Unintentional Exposure to Chemo High Among Nurses

Roxanne Nelson

August 26, 2011

August 26, 2011 — Chemotherapy can be life saving to a cancer patient, but unintentional exposure to these powerful agents may be endangering the lives of healthcare workers. Exposure to "secondhand chemo" can confer significant health risks, such as immediate nervous system effects, acute and long-term reproductive effects (eg, infertility and miscarriage), and a subsequent risk for hematologic malignancies.

According to a new study, published online August 16 in BMJ Quality & Safety, the overall rate of exposure to the skin or eyes in the past year among nurses working in outpatient settings, was 16.9%.

The authors found that a favorable working environment, lower nursing workloads, and adherence to 2-nurse chemotherapy verification were associated with reduced exposure.

There has been a big push for needle safety, but safe handling of chemotherapy does not receive much attention. "We have minimized needle stick incidents so that they are rare events that elicit a robust response from administrators," said lead author Christopher Friese, RN, PhD, assistant professor at the University of Michigan School of Nursing, Ann Arbor. "Nurses go immediately for evaluation and prophylactic treatment. But we don’t have that with chemotherapy exposure."

But we don’t have that with chemotherapy exposure.

"I think the untapped areas are consistent use of personal protective equipment and safe disposal of drugs/tubing," he told Medscape Medical News. "What it really comes down to is training and behavior change. Arguably these things are challenging to alter."

Dr. Friese suggests that more time needs to be spent on these issues. "The key is to get practicing nurses to think differently about their approach to handling these agents," he said.

Accidental Exposure Underreported?

It is also quite possible that accidental exposure is being underreported by nurses. "As we have talked with nurses about out findings, we also learned that very few report spills, leaks, and so on, to their managers," Dr. Friese said. "This reduces the ability for managers to troubleshoot current practice to improve safety."

"I get the sense nurses are embarrassed when spills occur," he added. "Just as we have focused on a blame-free culture in patient safety, it's time to do the same for employee safety."

Lack of Regulations

Care that was once delivered in hospital is now increasingly being delivered in outpatient settings, and chemotherapy administration is also largely administered by nurses. But despite the risks associated with exposure to these agents, there is no regulatory framework for chemotherapy delivery in ambulatory oncology settings. The National Institute for Occupational Safety and Health issued an alert in 2004 on occupational exposure to antineoplastic and other hazardous drugs, which makes perhaps the strongest case regarding the dangers associated with these drugs.

At the beginning of the document, a prominent and ominous boxed warning states:

"Working with or near hazardous drugs in health care settings may cause skin rashes, infertility, miscarriage, birth defects, and possibly leukemia or other cancers."

However, the alert is advisory and has no regulatory enforcement. The Centers for Medicare and Medicaid Services also performs little oversight over the delivery of chemotherapy, the author note.

In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) issued voluntary safety standards for chemotherapy administration in the ambulatory setting (J Clin Oncol. 2009;27:5469-5475). However, it is unknown how many practices are incorporating these standards, and thus far, only 74 are certified by ASCO’s Quality Oncology Practice Initiative for standard adherence.

The 17 standards that were assessed for Quality Oncology Practice Initiative certification are largely geared toward patient safety and do not address safe handling practices and related policies, Dr. Friese and coauthors point out. In addition, there is also currently no mechanism in place to track unintentional exposures to chemotherapy or the conditions under which the exposure occurred.

Workloads and Culture of Safety

The majority of chemotherapy is delivered in ambulatory settings, thus highlighting the importance of this study, commented Martha Polovich, PhD, RN, associate director of clinical practice at the Duke Oncology Network, Durham, North Carolina, who was approached for an outside commentary.

"This study is useful in that it shows how safety is affected — not just for patients but for employees," said Dr. Polovich, who is also one of the coauthors of the ASCO/ONS guidelines. "It all ties together because it concerns the health of the healthcare providers."

There is variation among practices, but workload was one of the most significant factors for exposure risk, Dr. Polovich pointed out. "Nursing workloads have been related to other issues in healthcare," she said. "This is not new in the industry, that workload is related to safety. We’ve known this since the 1970s, but no one has tried to apply it to healthcare until recently."

However, one of the problems in the ambulatory setting is that there aren’t any really good tools for measuring acuity. "There’s really not a good measure that has been well validated," she said.

Another interesting finding was that exposure was decreased when chemotherapy doses were verified by 2 nurses. "The double check describes a culture of safety," said Dr. Polovich.

The ASCO/ONS guidelines have recently been revised, and the updated version will be published in January. "The biggest change in the recommendations is that they will be applied to all settings, not just ambulatory," she explained. "And there is added content about staff safety, as well as patient safety."

Favorable Environment, Lower Workload

In the current study, Dr. Friese and colleagues sent questionnaires to 1339 oncology nurses who were employed outside of hospital inpatient units. Their survey examined the likelihood of self-reported exposure to chemotherapy as "a function of perceived quality of the practice environment," nursing workload, and 7 ambulatory chemotherapy administration safety standards.

Of this group, 402 nurses responded to the survey (response rate of 30.5%).

Although not a statistically significant finding, 62.2% of nurses who were exposed to chemotherapy reported a favorable practice environment, as compared with 74.7% of nurses who were not exposed to chemotherapy (P = .12).

The workload was also higher among nurses who reported exposure — they had an average patient assignment of 11.1 patients per shift vs 8.43 patients per shift reported by those who were not exposed (P = .02). The range of the reported nurse workload across the sample stretched from 0 to 38 patients on the last shift.

Chemotherapy orders were verified by 2 or more nurses on a frequent or very frequent basis 94.5% of the time for the entire cohort. However, only 82.9% of nurses exposed to chemotherapy indicated this was true for them, as compared with 96.9% of nurses not exposed to chemotherapy (P < .01). Years of nursing employment did not differ significantly by exposure status (P = .58).

The study was funded by a Pathway to Independence Award from the National Institute of Nursing Research, National Institutes of Health, and in part the University of Michigan Comprehensive Cancer Centre. The author have disclosed no relevant financial relationships.

BMJ Qual Safety. Published online August 16, 2011.

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