Health care workers who handle hazardous drugs are at risk of skin rashes, cancer, and reproductive disorders. NIOSH recommends that employers provide appropriate personal protective equipment (PPE) to protect workers who handle hazardous drugs in the workplace.
Description of Exposure
Health care workers face serious health risks when exposed to hazardous drugs. This is a group of drugs that cause spe-cific health effects such as cancer or birth defects, or are highly toxic at low doses. A list of hazardous drugs has been de-veloped by NIOSH . For patients, potential benefits of treatment outweigh the risks from adverse side effects. How-ever, health care workers should minimize their exposure and health risks.
In the United States, an estimated 8 million health care workers [BLS 2007] are potentially exposed to hazardous drugs or drug waste at their worksites. These workers include pharmacy and nursing personnel, physicians, operating room personnel, veterinary personnel, shipping and receiving personnel, laundry workers, waste handlers, and maintenance workers. They may be exposed to hazardous drugs when they handle drug vials; compound, administer, or dispose of hazardous drugs; clean spills; or touch contaminated surfaces. These activities may create aerosols, thereby increasing the risk of exposure [NIOSH 2004]. Inhalation, ingestion, (from hand to mouth), injection with a sharp, and transconjunctival or skin absorption are possible routes of exposure.
NIOSH recommends minimizing exposure to hazardous drugs [NIOSH 2004] through primary prevention measures such as engineering controls, administrative controls, and personal protective equipment (PPE). Engineering controls include Class II or III biological safety cabinets (BSC), compounding aseptic containment isolators, closed system transfer devices, and needleless systems. Administrative controls include implementing work practices, management policies, and training programs to reduce worker risk. A medical monitoring program serves as a form of secondary prevention by identifying indicators of exposure or early disease [NIOSH 2007]. PPE should be used when engineering controls and/or administrative controls are not feasible in reducing exposures to hazardous drugs or when other control measures are not available or practical [OSHA 1999]. PPE should always be used in the context of an overall health and safety program that provides adequate training, retraining, and periodic testing of the workers’ knowledge of the proper use of PPE.
PPE such as NIOSH-certified respirators and protective clothing must be used to reduce exposure to hazardous drugs when other measures are not possible. The following general guidelines apply to PPE use and care:
Surfaces in areas where hazardous drugs are present may be contaminated with these drugs [NIOSH 2004]. Not all gloves offer adequate protection from dermal exposure to hazardous drugs. Some gloves may permit rapid permeation of hazardous drugs. For example, polyvinyl chloride exam gloves offer little protection against drug exposures [Walle-macq et al. 2006]. Although thicker gloves may offer better protection, glove thickness does not always indicate the level of protection and may make work activities more difficult. Instead, it is important to rely on test information pro-vided by the glove manufacturer that demonstrates permeation resistance to specific hazardous drugs. Currently, guide-lines are only available for testing “chemotherapy gloves” [ASTM 2005] and information may not be available for other types of hazardous drugs.
Follow these work practices when using gloves:
Proper gowns protect the worker from spills and splashes of hazardous drugs and waste materials. Gowns should not have seams or closures that could allow drugs to pass through. They should have long sleeves with tight fitting cuffs. Disposable gowns made of polyethylene-coated polypropylene or other laminate materials offer better protection than those of non-coated materials [NIOSH 2004; ASHP 2006]. Cloth laboratory coats, surgical scrubs, or other absorbent materials permit the penetration of hazardous drugs, and can hold spilled drugs against the skin and increase exposure.
Follow these work practices when wearing gowns:
For most activities requiring respiratory protection, a NIOSH-certified N–95 or more protective respirator is sufficient to protect against airborne particles [NIOSH 2005]; however, these respirators offer no protection against gases and va-pors and little protection against direct liquid splashes. A surgical N-95 respirator provides the respiratory protection of an N-95 respirator and the splash protection provided by a surgical mask. Surgical masks alone do not provide respira-tory protection from drug exposure and should not be used to compound or administer drugs [NIOSH 2004].
Follow these recommendations when using respiratory protection:
Following medical evaluation, fit-test and train workers to use respiratory protection. Follow all requirements in the Occu-pational Safety and Health Administration respiratory protection standard [29 CFR 1910.134] (www.osha.gov/SLTC/etools/respiratory/index.html).
Eye and Face Protection
Proper eye and face protection is needed whenever hazardous drugs may splash in the eyes since many hazardous drugs are irritating to eyes and mucous membranes and may be absorbed by the eyes.
Follow these work practices when using eye and face protection:
Sleeve, Hair, and Shoe Covers
Other types of PPE may be used to reduce exposure or to protect workers from contamination.
Use sleeve covers constructed of coated materials to provide additional protection for the areas of the arms that come in contact with the BSC.
Use hair and shoe covers constructed of coated materials to reduce the possibility of particulate or microbial contamina-tion in clean rooms and other sensitive areas.
Do not wear shoe covers outside drug compounding areas to avoid spreading drug contamination to other areas and possibly exposing nonprotected workers.
Consider all PPE worn when handling hazardous drugs as being contaminated with, at a minimum, trace quantities of hazardous drugs.
Contain and dispose of such PPE either as trace or bulk contaminated waste [NIOSH 2004].
The principal authors of this document were Thomas H. Connor and Laurence D. Reed, National Institute for Occupa-tional Safety and Health; Martha Polovich, Oncology Nursing Society; Melissa A. McDiarmid, University of Maryland; Melissa M. Leone, Apria Healthcare; and Luci A. Power, University of California Medical Center, San Francisco. John J. Whalen, under a contract with the Public Health Service, Division of Federal Occupational Health, served as the lead writer/editor.
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