EVALUATION RESULTS AND DISCUSSION
Housekeeping services were provided by the hospital, which leased the space to the oncology clinic. Clinic employees and the employer expressed concerns that cleaning and chemotherapy drug waste disposal practices were inadequate. Most of the surface-wipe samples contained platinum, but two hand wipes collected from nurses who had recently handled these drugs had no platinum on the first clinic visit. Surface-wipe samples from locations throughout the clinic contained cyclophosphamide and ifosfamide, which suggests inadequate work practices and housekeeping. Cyclophosphamide was found in the checkout area, an area that should not have chemotherapy drug contamination. Furthermore, one sample location remained positive for cyclophosphamide for all 3 days of our second visit to the clinic, which suggests this drug was not being effectively removed in one cleaning. None of the surface-wipe samples detected doxorubicin; however, its recovery may have been poor because these samples had been frozen for approximately 7 months awaiting development of an analytical method (Gregory A. Burr, CIH, e-mail communication, October 7, 2011).
Our inspection of the class 2 BSC indicated it was operating properly; it was certified annually. The average face velocity of the BSC met the CDC recommendation of at least 100 linear feet per minute.11
Four employees reported having runny nose, sneezing, eye irritation, or headache that improved on their days off work. One employee reported experiencing a recurring rash with a burning sensation on the nose after handling chemotherapy drug waste. Because upper respiratory symptoms are nonspecific and common in the general population, we cannot determine if these symptoms were associated with chemotherapy drug exposures. All employees who were interviewed reported they were adequately trained on how to safely prepare, administer, and dispose of chemotherapy drugs. However, a few employees reported inadequate training on potential short- and long-term health effects of chemotherapy drug exposure.
Clinic employees said they did not wear personal protective equipment (PPE) consistently. They wore double gloves, goggles, and chemotherapy-protective gowns when preparing chemotherapy drugs, but some employees did not always wear double gloves or chemotherapy-protective gowns when administering the drugs to patients. In addition, some employees voluntarily wore a filtering facepiece respirator or a surgical mask to avoid contaminating the chemotherapy drugs or to protect the patients; however, some of them reported using their surgical masks more than one time. We did not observe any activities during our evaluation that required using respiratory protection.
Due to inconsistent use of personal protective equipment and the presence of chemotherapy drug residue in the clinic, our HHE report concluded that clinic employees were at risk of acute and chronic health effects from exposure to chemotherapy drugs. Our recommendations included improving employee work practices and housekeeping, starting a medical surveillance program for employees, providing annual training, and requiring the use of appropriate PPE when handling chemotherapy drugs.
Many of our recommendations for improving employee health and safety at this oncology clinic can be utilized to reduce hazards at any workplace. The hierarchy of a controls approach groups actions by how effectively they reduce or remove hazards. The most effective way to reduce exposure or shield employees from hazards is to eliminate hazardous materials and processes or install engineering controls. Until such controls are in place, or if they are not effective or feasible, administrative measures and diligent use of PPE may be needed. Additional information on preventing occupational exposure to antineoplastic and other hazardous drugs in health care settings is available at www.cdc.gov/niosh/docs/2004-165/.10
As a result of the HHE of this oncology clinic, our report included the following recommendations to improve the health and safety of employees handling chemotherapy drugs.
• Carry chemotherapy drug bags and related equipment to the administration area in a sealed plastic bin to prevent spills and minimize contact with potentially contaminated surfaces. Clean the plastic bin after each use.
• Place a physical indicator (or sign) on the biological safety cabinet to identify the proper sash height to ensure that airflow into the hood is at least 100 linear feet per minute. The physical indicator would also serve as another way to identify the proper sash height in the event that the BSC sash alarm is malfunctioning.
• Organize a health and safety committee that includes managers and employees to routinely discuss health and safety concerns.
• Initiate a medical surveillance program and provide annual training for employees who handle chemotherapy drugs, including waste disposal.
• Review cleaning procedures with employees. Dispose of chemotherapy drugs and disposable administration equipment in approved chemotherapy waste bags. Clean up chemotherapy drug spills quickly using the proper spill kit. Test kits using fluorescein dye can be used to assess the techniques of clinic employees who Instruct employees and cleaning staff to clean work surfaces after chemotherapy drugs are used, and at the end of each day. Establish janitorial policies and procedures for each clinic area where chemotherapy drugs are handled, and clearly communicate these policies and procedures with the cleaning contractor.
• Observe employee and patient activities in the checkout area to determine where chemotherapy drug cross-contamination may occur.
• Clean BSCs with a deactivating agent and disinfectant at the beginning and end of each work shift, before and after each activity, and after spills. The American Society of Health-System Pharmacists notes that strong oxidizing agents such as sodium hypochlorite solution may effectively deactivate many chemotherapy drugs.12 Use a thiosulfate-based solution after cleaning with sodium hypochlorite to neutralize its corrosive effect to surfaces. US Pharmacopeia and National Formulary guidelines require a final cleaning with a residue-free disinfecting agent, such as sterile 70% isopropyl alcohol.13
• Report workplace safety or health concerns to your supervisor. Follow up with a health care provider who is knowledgeable about occupational diseases.
• Do not consume food or beverages in work areas where chemotherapy drugs are handled.