Health Articles

Sun-nurses.sk.ca

December 2010
OH&S FAST FACTS:
Drugs that fight cancer and other hazardous agents are valuable and vital to the care of patients. Health care workers need to know the hazards they Your Health. Your Safety.
are dealing with to ensure they remain safe while caring for their patients. Hazardous Drugs in Health Care
Drugs that meet one or more of the following criteria should be Working with or near hazardous drugs
handled as hazardous: in health care settings may cause skin
rashes, infertility, miscarriage, birth
• Carcinogenicity defects, and possibly leukemia or other
• Teratogenicity or developmental toxicity • Reproductive toxicity The concern for health care workers • Organ toxicity at low doses exposed to cytotoxic drugs has been • Genotoxicity present since the 1970s. If you are like • Structure or toxicity similar to me, you may recall administering drugs classified as hazardous chemotherapy as if it were any other drug, legislation to protect workers from the using the above criteria without a concern for your own health or adverse effects. During the revisions to your surrounding environment. the Saskatchewan Occupational Health From Preventing Occupational and Safety Regulations in 1996, a section Exposures To Antineoplastic Even in the '80s, I had not been made was added specifically for health care And Other Hazardous Drugs In aware of the personal protection I workers. Section 471 requires Employers Healthcare Settings. (NIOSH, 2004) required. I went on blissfully unaware of in health care facilities to take all the possible harmful effects. I cringe at practicable steps to minimize worker the memory of standing in the hospital exposure to cytotoxic drugs or materials, hallway reconstituting the powder and or equipment contaminated with cytotoxic priming the IV tubing – no mask, no Inside this issue:
respirator, no gown, no gloves, no biological safety cabinet. I remember Where workers are required to prepare, reading the study in the '80s of nurses administer, handle, or use cytotoxic drugs, who prepared and administered cytotoxic or are likely to be exposed to them, the Hazardous Drugs drugs. They were found to have mutagenic Employer must prepare and implement a in Health Care 1 substances in their urine. This mobilized written program. The program includes me to make changes in my workplace and written procedures and other precautions List of Antineoplastic and Other in my personal nursing practices. to ensure the health and safety of workers. Hazardous Drugs in Healthcare The Employer must train workers on the Since then, there have been numerous content of the program and its procedures studies and surveys regarding the when implementing the program. In 1999, Personal Protective Equipment occupational exposure to cytotoxic and the OH&S Branch produced "Guidelines Standards and pH1N1 other hazardous drugs, and the adverse on Cytotoxic Drugs." Hand Hygiene: #1 effects on health care workers. Saskatchewan joined other jurisdictions What drugs are considered "hazardous?" Precaution for NDM-1 and implemented occupational health Hazardous drugs include those used for cancer chemotherapy, antiviral drugs, OH&S Courses, 2011

hormones, some bioengineered drugs, and other • Prepare hazardous drugs inside a ventilated cabinet miscellaneous drugs. The National Institute for Occupational designed to protect workers and others from exposure Safety and Health (NIOSH) provided a list of the hazardous and to protect all drugs that require sterile handling. drugs in the Alert: Preventing Occupational Exposures to • Use two pairs of powder-free, disposable chemotherapy Antineoplastic and Other Hazardous Drugs in Health Care gloves, with the outer one covering the gown cuff Settings, published in September 2004. In 2010, the list was whenever there is risk of exposure to hazardous drugs. updated by NIOSH.
• Avoid skin contact by using a disposable gown made of polyethylene-coated polypropylene material (which is Are health care providers who work with cancer drugs at non-linting and non-absorbent). Make sure the gown has an increased risk for toxic events? The studies describe an a closed front, long sleeves, and elastic or knit closed association between exposure to a ntineoplastic drugs and cuffs. Do not reuse gowns. adverse reproductive effects in female health care workers. • Wear a face shield when splashes to the eyes, nose, or Various acute toxic effects of antineoplastic agents are well mouth may occur and when adequate engineering documented in patients treated with high doses of these controls (such as the sash or window on a ventilated agents. These include such effects as nausea, rashes, hair cabinet) are not available. loss, liver and kidney damage, hearing loss, cardiac and hematapoetic toxicities and others. Some of these effects • Wash hands with soap and water immediately before have been documented in workers handling antineoplastic using personal protective clothing (such as disposable agents (CDC).
gloves and gowns) and after removing it. What activities put you at risk for exposure to hazardous drugs? If you work with hazardous drugs, or the patients receiving the drugs, you are at risk to exposure from actions such as preparing meds, expelling air from the syringe, administering the med, handling waste, counting/ crushing pills, generating aerosols, priming IV set, decontaminating, transporting, handling bodily fluids, etc.
What steps should health care workers take to protect themselves from hazardous drugs? NIOSH offers this • Read all information and material safety data sheets (MSDSs) your Employer provides to you for the hazardous drugs you handle. • Participate in any training your Employer provides on the • Use syringes and IV sets with Luer-Lok™ fittings for hazards of the drugs you handle and the equipment and preparing and administering hazardous drugs. procedures you should use to prevent exposure. • Place drug-contaminated syringes and needles in • Be familiar with and able to recognize sources of chemotherapy sharps containers for disposal. exposure to hazardous drugs. Sources of exposure include all procedures involving hazardous drugs • When supplemental protection is needed, use closed- (including preparation, administration, and cleaning), system drug-transfer devices, glove bags, and needleless and all materials that come into contact with hazardous systems inside the ventilated cabinet. drugs (including work surfaces, equipment, personal • Handle hazardous wastes and contaminated materials protective equipment [PPE], intravenous [IV] bags and separately from other trash. tubing, patient waste, and soiled linens). • Clean and decontaminate work areas before and after • Prepare hazardous drugs in an area that is devoted to that each activity involving hazardous drugs and at the end of purpose alone and is restricted to authorized personnel.
• Clean up small spills of hazardous drugs immediately, using proper safety precautions and PPE.
• Clean up large spills of hazardous drugs with the help of NOTE: This article will appear in the next issue of
an environmental services specialist. SUNSpots. Below, I have added a section listing the
Hazardous Drugs listed in the NIOSH Alert for 2010.
Please check your workplace safety plan regarding hazardous drugs. Refer to the OH&S guidelines from Sask (NIOSH info at http://www.cdc.gov/niosh/docs/2010-
OH&S or NIOSH. Yes, we have come a long way since the 167;Saskatchewan's Cytotoxic Guidelines are found
'70s. You know the risks – insist on hazard controls. Norma Wallace, SUN OH&S Officer NIOSH ALERT: List of Antineoplastic and Other Hazardous
Drugs in Healthcare Settings 2010
NIOSH Alert states: Workers may be exposed to
proper procedures and protective equipment for handling hazardous drugs in the air or on work surfaces, clothing, hazardous drugs. medical equipment, and patient urine or feces. The term hazardous drugs, as it is used in this Alert, includes drugs This Alert warns health care workers about the risks of that are known or suspected to cause adverse health effects working with hazardous drugs and recommends methods from exposures in the workplace. They include drugs used and equipment for protecting their health. The Alert for cancer chemotherapy, antiviral drugs, hormones, some addresses workers in health care settings, veterinary bioengineered drugs, and other miscellaneous drugs. The medicine, research laboratories, retail pharmacies, and health risk depends on how much exposure a worker has home health care agencies; it does not address workers in to these drugs and how toxic they are. Exposure risks can the drug manufacturing sector. Included in the Alert are five be greatly reduced by (1) making sure that engineering case reports of workers who suffered adverse health effects controls such as a ventilated cabinet are used and (2) using after being exposed to antineoplastic drugs.
Arsenic trioxide Mitoxantrone HCl Antivirals
Imatinib mesylate  Trifluridine Cyclophosphamide Interferon alfa-2a Interferon alfa-2b Interferon alfa-n1 Interferon alfa-n3 Toremifene citrate Daunorubicin HCl Leuprolide acetate Vinblastine sulfate Androgens
Vincristine sulfate Methyltestosterone phosphate sodium Oxytocics
lists are intended to guide  Estrogen-progestin  Alitretinoin health care providers in methylergonovine  Podophyllum resin diverse practice settings and  Mifepristone should not be construed as complete representations of Estrogens
all of the hazardous drugs Antibiotics
used at the referenced  Chloramphenicol  Mycophenolate institutions.  Estrogens, esterified Some drugs defined as Unclassified therapeutic
hazardous may not pose a significant risk of direct occupational exposure because of their dosage antagonists
formulation (for example,  Cetrorelix acetate  Trimetrexate intact medications such as  Ganirelix acetate coated tablets or capsules  Choriogonadotropin that are administered to  Azathioprine Vaccines
patients without modifying  Gonadotropin, the formulation). However, they may pose a risk if solid drug formulations are al- Cell stimulants and
NIOSH states: These lists
tered outside a ventilated of hazardous drugs were used with the permission of cabinet (for example, if the institutions that provided tablets are crushed or dis- solved, or if capsules are Miscellaneous skin and
them and were adapted for pierced or opened). mucous membrane agents
use by NIOSH. The sample
Personal Protective Equipment Standards and pH1N1
The Saskatchewan Ministry of Health has released a
If this decision is based on new scientific evidence that has document regarding new infection control and personal proven the influenza virus is not transmitted via aerosol or protective equipment standards for dealing with influenza droplet nuclei then this is good news. including pH1N1. If this document is not based on proven modes of Their bulletin has been based on a draft PHAC document transmission, then health care workers must continue to "Routine Practices and Additional Precautions for protect themselves with the N95 respirator, gown, gloves Preventing the Transmission of Infection in Healthcare, 2010." and face shield. According to the Health Ministry memo, the new guide- The flu vaccination is now available for health care workers lines state that influenza is transmitted only through droplet and is another measure to protect yourself and others. and requires only a surgical mask for your protection. Norma Wallace, SUN OH&S Officer FYI: The G22 Safety Association has now been renamed: Association for Safe
Workplaces in Health. The Interim Executive Director is Dan Clarke and he is
working to have the office up and running in January, 2011. The Safety
Association office will be located in Regina. Staff hiring will begin soon.

OH&S Newsletter
Hand Hygiene: #1 Precaution for NDM-1
NDM-1 is an enzyme that can spread between bacteria, Infection control signage should be placed on the room making germs impervious to many antibiotics. NDM-1 door indicating Contact Precautions required upon entry to stands for "New Delhi metallo beta-lactamase." Health the room. Gloves should be worn when entering the room care workers have had VRE and MRSA concerns in their of a patient colonized or infected with a CRGNB. Gowns workplaces, for their patients and themselves, and can now should be worn if it is anticipated that clothing or forearms add NDM-1 to that list of "superbugs" (although NDM-1 will be in direct contact with the patient or with environmental surfaces or objects in the patient care Cases found in Canada
NDM-1 has been found in Canada and there have been Highly resistant strain
eight cases reported this year. The Public Health Agency In a recent bulletin, the World Health organization featured of Canada (PHAC) has developed John Conly, a Professor of Medicine, a document to provide infection Microbiology and Infectious Diseases and prevention and control Pathology and Laboratory Medicine at the guidance to health care workers Centre for Antimicrobial Resistance at the (HCWs) in the management of University of Calgary. Conly is also the patients colonized or infected co-director for the Snyder Institute of with carbapenem-resistant Infection, Immunity and Inflammation at Gram-negative bacilli (CRGNB), the University of Calgary, and the former including the New Delhi metallo Chairman of the Board for the Canadian beta-lactamase (NDM-1). It can Committee on Antibiotic Resistance. He be found on their web site at : states: "NDM-1 is an enzyme that confers resistance to one of the most potent classes of antibiotics, known as ipcm-mpci-eng.php. carbapenems, but what has been observed is different in many ways to what we They state that in addition to have seen to date. This new resistance routine practices, patients As with all infectious organisms, HAND pattern has been reported in many
colonized or infected with WASHING is the key protective measure. different types of bacteria compared to
CRGNB, including bacteria previously and at least one in 10 of these harbouring the NDM-1 in health care settings, should be NDM-1-containing strains appears to be pan-resistant, placed on Contact Precautions. This should include which means that there is no known antibiotic that can treat patients suspected of harbouring a CRGNB (e.g. based on it. A second concern is that there is no significant new drug prolonged contact with a person known to carry CRGNB, development for antimicrobials. Third, this particular or if preliminary laboratory testing suggests possible resistance pattern is governed by a set of genes that can CRGNB) until etiology is confirmed. Specific move easily from one bacterium to another. Fourth, NDM-1 attention should be given to laboratory testing/surveillance, has been found in the most commonly encountered screening, hand hygiene, accommodation, personal bacterium in the human population, E. coli, which is the protective equipment, patient care equipment, most common cause of bladder and kidney infections. environmental cleaning, laundry/waste management, reporting, discontinuing of Contact Precautions, and A further concern is that of the two drugs potentially capable of treating an infection due to one of these new multiresistant strains, one of them, colistin, causes toxic Hand washing critical
effects to the kidney in about a third of people." Occupational health and safety measures are based on the hazard and its transmission. As with all other infectious As Canada, and perhaps Saskatchewan, may encounter organisms, HAND WASHING is the key protective additional patients with NDM-1, all health care workers measure. Alcohol-based hand rubs are effective against must remain vigilant in identifying possible cases and gram-negative bacilli so rubs can be used as well as soap ensuring infection control and personal protective and water. In accordance with the PHAC guideline, measures are maintained. patients should be cared for in single rooms, or cohorted Norma Wallace, SUN OH&S Officer with other patients with the same strain of CRGNB. Occupational Health and Safety Division Courses Page 6
January to March, 2011The Occupational Health and Safety Division of the Labour Weyburn: Relations and Workplace Safety provides training for OH&S Committee members. Courses are free of charge. Jan 11 - 12; Mar 1- 2 Occupational Health Committee members may attend OCCUPATIONAL HEALTH COMMITTEES:
without loss of pay or benefits, as per subsection 46(4) of LEVEL 2 (LEVEL 1 IS A PREREQUISITE)
the Regulations. Lunch is not provided (one hour break). You must register if you wish to attend. Please have your Occupational Health Committee number and names of attendees ready when you call. Details on location of course will be given when you register.
North Battleford: To register call:
1-800-567-7233 or 787-4496
1-800-667-5023 or 933-5052
Jan 13 -14; Jan 27 – 28; Feb 24 – 25; Mar 10 – 11; January – March 2011 Training
Jan 20 – 21; Feb 3 – 4; OCCUPATIONAL HEALTH COMMITTEES:
Feb 24 – 25; Mar 3 – 4; SUPERVISION AND SAFETY
North Battleford: INTRODUCTION TO THE WORKPLACE
HAZARDOUS MATERIALS INFORMATION
Need More Information??
Visit SUN's web site for additional resource information: www.sun-nurses.sk.ca
OR contact Norma Wallace, SUN OH&S Officer to request an OH&S session in your
Saskatoon SUN Office
204-440 2nd Avenue
Toll free: 800-667-3294
Saskatoon, SK S7K 2C3

Source: http://sun-nurses.sk.ca/+pub/document/OH&S/Newsletter/2010/OH%20&%20S%20Bulletin%20December%202010.pdf