Consolidation of community oncology practices with hospital-based cancer centers is an accelerating trend that will affect future healthcare delivery models.

 This year, the Community Oncology Alliance reported hospital acquisitions and corporate mergers among 55% of 1338 community oncology practices surveyed, representing a 20% increase over the previous year’s results.

Primary drivers of this trend include declining physician reimbursements for cancer treatment and care outside the hospital setting, increasing overhead for care delivery, and mounting shortages of medical oncologists available to care for a growing cancer patient population. Hospitals are motivated to acquire physician practices to expand their referral base, optimize payer relationships, and to maintain and/or grow pricing power for medical services.

In keeping with this trend, the Smilow Cancer Hospital at Yale-New Haven acquired two large medical oncology practices operating in 10 discrete community locations. The acquisition, which occurred in 2011-2012, included 23 physicians and more than 150 staff, and Smilow is preparing to integrate additional practices.

Physician practices joining hospital-based programs must comply with federal, state, and accrediting body regulations established to ensure patient safety and care quality. Historically, private office practices have not been responsible for meeting these requirements, and the resulting gap in compliance with national and local patient safety mandates is oftentimes significant.

Customary practices in office settings, such as verbal orders, administration of medications and prescription renewals by unlicensed personnel, and the admixture of hazardous drugs in uncontrolled environments, are not permitted in hospital-based facilities. Patient identification processes are often loose, and targeted patient assessments, such as pain, nutritional status, distress levels, and fall risk, are typically not performed or are undocumented in office practices, whereas these elements are mandatory in hospital-based settings and/or for cancer program accreditation.

Similarly, while patient/family education is commonly delivered in office practices, documentation is often absent or limited. Regulatory noncompliance can result in loss of accreditation and reimbursement for services. Consequently, hospitals must incorporate regulatory compliance in merger agreements and establish clear methodologies for achieving alignment of candidate practices with regulatory body requirements and institutional standards.

Oncology nurses—because of their education, experience, and critical place on the healthcare team&mdash;are ideally suited to evaluate gaps, to design and implement strategies to promote compliance in newly acquired medical practices, and, ultimately, to ensure patient safety and quality care.

The Smilow community oncology integration project engaged 15 institutional teams, each focused on its specific area of expertise (eg, nursing, pharmacy, infection prevention, life safety) and coordinated by a steering committee. The teams participated in preliminary gap analyses, made recommendations for and implemented alignment plans, and conducted interval monitoring—not only to determine degree of compliance but also to reinforce practice changes designed to achieve alignment with institutional standards.

Assessment was accomplished through one-onone interviews and focus groups, onsite observations, and medical record reviews guided by structured instruments. Alignment strategies involved the integration of best practices, including unique telepharmacy technology, novel staff and physician engagement strategies and practice-based educational programming.

To ensure successful transformative practice and process change, transition planning incorporated understanding of restraining and driving forces and incorporated coalition building, targeted staff engagement strategies, consistent and clear communication, focused education, and reinforcement.

More than 50 practice and process changes in seven key areas, including patient safety, medication management, communication, environment of care, operations, infrastructure, and professional development, were implemented during a 7-month post-assessment period.

Top challenges experienced during the early transition phases included: (1) staff and physician resistance to the adoption of a new identity and different processes (especially with multiple changes happening simultaneously); (2) communication pattern disruptions associated with reporting decentralization, and (3) role restructuring to comply with scope of practice mandates. Adding a new discipline (ie, pharmacy) to the team to perform functions that were traditionally a primary nursing role was also difficult. However, with time and experience, these challenges have dissipated somewhat, and nurses have been able to integrate more comprehensive patient assessment and other best practices into their clinical practice repertoire.

At 12 and 18 months post -“Go Live,” process change continues to evolve for the two newly acquired practices as a new electronic medical record unifying all practice sites has been implemented. Going forward, opportunities for performance improvement include increasing clinical trial accrual, provision of supportive care services to identified patient subpopulations, development of electronic reporting of key processes, and communication enhancements.

Transitioning community oncology practices from office- to provider-based structures is a challenging project that offers opportunities for experienced oncology nurses to explore new roles as change champions and transition leaders. At Smilow, the nursing staff—together with their physician counterparts and leadership&mdash;made the network vision a true reality.

			Butcher L. Oncology landscape continues consolidation. 

			Forte GJ, Hanley A, Hagerty K, Kurup A, Neuss MN, Mulvey TM. American Society of Clinical Oncology national census of oncology practices: preliminary report. 

			Community Oncology Alliance. Community Oncology Practice Impact Report: The Changing Landscape of Cancer Care. http://glacialblog. com/userfiles/76/Community_Oncology_Practice_Impact_Report_6-25- 13F(1).pdf. Accessed June 27, 2013.

			Kocher R, Sahni NR. Hospitals’ race to employ physicians—the logic behind a money-losing proposition. 

			Appelbaum SH, Habashy S, Malo JL, Shafiq H. Back to the future: revisiting Kotter’s 1996 change model. 

Articles

Partner Perspectives

Consolidation of community oncology practices with hospital-based cancer centers is an accelerating trend that will affect future healthcare delivery models. This year, the Community Oncology Alliance reported hospital acquisitions and corporate mergers among 55% of 1338 community oncology practices surveyed, representing a 20% increase over the previous year's results.

Merging Community Practices With an Academic Cancer Center

		Michigan State University College of Nursing

		Florence Schorske Wald Professor of Nursing

		Clinical Faculty, Frances Payne Bolton School of Nursing at Case Western Reserve University

		Clinical Nurse Specialist University Hospitals Seidman Cancer Center

		Director of Nursing Research at The James Cancer Hospital & Solove Research Institute Clinical Associate Professor The Ohio State University College of Nursing

This is the second installment from our roundtable with oncology nursing experts discussing some of the key challenges in oncology nursing today. Part 1, on symptom management, appeared in our August issue. For video highlights from our Oncology Nursing News roundtable,

: Palliative care is an essential component of good oncology care. In most institutions, considerable efforts are being undertaken to improve this care for our patients. How has palliative care changed in recent years, and what are some of the key issues and challenges nurses today face in providing this care?

: Palliative care still sometimes has a bad name. For years, the public and physicians have really associated it with end-of-life and hospice care. Now, the Institute of Medicine and others have redefined palliative care in terms of a symptom management approach— helping people from the time of diagnosis through to recovery and cure, rather than just through the progression of a disease. Changing the mindset is not easy. At the University of Texas MD Anderson Cancer Center, for example, palliative care is called supportive care. We need a way to expand the concept to include keeping patients comfortable at diagnosis and understanding that comfort means really improving someone’s quality of life.

: We already have palliative care as part of the treatment plan, from diagnosis through treatment. Even into survivorship, palliative care has a big role, doesn’t it?

: Palliative care isn’t just relief. It also involves prevention and endorsing a healthy lifestyle, including nutrition, exercise, and stress relief.

: Palliative care happens in many arenas, from the home to inpatient care, and it involves chemotherapies and radiation therapies to reduce pain. We are now redefining all of the tools to combat pain and provide comfort to patients. As we develop a larger arsenal of options, we will continue to see palliative care reshaped. We, as nurses, not only help to provide this care but also can help to educate families, other nurses, and nursing students regarding palliation.

: Do you think that patients and families have a certain mindset about palliative care?

: This can be folded into the notion of hospice, a concept that families aren’t ready for. We have to educate our patients and families that palliative care has changed. It isn’t about end of life. It is about comfort. It is about doing things as we’ve just been suggesting, proactively, to help ward off unpleasant symptoms. This is a changing dimension of science and of care.

: There is still a disconnect that contributes to families and others feeling both weary and wary of what is going on. When the oncologist says that palliative care or supportive care—whatever the word they use&mdash;is going to happen, that the patient doesn’t have to come back now for a few months, the family feels left alone, because whatever they have gone through for 1, 2, or 3 years of care in that setting is now over. Families are worried about that disconnect and feel there is a certain message when they don’t need to come back anymore. Family members who don’t understand or aren’t assertive enough to say, “I want some connection here,” or when no one checks them for 2 months, this can add to their loneliness and loss of security.

: That is where we really need to involve a multidisciplinary team that includes a visiting nurse or a social worker. Palliative care presents an important opportunity to involve other team members.

: Early and often, I would say, too. That is one of our problems. We wait so long to introduce the idea of palliative care.

: I also think the whole payment mechanism interferes with the smooth transition in families’ understanding. When half of the first discussion or the second discussion is about payment, it is really very traumatic for a family now believing this is the end or close to the end.

: That leads in to our next question: What needs to be done to improve palliative care options?

: One of the really important initiatives is out of the Robert Wood Johnson Foundation, which has supported this area, under the guidance of Diane Meier, MD, and Sean Morrison, MD. [More information on The Center to Advance Palliative Care can be found at

From a nursing perspective, if you look at the hospice movement, there are national or world movements driven by physicians. The public still sees the physician as the captain and the individual in charge. As nurses become more comfortable and knowledgeable, along with a shortage of physicians, the public will begin to understand that nurses have these skills. There are now initiatives in place to make palliative care available to patients, acknowledging that it’s their right to have this care. There is going to have to be a major campaign by physicians and other healthcare professionals, and that is a good thing. We are not going to take your patient away from you; we are going to work collaboratively. There is enough for everybody to do.

: Perhaps the best thing that has happened in the last few years is the research which demonstrated that patients can actually live longer if they get palliative care from the point of diagnosis. Again, early and often. Our physician colleagues are now seeing the real benefit of palliative care as part of the treatment plan, which is fantastic.

: The interesting thing about this is that we also have nurse research demonstrating these same results. It just doesn’t get the same kind of publicity. We have demonstrated that we have good outcomes to show that nurses helping patients to manage their symptoms and coordinating their care can make a tremendous difference.

: Improving the quality of life not only for the patient, but for the family.

: We can do this at big academic medical centers or in urban areas, but a lot of our patients are out in small rural areas where options through palliative care agencies may be more limited. We have a long way to go to continue to serve our patients in palliative care throughout our nation and throughout various communities.

The second installment from our roundtable with oncology nursing experts discussing some of the key challenges in oncology nursing today.

Redefining Palliative Care

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

Occupational exposure to hazardous drugs is a known risk of working in settings in which these drugs are administered. While we often immediately think about exposure of staff who prepare and administer hazardous drugs, other people who may inadvertently be exposed to hazardous drugs are housekeeping and clerical staff, patients’ family members, and visitors. So how does this happen? How is it possible that the mail carrier can come in contact with hazardous drugs?

The answer is hazardous drug residue. A 2010 study identified locations in oncology settings that have the highest likelihood of residue, and they include work surfaces within biological safety cabinets (BSCs) and compounding aseptic containment isolators, their airfoils and vents, and on the floor directly below them.

 In addition, other locations at risk for hazardous drug residue are countertops where these drugs are placed or stored, door handles, refrigerator shelves, infusion chairs, infusion pump keypads, and hazardous waste containers.

In June 2012, a National Institute for Occupational Safety and Health (NIOSH) team reported its findings of a health hazard evaluation of an outpatient oncology clinic employing 54 people.

 The team collected surface wipe samples to detect chemotherapy residue. Platinum was detected in 18 of 26 surface wipe samples (69%) on the first of two visits to the clinic, and the highest level (91 ng/100 cm2) was collected in the clinic’s pharmacy on the floor in front of the class 2 BSC.

Platinum was detected in 16 of 20 surface wipe samples (80%) during the second visit to the clinic 14 months later. This time, the highest surface wipe levels of platinum were found on the middle of the BSC work area and on the countertop next to the sink in the treatment room. Surface wipe samples detected cyclophosphamide in the clinic pharmacy (on the floor in front of the BSC, and on the floor beneath the counter where prepared drugs were placed), and treatment room floor (eg, on the floor underneath an IV pole), which suggested inadequate work practices and housekeeping.

Cyclophosphamide also was found in the checkout desk area, an area that should not have had chemotherapy contamination. One sample location remained positive for all three days of visit two, which suggested that cyclophosphamide was not being effectively removed after one or two cleanings of the area. Of note, the team also inspected the BSC and found that it operated properly and was certified annually. However, the employees in this clinic reported inconsistent use of personal protective equipment (PPE) (eg, four employees reported not consistently double-gloving or using chemotherapy-protective gowns when administering chemotherapy).

Exposure to hazardous drugs can occur via inhalation, oral ingestion from hand-mouth contact, skin contact, and injection (needlestick injury). Strategies to reduce potential exposure include transporting chemotherapy in plastic bins to reduce contact with other surfaces, such as countertops, and cleaning the bins after each use. The BSC sash height should be high enough to ensure at least 100 feet per minute of airflow. Policies and procedures should be reviewed with staff, and additional training provided when indicated. If not already in place, a medical surveillance program for staff handling hazardous drugs should be implemented (information can be found on the NIOSH website at www.cdc.gov/NIOSH).

The BSC needs to be cleaned with a deactivating agent and disinfecting agent at the beginning and end of each shift/day, before and after each activity, and after a spill, should one occur. Cleaning with an oxidizing agent, such as sodium hypochlorite solution, is recommended. Because of its corrosive nature on work surfaces, following with a sodium thiosulfate solution after cleaning can help neutralize its effects. A final cleaning with a residue-free disinfecting agent, such as sterile 70% isopropyl alcohol, is recommended. Staff who prepare and administer chemotherapy should use PPE.

Work surfaces should be sampled periodically for chemotherapy drugs. Companies that perform hazardous drug sampling testing include ALS (DataChem): www .datachem.com; Bureau Veritas: www.bureauveritas.com; ChemoGlo: www.chemoglo.com, and RJ Lee Group, Inc: www.rjlg.com.

Although NIOSH does not have occupational exposure limits defined for surface levels of chemotherapy drugs, periodic sampling identifies presence of chemotherapy in areas in which it should not be present, and allows comparisons over time that may be used to evaluate employee work practices, administrative controls, and housekeeping.

Surface testing for chemotherapy residue may seem unnecessary; however, as one clinic found, it helped identify residue in unexpected places—including the elevator buttons down the hall.

Connor TH, DeBord DG, Pretty JR, et al. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. J Occup Environ Med. 2010;52(10):1019-1027.

Couch J, West C. Chemotherapy drug exposures at an oncology clinic—Florida. Health hazard evaluation report, National Institute for Occupational Safety and Health. June 2012. Retrieved from http://www.cdc.gov/niosh/hhe/reports/ pdfs/2009-0148-3158.pdf. Accessed September 10, 2013.

Nurse's Notes

Occupational exposure to hazardous drugs is a known risk of working in settings in which these drugs are administered.

Chemotherapy Residue on the Checkout Desk?

	Assistant Professor, Duquesne University, Pittsburgh, PA

The American Cancer Society estimates that in 2013, 142,820 individuals in the United States will be diagnosed with colorectal cancer and 72,570 with bladder cancer.

 Many patients affected by these cancers will require either a temporary or permanent ostomy. During the past decade, changes in ostomy product options offer patients a variety of choices. Knowledgeable nurses who can match a patient’s ostomy needs to the appropriate product ensure that patients experience the highest degree of comfort, ease, and security.

These product decisions fall into four general categories: pouching systems, skin barriers (also called wafers or flanges), pouches, and accessories.

Pouching methods can be either one- or twopiece systems based on whether or not the wafer and pouch are combined into a single unit or function separately. One-piece systems tend to be thinner and more flexible than two-piece systems. 

 This helps the barrier to mold to the body’s contours, making it a good choice for patients with an uneven peristomal skin surface, rods in place, decreased manual dexterity, and/or those who need to streamline the pouching system change procedure. For other patients, a two-piece system is a better option because the pouch can be removed without removing the barrier. Many patients prefer this system, as they are able to change the pouch while only needing to change the full system once or twice a week.

Options for skin barriers include cut to fit, precut, and convex. Cut-to-fit barriers, where the opening is cut manually, provide a custom fit for each stoma. These barriers are often used in the postoperative period due to the stoma decreasing in size as edema resolves. Once the stoma size and shape stabilizes, a precut barrier where the opening is cut during the manufacturing process may be an option.5 Designed to fit standard round and/or oval stomas, these barriers eliminate several steps in the change procedure; however, they are not designed for stomas that are irregular in shape or size.

		United Ostomy Associations of America, Inc.— 

		Wound Ostomy and Continence Nurses Society— 

		American College of Surgeons Surgical Patient Education Program — 

Standard skin barriers have a flat surface on the back, whereas convex barriers have a rounded or curved backing. Convex barriers are used for patients whose stoma is flush to the abdominal surface, retracted below the skin surface, located in a skinfold, or when the stoma opening rests against the abdominal skin.5 The convex shape of the barrier pushes the peristomal skin down, helping the stoma output to be directed into the pouch, versus between the barrier and the peristomal skin causing leakage.

Pouch options involve transparency, filter, size and ability to be drained. Transparent pouches facilitate visualization and assessment of the stoma during the immediate postoperative period; opaque pouches conceal the ostomy’s output. Filtered pouches allow for elimination of gas from the pouch, thus preventing the pouch from ballooning in size and becoming visible under clothing. Nonfiltered pouches enable the patient to control the time and place for gas to be released from the pouch. The bottom of the pouch may be opened, closed, or contain a spout to facilitate drainage. Closed-end pouches must be completely removed to empty the pouch. This type of pouch works well for patients with descending colostomies due to output that is thick or formed and difficult to drain from a pouch.

Open-ended pouches have a clip or Velcro at the bottom of the pouch that allows the pouch to be opened and emptied periodically throughout the day. This is effective for output that is thin or liquid in consistency, such as that of ileostomies and ascending colostomies. Spigot-type openings have an on-and-off position to control emptying of the pouch. These are typically utilized for urostomy patients.

Accessory options include belts, adhesives, barrier sprays and powder, and designer-wear items. Ostomy belts are often worn for additional security and comfort, especially during physical exerexertion. Adhesives come in the form of strips, paste, flat rings, and convex ovals. They are utilized to fill in crevices in the peristomal skin to create a flat surface and facilitate barrier adherence and increased wearing time. Barrier sprays are used for additional protection of the peristomal skin against irritation and leakage. Stoma powders are used to absorb moisture and to provide protection when the patient experiences denuding of the peristomal skin.

Designer-wear items include specialty products that facilitate an active lifestyle. Products such as neoprene pouches/belts that encompass the patient’s pouching system offer support and waterproof protection for swimming, snowboarding, etc. Additionally, there are sport shorts for men and women with an interlining that contains the pouching system to provide additional support and protection.

The selection of appropriate products to meet patients’ individualized ostomy needs can facilitate prevention of common stomal and peristomal skin complications, as well as ensure the highest degree of comfort, ease, and security.

			The American Cancer Society. Leading New Cancer Cases and Deaths—2013. www.cancer.org/acs/groups/content/@epidemiologysurveilance/ documents/document/acspc-037129.pdf. Accessed July 14, 2013.

			The American Cancer Society. Bladder Cancer. www.cancer.org/cancer/ bladdercancer/detailedguide/index. Accessed July 14, 2013.

			Bak GP. Teaching ostomy patients to regain their independence. 

Ostomy Management. It’s easier than you think

. Brockton, MA: Western Schools. 2012:27-29.

			Zane Cohen Centre for Digestive Diseases. Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex. Ostomy Care—Selecting an Appliance. http://www.zanecohencentre.com/ibd/for-patients/ostomy-care. Accessed July 14, 2013.

The American Cancer Society estimates that in 2013, 142,820 individuals in the United States will be diagnosed with colorectal cancer and 72,570 with bladder cancer

Matching Ostomy Pouching Systems to Patient Need

It has been nearly a decade since the National Institute on Occupational Safety and Health (NIOSH) issued its seminal 2004 Alert warning healthcare workers about the risks of working with hazardous drugs. Unfortunately, unintended exposure to these dangerous drugs through surface contamination persists. And, the problem may get worse with the expanding number of cancer patients and the corresponding workload demands on those who treat them.

The situation poses a “clear and present danger,” cautioned Christopher R. Friese, PhD, RN, AOCN, FAAN. Friese, an assistant professor at the University of Michigan School of Nursing in Ann Arbor, conducts research on nursing practice environments in outpatient chemotherapy settings. He expressed concern that following the NIOSH Alert, a degree of complacency set in, with clinicians believing that “we’re doing better than we actually are.”

“Surface contamination is still widespread,” he noted, a concern echoed by Martha Polovich, PhD, RN, AOCN, who said that surface contamination from hazardous drugs (HDs) was documented in some 30 studies she has seen, making it likely that “every setting where chemotherapy is administered has this contamination.”

Polovich, an instructor at Georgia State University’s Byrdine F. Lewis School of Nursing & Health Professions in Atlanta, has published extensively on the subject of safe handling and serves as one of the reviewers on an update of the NIOSH Alert currently in progress. She said that while the possibility that a patient’s family and others may be exposed to chemotherapy residue is concerning, it is the occupational exposure of nurses, pharmacists, and others “who work with these drugs daily and often, over many, many years” that most worries her.

“What I’m hearing from nurses is that many don’t know about the problem of surface contamination because they’re not reading the literature, while others may be aware of the problem and are either very concerned about it, or they think that their workplace is safe.” For some nurses, she said, the first time they hear about the issue of surface contamination is when they take the online chemotherapy course she co-teaches for the Oncology Nursing Society (ONS) that is offered several times throughout the year.

Both experts agree that the problem of surface contamination is a multifaceted one, requiring a multipronged approach. “First and foremost,” said Friese, “we need to measure the degree to which exposure is happening,” adding that “we can’t recommend policy and practice changes for a particular site until we understand the size and scope of the problem.”

One obvious way to do this is through surface wipe testing, which takes place in some of the larger cancer centers, Friese noted, “but it is still a very expensive procedure, so that’s a deterrent,” especially for smaller practices which may not have the resources or facilities to do the testing.

Polovich added that the assays needed to measure surface contamination are not readily available. She said that there are only a few specialty labs in the United States and a couple in Europe that have the assays to do this testing.

Furthermore, there is currently no requirement or reimbursement for such routine testing, so that when surface-wide sampling for chemotherapy residue is conducted, it’s usually in the context of a study or when an organization is contemplating the purchase of a closed system transfer device (CSTD), whereby the testing is provided by the vendor as a way to demonstrate the need for its product, Polovich continued.

In addition to surface monitoring, said Friese, nurses must be encouraged to report spills when they occur to help develop a better understanding of when and why there is unintentional or accidental exposure.

“It is clear that nurses remain at risk of exposure,” Friese continued. He said that research that he and others have conducted has found that the hazardous agents are detected in the urine of nurses who handle them.

“We need to understand how often it is happening, under what circumstances. This is a ripe area of opportunity, because nurses are not routinely reporting these spills and the context in which they occur,” said Friese.

Surveillance isn’t enough, however. As Friese noted, even among those larger centers that may be conducting more regular surface testing, the need to know how they are using the data to improve safety remains.

CSTDs are effective in reducing environmental contamination, explained Polovich, because, unlike routine IV equipment, these closed systems prevent leakage, thus controlling exposure. Yet currently, these devices increase costs, and there is no reimbursement. Interestingly, she added, Japan does provide reimbursement for their use.

Routine cleaning of the environment and wiping down surfaces where chemotherapy residue is likely to be present is extremely important. She added that some states, such as California, Washington, and North Carolina, are moving to enact measures mandating that employers comply with the NIOSH Alert requirements, such as use of personal protective equipment (PPE) and employee training, but there is currently no nationwide regulation that workplaces must do this.

Polovich said that much attention has been focused both on the need for nurses and other handlers to be educated on safety and on each individual worker’s commitment to take precautions. When employees don’t do this, “there can be some finger-pointing,” she said, and suggestions that the worker isn’t doing a good job.

However, she said, “My research really doesn’t show that.” She explained that the biggest predictor of compliance with HD handling precautions, or lack thereof, is the workplace safety climate. “How an organization addresses safety and supports safety is extremely important.”

Again, it comes back to workload, she said, noting that her research has found that as the number of patients treated per day increases, the use of safety precautions decreases. “What that tells me is that when you’re busy, you may take shortcuts, because that’s the only way you can get through your day, and that’s not the workplace supporting safety,” said Polovich, adding that patient assignment is not within the control of nurses.

In research published last year and based on responses to a mailed survey of nurses who handle chemotherapy and telephone interviews with managers, Polovich found that although nurses demonstrated knowledge of the risk of harm from exposure to HDs and a sense of self-efficacy about use of PPE, total use of precautions was low. The researchers determined that a better workplace safety climate and fewer patients per day were independent predictors of HD precaution use.

“I have found that nurses know what precautions are required to minimize exposure, but the circumstances in the workplace interfered with their ability to do that. In organizations where the issue is taken seriously and safety is a priority, precaution is better.”

Friese said that his research has found that nurses taking care of a higher number of patients were those who reported more spills, and that clinic congestion adds to the difficulties. “We found that the more congested areas of a cancer center tend to be the places where spills occur,” and he suggested that both workload and congestion warrant further investigation. In fact, he said, “Right now, we are working with colleagues in engineering to figure out better ways to assign patients to nurses in chemotherapy suites,” in an effort to make the workflow smoother and create a safer environment in which to practice.

					NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings (

					Occupational Exposure to Antineoplastic Agents—National Institute for Occupational Safety and Health (

					ASCO/ONS Chemotherapy Administration Safety Standards—2013 Update (

					Safe Handling of Hazardous Drugs —2nd edition (

					Chemotherapy and Biotherapy Guidelines—3rd edition (

					Online Chemotherapy Courses—Oncology Nursing Society (

					Lifesaving Drugs—Deadly Consequences &mdash;video (

He noted that in ambulatory settings, less regulatory oversight occurs compared with an infusion room attached to a hospital. “That heightened sense of awareness of a safety problem may not be as apparent in the ambulatory setting.” Friese and colleagues have conducted research on exposure to chemotherapy in this setting and found that oncology nurses reported “substantial unintentional skin and eye exposure to chemotherapy,” and the likelihood of exposure was lower when nurses indicated sufficient resources and staffing.

In addition to workload, Polovich offered some fundamental practical suggestions for increased use of PPE by nurses—including simply making the equipment available and readily accessible. “I’ve heard nurses say, ‘the gowns are so expensive and we only have a few, so we have to conserve their use.’” She added that studies have shown that when PPE is abundantly available, workers are more likely to understand that they need it and will use it.

Cover Story

It has been nearly a decade since the National Institute on Occupational Safety and Health (NIOSH) issued its seminal 2004 Alert warning healthcare workers about the risks of working with hazardous drugs

September 2013

Merging Community Practices With an Academic Cancer Center

Redefining Palliative Care

Chemotherapy Residue on the Checkout Desk?

Matching Ostomy Pouching Systems to Patient Need

A Clear and Present Danger: Awareness, Vigilance Remain Key to Safe Chemotherapy Handling