No available data demonstrate a correlation between workers’ age and occupational exposure to hazardous antineoplastic drugs or adherence to PPE. Nevertheless, a 10-member nurse advisory council—all subject matter experts—assembled in August 2014 by Equashield, a leading developer of CSTDs, reached a consensus opinion concerning generational differences in uptake of adherence to recommended PPE. Younger nurses, those of childbearing age, seem more likely to be concerned about exposure risk and outcomes. Yet younger nurses are most often mentored by baby-boomer nurses who seem relatively unconcerned about known adverse effects of antineoplastic drug exposure. For sure, many if not most experienced nurses serving as mentors are beyond childbearing age, and perhaps, perceive minimal personal risks. In fact, no long-term data is available or is being collected to assess and document effects of chronic long-term exposure.11

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Nurses have critical roles in developing policies and procedures to foster a culture of safety in the workplace, and in oncology settings, responsibilities include safe handling of hazardous drugs and selection, introduction, and adherence to correct use of PPEs. Workplace safety in the context of hazardous drug exposure is complex and challenging, involving interdependencies that surround the problem. There is no quick and easy solution in sight. Davis and colleagues contend: “A basic tenet of employment is the provision of a safe workplace. It may be impossible to remove all risk but it is imperative that risk is minimized.”11

The proposed USP <800> protocol mandates the use of CSTDs for nurses administering hazardous drugs, and NIOSH now suggests that, in addition to use of PPE, “closed system drug transfer devices for both pharmacy and nursing personnel can provide an additional level of protection.”17 An effective CSTD, as defined by NIOSH, is a system that “mechanically prohibits the transfer of environmental contaminants into the system and the escape of hazardous drug or vapor concentrations outside the system.”7


Occupational safety experts contend that CSTD use should not be optional; that purchase and use of these devices must be viewed as a cost of doing business.18 Variables to consider when purchasing and implementing a CSTD include efficacy, cost, and ease-of-use. For nurses in particular, two key areas should be assessed when selecting a CSTD. First, the efficacy of the system in containing hazardous drugs, vapors, and aerosols should be a key concern. Systems that are truly closed have a full pressure equalization system (rather than a vented system, as some closed systems have). Without completely containing the contents within a closed system, the environment is susceptible to contamination by hazardous drug vapors and aerosols.19

Other key routes of exposure that should be closed by an effective CSTD include the syringe, needle, connection ports, and the syringe barrel and plunger.20 These four routes can be closed by using needleless or needle-safe systems in which the needle is never exposed, using a truly dry connector system that prevents drug residuals at connection points even after multiple connections (including between drug vial and syringe, between syringe and infusion bag, and between connector pieces on tubing sets), using a syringe that is fully encapsulated at the back of its barrel and has a sealed plunger to prevent plunger contamination and major spills by accidental removal of the plunger.

A second major consideration for nurses when implementing a CSTD is the system’s ease of use. This includes the number of steps required to use the system, time/efficiency of process, and the ease of connecting various pieces. Berdi and colleagues assessed the efficiency of three CSTD brand name devices for compounding hazardous drugs.18 The authors found that having “simple, intuitive connections ensures consistent use and ease the staff training process.”18 Although this article examined the efficiency of CSTDs in pharmacy use, a logical assumption is that the fewer the steps, and the easier the processes involved, the higher the adoption and consistent use of CSTDs will be among nurses as well.