AnnMarie Walton on Reducing Antineoplastic Drug Residue in Inpatient Units


AnnMarie Walton, PhD, MPH, RN, OCN, CHES, FAAN, discusses her research on plastic-backed pads and discusses the importance of better methods to reduce exposure to antineoplastic drug residue.

Mounting evidence suggest that antineoplastic drug residue is present on surfaces where they are not expected, explains AnnMarie Walton, PhD, MPH, RN, OCN, CHES, FAAN. Walton, who is an associate professor at the Duke University School of Nursing, discusses her research on antineoplastic drug residue exposure, which was presented during the 48th Annual Oncology Nursing Society (ONS) Congress.

In earlier findings from Walton and her team, toilet seats were identified as the most contaminated item on the inpatient unit. Consequently, her team sought to understand whether plastic-backed pads, which ONS recommends, would effectively reduce surface contamination on the toilet seats. They also wanted to understand how effective their current discharge cleaning method was, since the team had identified drug residue in rooms where the patients were not receiving that same drug.

The study was conducted using a crossover design and looked at a clinical unit for approximately 1 year. The plastic-backed pad represented the intervention, and was implemented for a 2-month period, followed by a 1-month washout period, and then another 2 months with no intervention, as a control. The entire cycle was repeated twice. Nurses were provided with a user guide to help familiarize themselves with using the plastic-backed pads during the experimental period.

The team collected samples at 3 specific surface sites: in front of the toilet, on the toilet seat itself, and on the wall beside the toilet. They were testing, specifically, for evidence of cyclophosphamide or etoposide. These surfaces were swabbed prior to the administration of the hazardous drug to the patient, between 24 to 72 hours post administration, and again, after the patient had been discharged and the room had been cleaned. Qualitative interviews were also conducted with the unit nurses and environmental services manager to better understand the daily and discharge cleaning practices.

Ultimately, the team did not find a statistically significant difference between the experimental and control conditions in terms of minimizing drug exposure. Chemotherapy levels were higher than the team had anticipated. Moreover, even after the discharge cleaning, the levels of cyclophosphamide were not close to zero. According to Walton, these findings emphasize how much research is needed to understand how to lower these levels through discharge cleaning.

“Daily cleaning was part of a good strategy, but discharge cleaning alone didn't do enough,” she concludes. “We really have to be aware of these potential sources of exposure for ourselves and for everyone in our healthcare environment.”


Walton A, Sung A, Bush P, Spasojevic I, Myers J, Jin H, Powell M. Examining occupational exposure risks and the efficacy of toilet seat covers and routine discharge cleaning in minimizing antineoplastic drug contamination. Presented at: 48th Annual Oncology Nursing Society Annual Congress; April 27-May 1, 2022; San Antonio, TX. Accessed April 5, 2023.

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