		Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

We’ve all heard “back in the day” stories about hazardous drug preparation and handling. Those of us who have been around a while remember the days of preparing chemotherapy in unventilated medication rooms, where we could tell what had previously been mixed in there just by looking at the colored streaks on the wall. Back in those days, we even shared tips on how to remove doxorubicin stains from white uniforms.

Early guidelines had the words “refrain from eating, drinking, smoking, and applying cosmetics while preparing chemotherapy.” We laugh now, but the reason these words were included is that hazardous drug preparation is exactly that—hazardous. We now know that exposure to these drugs can cause acute symptoms such as skin and nasal irritation, and long-term exposure has been linked to infertility and miscarriages, genetic changes, and an increased risk of developing cancer.

Hazardous drugs require safe handling—no one is going to argue about that. Although safe handling guidelines have been published by several organizations, their adoption remains elusive. For instance, some nurses forgo wearing protective gowns while administering chemotherapy. Others misuse personal protective equipment (PPE), and reuse a disposable gown all day long&mdash;sometimes all week long. Some would argue that misuse of PPE may be as hazardous as not using PPE at all.

Having administered chemotherapy as long as I have, I understand their actions. There was a time when chemotherapy infusion bags were spiked at the chair or bedside, so there was a risk of hazardous drug exposure when spiking the bag and then priming and connecting the tubing. However, chemotherapy infusion bags now are routinely primed with saline, so the risk of exposure while assembling the infusion system is virtually eliminated.

Safety experts argue that the tubing spike could fall out of the chemotherapy infusion bag as it is being hung or once it’s hanging on the IV pole. Aside from the fact that the RN should be checking the security of the tubing prior to hanging the bag on the pole, if there is concern that the chemotherapy could shower down on us from the IV pole, then the guidelines should include wearing rubber caps and other PPE to protect the tops of our heads. However, how practical is this? What we need now are hazardous drug handling guidelines that are evidence-based, acceptable to users, easy to implement, and cost-effective.

In other words, what is reasonable, as well as effective?

The Oncology Nursing Society (ONS) hosted a stakeholders meeting earlier this year on handling hazardous drugs, with representatives from the American Society of Clinical Oncology (ASCO), the American Society of Health-System Pharmacists, the Association of Community Cancer Centers, the Association of Pediatric Hematology/Oncology Nurses, and the Hematology/Oncology Pharmacy Association (HOPA) in attendance. A joint position statement that outlines strategies to protect healthcare workers was then developed and approved by ONS, ASCO, and HOPA.

The statement, “Ensuring Healthcare Worker Safety When Handling Hazardous Drugs,” notes that healthcare workers preparing hazardous drugs typically work as employees; consequently, safe handling is a shared responsibility of the employee and employer (Box).

The items listed in the position statement are generic statements, and leave many wondering how to implement the recommendations. The stakeholder group also identified areas for further collaboration, and the group plans to provide resources and tools to promote compliance with implementing safe handling precautions. They also plan to develop resources for using PPE and other safety devices, such as closed system transfer devices, and provide free access to a medical surveillance questionnaire template. These resources will provide valuable guidance to healthcare workers handling hazardous drugs.

		1. Joint position statement from the Oncology Nursing Society, American Society of Clinical Oncology, and Hematology/Oncology Pharmacy Association. Ensuring Healthcare Worker Safety When Handling Hazardous Drugs. https://www.ons.org/advocacy-policy/positions/practice/hazardous-drugs. Accessed April 17, 2015.	

Articles

Nurse's Notes

Although safe handling guidelines have been published by several organizations, their adoption remains elusive. 

More Than Guidelines: Safe Handling in Everyday Practice

	(left to right) Lisa Truini-Pittman is quality and patient safety coordinator, Linda Sullivan is infection preventionist, Kirsten Pedersen is service line educator, Tanaz Mistry is assistant patient services manager, and Jill Williams is patient services manager at the Smilow Cancer Hospital at Yale-New Haven in New Haven, Connecticut.

Decreasing hospital associated infection rates including Central Line—Associated Bloodstream Infections (CLABSIs) is an issue of ongoing focus nationwide. CLABSIs increase patient morbidity, mortality, and length of stay and are estimated to add between $3700 and $39,000 to the cost of a hospitalization.

Evidence-based guidelines have resulted in substantial improvements in many clinical settings. However, institutions continue to struggle to reduce CLABSI rates in the hematology, oncology, and post—stem cell transplant patients for many clinical reasons. The uniqueness of the disease, its treatment with cytotoxic agents, resulting immunodeficiency, risk of mucosal barrier injury, and the duration of central venous catheter use all play a role in increasing the susceptibility in this population.

A multidisciplinary team from the Hematology Oncology and Medical Oncology units at Smilow Cancer Hospital at Yale-New Haven has worked tirelessly to monitor, implement changes, and measure the resulting levels of success. Initially, they engaged frontline staff in the initiatives, provided education, validated competency, tracked staff caring for patients who developed CLABSI, and involved patients in the monitoring of clinical practice. Improvement in the CLABSI rates was nominal.

The Yale-New Haven Hospital CLABSI Prevention Committee instituted a guideline restricting clinicians from drawing blood cultures from central venous access devices (CVADs). This guideline is based on strong evidence that blood cultures drawn from CVADs have higher contamination rates and higher false positive infection rates. In the Oncology Services, this posed a challenge. Traditionally, management of CVADs by the oncology team was directed by the published guidelines of the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN). These guidelines recommended obtaining blood cultures from CVADs and peripherally.

Additionally, clinicians were concerned about patient discomfort and the quality of the patient experience. In fact, many clinicians informed patients that the CVADs would prevent them from having needle sticks for blood drawing.

In an effort to assist the two oncology units in the reduction of their CLABSI rates, an infectious disease physician and an infection preventionist, joined forces with the multidisciplinary team working on CLABSI reduction on these units. Discussions were held about the benefits and evidence behind the value of reducing blood cultures drawn from CVADs. Collaboratively, they developed a strategy to minimize the number of blood cultures drawn from CVADs. The end product was an algorithm that gave consideration to the clinicians’ concerns and minimized the number of central line cultures drawn.

Subsequently, the team implemented multiple rapid-fire interventions in its efforts to reduce CLABSI. A vein illuminator was purchased to assist nursing staff with obtaining peripheral blood cultures. Scripting was developed for clinicians to use to educate patients on the importance of obtaining blood cultures peripherally. Lastly, a CVAD blood drawing kit was customized and implemented along with a two-nurse process for drawing blood cultures from a CVAD. The two-person process was not continued, as it was not operationally sustainable. Introduction of these interventions was challenging for the clinical staff. However, staff demonstrated an eagerness to embrace changes that would result in both reduced CLABSI rates and better outcomes for their patients.

Prior to implementation of the algorithm and CVAD blood culture kit, the rate of blood cultures obtained from CVADS was 35.9% over 6 months, and the CLABSI rate was 3.4 infections/1000 device days. Following implementation, the percentage of cultures obtained from CVADs decreased to 20.3%, and the CLABSI rate decreased to 2.1 infections/1000 device days for the following 6 months. Hence, they achieved success in both reducing the number of blood cultures drawn from CVADs and in reducing their CLABSI rates.

Engagement of the patient and interdisciplinary team was critical to the success of this project. In 2014, these units demonstrated sustained success over the first three quarters. However, the fourth quarter of 2014 proved challenging and brought the team back to the conference table for additional strategizing on sustainability.

CLABSI prevention is a challenging national initiative. The patient with an oncology diagnosis is at high risk because of cancer’s unique biology and because of its unique treatment and toxicities. It will take ongoing efforts and vigilance to sustain successes in reducing CLABSI in this population. The teams of inpatient units NP 11 and 12, in collaboration with our Infection Control partners, will persevere with deliberate steps toward this goal.

			Metzger KE, Rucker Y, Callaghan M, et al. The burden of mucosal barrier injury laboratory-confirmed bloodstream infection among hematology, oncology, and stem cell transplant patients. 

			Schiffer CA, Mangu PB, Camp-Sorrell D, et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. 

			Snyder SR, Favoretto AM, Baetz RA, et al. Effectiveness of practices to reduce blood culture contamination: a Laboratory Medicine Best Practices systematic review and meta-analysis. 

Partner Perspectives

Decreasing hospital associated infection rates including Central Lineâ€“Associated Bloodstream Infections is an issue of ongoing focus nationwide.

May 2015

More Than Guidelines: Safe Handling in Everyday Practice

Reducing Central Line-Associated Bloodstream Infections