistically significant improvement in sterile compounding written exam scores (P < .0001) and aseptic technique observation scores (P < .0001) after implementation of refresher training. The validated training program was then included in the development and implementation of standardized training for all new and existing sterile compounding personnel across a multihospital health system. Conclusion: A standardized and consistent, sterile compounding training program was developed for all new and existing sterile compounding personnel incorporating a live, in-person training course, as well as online and hands-on training.

Improvement of Chemotherapy Solutions Production Procedure in a Hospital Central Chemotherapy Preparation Unit: A Systematic Risk Assessment to Prevent Avoidable Harm in Cancer Patients

OBJECTIVE

This study was designed to reevaluate and improve the quality and safety of the chemotherapy preparation in a Central Chemotherapy Preparation Unit of a Public Hospital.

METHODS

A failure modes, effects, and criticality analysis (FMECA) was conducted by a multidisciplinary team. All potential failure modes at each stage of the chemotherapy preparation were recorded, and the associated risks were scored for their severity, occurrence, and detectability with a risk priority number (RPN). Corrective actions were suggested, and new RPNs were estimated for the modified process.

RESULTS

Failure modes, effects, and criticality analysis and priority matrix construction, revealed that the partial compliance of Unit's premises with international standards (RPNstage: 307), the human errors throughout the compounding (RPNstage: 223)-labeling (RPNstage: 216)-prescribing (RPNstage: 198) steps, and the violation of working protocols by employees (RPNstage: 215), were the most important risks for which either urgent or immediate corrective actions had to be taken. Modifying the procedure through the proposed corrective actions is expected to lead to a significant (71.3%) risk containment, with a total RPNpreparation process reduction from 2102 to 604.

CONCLUSIONS

Failure modes, effects, and criticality analysis and priority matrix development identified and prioritized effectively the risks associated with chemotherapy preparation allowing for the improvement of health services to cancer patients.

Surface contamination of the outer and blister packages of oral anticancer drugs: A multicenter study

INTRODUCTION

All guidelines necessitate wearing personal protective equipment during dispensing of oral anticancer drugs. This study aims to measure the degree of contamination on the press-through-package strips of oral anticancer drugs in Japan.

METHOD

Surface contamination of the external packaging of anticancer drugs was examined by performing wipe tests at four hospitals and two community pharmacies. The following commercially available drugs were examined: Xeloda®, TS-1®, and methotrexate tablets and SA-1® and Rheumatrex® capsules.

RESULTS

The wipe tests' results revealed that the contamination levels of Xeloda® and TS-1® tablets and SA-1® capsules were within their detection limits. In some facilities, the contamination levels on the press-through-package strips of Rheumatrex® capsules were 3.27 × 10^-1, which is close to its detection limit. However, across all facilities, the contamination level of methotrexate tablets was above its detection limit.

CONCLUSION

The results of this study suggested that adherence to oral anticancer drugs may not occur during manufacture or transportation. However, it may be due to the presence of pollutants in the facilities. Prevention of pollution in facilities might eliminate the need to wear personal protective equipment during dispensing of oral anticancer drugs.

Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach

Purpose

To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting.

Methods

A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders. A draft of the statements was circulated broadly within the community pharmacy community in an effort to assess relevance and implementation feasibility.

Results

The final report included 44 recommendations that addressed 11 key areas germane to the safe handling of oral anti-cancer drugs in community pharmacies. Mean agreement increased from 70% to 95%. Early feedback from community pharmacy leaders during the external review suggests that many of the proposed recommendations can be feasibly implemented within a reasonable timeframe when released with appropriate education and resource materials.

Conclusions

A modified-Delphi approach supplemented by key informant interviews and a comprehensive external review resulted in a set of evidence-informed, community-driven recommendations for community pharmacies. The recommendations address a gap in existing literature to improve understanding of the risks associated with handling and dispensing oral anti-cancer drugs for both community pharmacy staff and management and offer mitigating strategies to reduce those risks. Incorporating feasibility assessment actions early (through the key informant interviews) and late (through the external review) ensures recommendations are grounded in practicality and support broad and early knowledge translation strategies.

Management of Pulmonary Arterial Hypertension in the ICU

Patients with pulmonary arterial hypertension (PAH) who are admitted to the intensive care unit (ICU) pose a challenge to the multidisciplinary health-care team due to the complexity of the pathophysiology of their disease state and the medication considerations that must be made to appropriately manage them. PAH is a progressive disease with the majority of patients ultimately dying as a result of right ventricular (RV) failure. During an acute decompensation, patients must be appropriately managed to optimize volume status, RV function, cardiac output, and systemic perfusion, while treating the underlying cause of the exacerbation. During times of critical illness, the ability to administer medications approved for use in PAH can be impacted by end-organ damage, hemodynamic instability, new drug interactions, or available dosage forms. Balancing the multimodal treatment approach needed to manage an acute exacerbation and the pharmacokinetic and administration concerns impacting baseline PAH therapy as a result of critical illness requires an expert multiprofessional PAH team. The purpose of this review is to evaluate specific management considerations for critically ill patients with PAH in the ICU.

Efficiency of degradation or desorption methods in antineoplastic drug decontamination: A critical review

Although considerable efforts have been made over the last 40 years, occupational exposure to antineoplastic drugs is still a daily concern, since eradicating such contamination from workplaces seems unattainable. Considerable data are currently available on the risks associated with their use at work. Hospital facilities are often cleaned with marketed antimicrobials whose chemical decontamination efficacy certainly differs but remains unknown. To keep compounding facilities sterile, alcohol-based solutions are frequently used but with very limited efficiency. It would be particularly useful if a decontamination method could be added to the means already available so that all conventional antineoplastic drug contamination could be removed. Several degradation methods or desorption methods have previously been experimented, with varying success. They have never been compared or discussed in terms either of efficiency or usability. This review aims to analyse and discuss the results of each degradation or decontamination procedure and to compare them. This should facilitate selection of the method to be implemented in daily practice.

A new, sensitive and versatile assay for quantitative determination of α-fluoro-β-alanine (AFBA) in human urine by using the reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) system

A method for the quantitation of α-fluoro-β-alanine (AFBA), the main metabolite of capecitabine (Cape) and 5-fluoruracil (5-FU), is described. Among antineoplastic drugs (ADs), 5-FU and Cape (the new oral prodrug) are the most commonly applied drugs in cancer therapy. The main objective of this study was to develop a reliable method that would be easy to run on a reversed-phase UHPLC system coupled to tandem mass spectrometry. AFBA was derivatized with Sanger's reagent to ensure complete yield of a stable 2,4 dinitrophenil-α-fluoro-β-alanine derivative. This method was based on the use of a mixed-mode anion exchange solid phase extraction enabling urinary extracts to be clear of endogenous interferences affecting quantitative results. The assay was validated in human urine according to FDA criteria with the use of a labeled internal standard (β-alanine-d4) to minimize experimental error. Good accuracy and precision were demonstrated by determining spiked urine QC samples in four consecutive days. The recovery of AFBA was between 70.0 and 82.6%, with a matrix effect that was 12.8%-18.5%. The lower limit of quantitation (LOQ) was 0.5 ng/mL with a coefficient of variation of 5.3%. This assay was successfully applied to determine the levels of this metabolite in a large number of urine samples taken from personnel who were occupationally exposed to ADs.

Important exposure controls for protection against antineoplastic agents: Highlights for oncology health care workers

BACKGROUND

A great number of antineoplastic drugs (ANPDs) are used globally in cancer treatment. Due to their adverse health effects, occupational exposure to ANPDs is considered a potential health risk to health care workers.

OBJECTIVE

The current study aimed to evaluate safe-handling practices of ANPDs, exposure controls, and adverse health implications for health care providers exposed to ANDPs.

METHODS

Prevention measures, including engineering, administrative, and work practice controls, as well as personal protective equipment (PPE), were recorded daily through a questionnaire for six weeks. Acute adverse health effects experienced by health care workers were also documented.

RESULTS

The implemented exposure controls for preparation, administration, cleaning, and waste disposal were not in accordance with the safe handling guidelines. Central nervous system disorders (26.33%) were the most frequent acute adverse effects reported by health care workers. A significant correlation was found between the number of experienced adverse effects and handling characteristics, including the number of preparations (r = 0.38, p < 0.05), dose, and the number of prepared drugs (r = 0.46, p < 0.01 and 0.39, p < 0.05), and working hours in different locations of oncology setting for six weeks (preparation room: r = 0.38, P < 0.05, treatment room: r = 0.46, P < 0.01, patient room: r = 0.63, P < 0.01, and station: r = 0.68, P < 0.01).

CONCLUSIONS

Due to inadequate control measures, oncology health care workers were in danger of exposure to ANPDs and experienced acute adverse health effects. Implementation of appropriate exposure controls is required to prevent occupational exposure to ANPDs.

A decontamination process adding a tensioactive agent and isopropanol to a closed-system drug transfer device for better control of isolator contamination. A prospective, parallel study

Background

Despite the use of closed system drug transfer devices (CSTD), residual contamination from antineoplastic drugs is still detected inside isolators. The aim of this study was to compare the decontamination level obtained using a CSTD + standard cleaning procedure with a CSTD + standard cleaning procedure + specific decontamination procedure.

Methods and findings

A comparative and prospective study was carried out in a newly opened compounding unit. Compounding was performed with a CSTD (BD-Phaseal, Becton-Dickinson). In the Control isolator (C), the cleaning process was completed daily with a standard biocide solution (Anioxyspray^TM, Anios, France). In the Intervention isolator (I), weekly decontamination with a homemade admixture of sodium dodecyl sulfate 10⁻² M/70% isopropanol (80/20, v/v) was added. Monitoring was performed via a validated LC-MS/MS method. Eight drugs (cyclophosphamide, cytarabine, dacarbazine, fluorouracile, gemcitabine, ifosfamide, irinotecan and methotrexate) were monitored daily over 14 consecutive weeks on three sites inside the isolators: gloves, workbench and window. Results are presented as the odds-ratio (OR) of contamination and as overall decontamination efficiency (Eff_Q, %). The proportion of Eff_Q ≥ 90% was assessed by a Fisher’s exact test (p<0.05). Overall contamination rates (CR, %) were significantly different from one isolator to the other (CR_C = 25.3% vs. CR_I = 10.4%; OR = 0.341; p<0.0001). Overall Eff_Q values (median; 1^st and 3^rd quartiles) were higher in the intervention isolator (I: 78.3% [34.6%;92.6%] vs. C: 59.5% [-5.5%;72.6%]; p = 0.0015) as well as the proportion of days with an Eff_Q ≥ 90% (I: 42.9% vs. C: 7.1%; p = 0.077) but very variable depending on drugs.

Conclusion

Adding a decontamination protocol with a tensioactive agent to a CSTD leads to better control of chemical contamination inside isolators. Improving decontamination by increasing decontamination frequency or modifying the protocol will be further studied.

Discriminative and Quantitative Analysis of Antineoplastic Taxane Drugs Using a Handheld Raman Spectrometer

This study was conducted to evaluate the ability of Raman spectroscopy (RS) to control antineoplastic preparations used for chemotherapy in order to ensure its physical and chemical qualities. Three taxane drugs: cabazitaxel (CBX), docetaxel (DCX) and paclitaxel (PCX) at therapeutic concentration ranges were analyzed using a handheld spectrometer at 785 nm. Qualitative and quantitative models were developed and optimized using a calibration set (n=75 per drug) by partial least square discriminant analysis and regression and validated using a test set (n=27 per drug). All samples were correctly assigned with an accuracy of 100%. Despite optimization, quantitative analysis showed limited performances at the lowest concentrations. The root mean square error of predictions ranged from 0.012 mg/mL for CBX to 0.048 mg/mL for DCX with a minimal coefficient of determination of 0.9598. The linearity range was validated from 0.175 to 0.30 mg/mL for CBX, from 0.40 to 1.00 mg/mL for DCX and from 0.57 to 1.20 mg/mL for PCX. Despite some limitations, this study confirms the potential of RS to control these drugs and also provides substantial advantages to secure the activity for healthcare workers. As a result of its rapidity and the uncomplicated use of a handheld instrument, RS appears to be a promising method to augment security of the medication preparation process in hospitals.

Guidelines for safe handling of hazardous drugs: A systematic review

Objective

To review the scientific literature related to the safe handling of hazardous drugs (HDs).

Method

Critical analysis of works retrieved from MEDLINE, the Cochrane Library, Scopus, CINHAL, Web of Science and LILACS using the terms "Hazardous Substances", "Antineoplastic Agents" and "Cytostatic Agents", applying "Humans" and "Guidelines" as filters. Date of search: January 2017.

Results

In total, 1100 references were retrieved, and from those, 61 documents were selected based on the inclusion and exclusion criteria: 24 (39.3%) documents related to recommendations about HDs; 27 (44.3%) about antineoplastic agents, and 10 (33.3%) about other types of substances (monoclonal antibodies, gene medicine and other chemical and biological agents). In 14 (23.3%) guides, all the stages in the manipulation process involving a risk due to exposure were considered. Only one guide addressed all stages of the handling process of HDs (including stages with and without the risk of exposure). The most described stages were drug preparation (41 guides, 67.2%), staff training and/or patient education (38 guides, 62.3%), and administration (37 guides, 60.7%). No standardized informatics system was found that ensured quality management, traceability and minimization of the risks associated with these drugs.

Conclusions

Most of the analysed guidelines limit their recommendations to the manipulation of antineoplastics. The most frequently described activities were preparation, training, and administration. It would be convenient to apply ICTs (Information and Communications Technologies) to manage processes involving HDs in a more complete and simpler fashion.

ACVIM small animal consensus statement on safe use of cytotoxic chemotherapeutics in veterinary practice

The purpose of this report is to offer a consensus opinion of ACVIM oncology diplomates and technicians on the safe use of cytotoxic chemotherapeutics in veterinary practice. The focus is on minimizing harm to the personnel exposed to the drugs: veterinary practitioners, veterinary technicians, veterinary staff, and pet owners. The safety of the patient receiving these drugs is also of paramount importance, but is not addressed in this statement. Much of the information presented is based on national recommendations by Occupational Safety and Health Administration, National Institute for Occupational Safety and Health, United States Pharmacopeia, and other published regulations. These directives reflect an abundance of caution to minimize exposure to medical personnel, but large-scale studies about the consequences of long-term occupational exposure are not available in veterinary medicine. Challenges in the delivery of optimal treatment safely and economically to veterinary patients in general practice without access to a veterinary oncologist or other specialist, because of costs or proximity, remain.

Assessment of exposure risk of irinotecan and its active metabolite, SN-38, through perspiration during chemotherapy

BACKGROUND

Irinotecan (CPT-11) is the key drug used in chemotherapy for many malignant tumors. CPT-11 has cholinergic activity and induces perspiration during intravenous administration. In this study, concentrations of CPT-11 and its active metabolite, SN-38, released during perspiration were measured and risk of exposure of these drugs was assessed.

METHOD

Beads of sweat were collected using a dropper from four patients undergoing a chemotherapy regimen involving intravenous administration of CPT-11. The concentrations of CPT-11 and SN-38 in sweat were measured using liquid chromatography tandem mass spectrometry.

RESULT

Chemotherapy regimens were capecitabine and irinotecan plus bevacizumab (n = 1), CPT-11 monotherapy (n = 1), and oxaliplatin-irinotecan-leucovorin-5-fluorouracil (n = 2). Uridine diphosphate-glucuronosyltransferase 1A1 phenotypes were *6 homo-type (n = 1), *6 hetero-type (n = 1), and wild type (n = 2). CPT-11 dose was 292.3 ± 75.5 mg/body weight (mean ± standard deviation). CPT-11 was detected in sweat secreted by all the four patients, and its mean (±standard deviation) concentration was 252.6 (±111.9) ng/ml. SN-38 was detected in only one of the patients who received oxaliplatin-irinotecan-leucovorin-5-fluorouracil treatment and who had the wild-type uridine diphosphate-glucuronosyltransferase 1A1 phenotype at a concentration of 74.37 ng/ml.

CONCLUSION

CPT-11 and SN-38 are detected in sweat released during intravenous CPT-11 administration. Beads of sweat or linen clothes that absorb the sweat might be the source of CPT-11 and SN-38 exposure.

Closed-system drug-transfer devices plus safe handling of hazardous drugs versus safe handling alone for reducing exposure to infusional hazardous drugs in healthcare staff

BACKGROUND

Occupational exposure to hazardous drugs can decrease fertility and result in miscarriages, stillbirths, and cancers in healthcare staff. Several recommended practices aim to reduce this exposure, including protective clothing, gloves, and biological safety cabinets ('safe handling'). There is significant uncertainty as to whether using closed-system drug-transfer devices (CSTD) in addition to safe handling decreases the contamination and risk of staff exposure to infusional hazardous drugs compared to safe handling alone.

OBJECTIVES

To assess the effects of closed-system drug-transfer of infusional hazardous drugs plus safe handling versus safe handling alone for reducing staff exposure to infusional hazardous drugs and risk of staff contamination.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, OSH-UPDATE, CINAHL, Science Citation Index Expanded, economic evaluation databases, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to October 2017.

SELECTION CRITERIA

We included comparative studies of any study design (irrespective of language, blinding, or publication status) that compared CSTD plus safe handling versus safe handling alone for infusional hazardous drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models. We assessed risk of bias according to the risk of bias in non-randomised studies of interventions (ROBINS-I) tool, used an intracluster correlation coefficient of 0.10, and we assessed the quality of the evidence using GRADE.

MAIN RESULTS

We included 23 observational cluster studies (358 hospitals) in this review. We did not find any randomised controlled trials or formal economic evaluations. In 21 studies, the people who used the intervention (CSTD plus safe handling) and control (safe handling alone) were pharmacists or pharmacy technicians; in the other two studies, the people who used the intervention and control were nurses, pharmacists, or pharmacy technicians. The CSTD used in the studies were PhaSeal (13 studies), Tevadaptor (1 study), SpikeSwan (1 study), PhaSeal and Tevadaptor (1 study), varied (5 studies), and not stated (2 studies). The studies' descriptions of the control groups were varied. Twenty-one studies provide data on one or more outcomes for this systematic review. All the studies are at serious risk of bias. The quality of evidence is very low for all the outcomes.There is no evidence of differences in the proportion of people with positive urine tests for exposure between the CSTD and control groups for cyclophosphamide alone (RR 0.83, 95% CI 0.46 to 1.52; I² = 12%; 2 studies; 2 hospitals; 20 participants; CSTD: 76.1% versus control: 91.7%); cyclophosphamide or ifosfamide (RR 0.09, 95% CI 0.00 to 2.79; 1 study; 1 hospital; 14 participants; CSTD: 6.4% versus control: 71.4%); and cyclophosphamide, ifosfamide, or gemcitabine (RR not estimable; 1 study; 1 hospital; 36 participants; 0% in both groups).There is no evidence of a difference in the proportion of surface samples contaminated in the pharmacy areas or patient-care areas for any of the drugs except 5-fluorouracil, which was lower in the CSTD group than in the control (RR 0.65, 95% CI 0.43 to 0.97; 3 studies, 106 hospitals, 1008 samples; CSTD: 9% versus control: 13.9%).The amount of cyclophosphamide was lower in pharmacy areas in the CSTD group than in the control group (MD -49.34 pg/cm², 95% CI -84.11 to -14.56, I² = 0%, 7 studies; 282 hospitals, 1793 surface samples). Additionally, one interrupted time-series study (3 hospitals; 342 samples) demonstrated a change in the slope between pre-CSTD and CSTD (3.9439 pg/cm², 95% CI 1.2303 to 6.6576; P = 0.010), but not between CSTD and post-CSTD withdrawal (-1.9331 pg/cm², 95% CI -5.1260 to 1.2598; P = 0.20). There is no evidence of difference in the amount of the other drugs between CSTD and control groups in the pharmacy areas or patient-care areas.None of the studies report on atmospheric contamination, blood tests, or other measures of exposure to infusional hazardous drugs such as urine mutagenicity, chromosomal aberrations, sister chromatid exchanges, or micronuclei induction.None of the studies report short-term health benefits such as reduction in skin rashes, medium-term reproductive health benefits such as fertility and parity, or long-term health benefits related to the development of any type of cancer or adverse events.Five studies (six hospitals) report the potential cost savings through the use of CSTD. The studies used different methods of calculating the costs, and the results were not reported in a format that could be pooled via meta-analysis. There is significant variability between the studies in terms of whether CSTD resulted in cost savings (the point estimates of the average potential cost savings ranged from (2017) USD -642,656 to (2017) USD 221,818).

AUTHORS' CONCLUSIONS

There is currently no evidence to support or refute the routine use of closed-system drug transfer devices in addition to safe handling of infusional hazardous drugs, as there is no evidence of differences in exposure or financial benefits between CSTD plus safe handling versus safe handling alone (very low-quality evidence). None of the studies report health benefits.Well-designed multicentre randomised controlled trials may be feasible depending upon the proportion of people with exposure. The next best study design is interrupted time-series. This design is likely to provide a better estimate than uncontrolled before-after studies or cross-sectional studies. Future studies may involve other alternate ways of reducing exposure in addition to safe handling as one intervention group in a multi-arm parallel design or factorial design trial. Future studies should have designs that decrease the risk of bias and enable measurement of direct health benefits in addition to exposure. Studies using exposure should be tested for a relevant selection of hazardous drugs used in the hospital to provide an estimate of the exposure and health benefits of using CSTD. Steps should be undertaken to ensure that there are no other differences between CSTD and control groups, so that one can obtain a reasonable estimate of the health benefits of using CSTD.