ICID > Clinical Management > Haematology > Management of Cytotoxic Chemotherapy Spillage  
 

Management of Cytotoxic Chemotherapy Spillage 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    Network Wide Statement

    The core contents of this protocol have been agreed by the Chemotherapy Policy Working Group as part of the Central South Coast Cancer Network.  These core contents form the basis for all locally produced policies although the structure will vary between trusts according to local policy making guidelines.

     

    1.1 Background

    Any spillage of a cytotoxic chemotherapy agent must be immediately and effectively managed in order to minimise the contamination of the environment and reduce the health risks to personnel.  Hence, there should be a spill kit in each area where cytotoxic chemotherapy is stored, prepared or administered.  Chemotherapy trained nursing staff administering cytotoxic chemotherapy outside of 'chemotherapy designated' areas must take a spill kit with them.  Spillages involving large and small volumes of agents are considered separately in this protocol.  A small volume spill is defined as involving less than 5ml or 5g of an agent; a large volume spill involves more than 5ml or 5 g of an agent.

     

    Spillage is one of the potential complications that may occur during the administration of cytotoxic chemotherapy.  Trust training of nurses in the administration of cytotoxic chemotherapy includes the management of complications such as spillage.

     

    Refer to:

    Policy for the Administration of Prepared Cytotoxic Drugs.

    Cytotoxic Chemotherapy Education Programme Open Learning Package

    Guidelines for the Management of Suspected Extravasation of Intravenous Cytotoxic Drugs.

    Waste Management Policy.

     

    1.2 Aim/Purpose

    This protocol outlines the steps required to effectively manage a cytotoxic chemotherapy spill.

     

    1.3 Patient/client group

    Spillage may occur in any area where cytotoxic chemotherapy is stored, prepared or administered.  Staff working in these areas should have received training in the management of cytotoxic chemotherapy spills.  Spillages of cytotoxic chemotherapy could take place during transportation, see Draft Guideline for the Transportation of Cytotoxic Drugs.

     

    1.4 Exceptions/contraindications

    None

     

    1.5 Options

    None

     

     


    2. Clinical Management

    2.1 Staff & equipment

    Each area where cytotoxic chemotherapy is stored, prepared or administered should have a cytotoxic spill kit.  An in-date eye wash bottle should be located with the spill kit.  Spillages involving cytotoxic chemotherapy should only be managed by staff who have been trained in the handling of cytotoxics.  Department leads should ensure that all other staff in these areas who are not trained to handle cytotoxic chemotherapy, e.g., ancillary staff, are aware of the health and safety issues concerning this group of drugs.  Where possible, spillages should be managed by staff who regularly handle cytotoxic chemotherapy.  However, drivers of Trust road vehicles who have received training in the management of cytotoxic chemotherapy spillage may undertake this activity.  Although portering staff should be familiar with the contents of the spill kits and this protocol, they may only provide assistance with rather than leading management of a spill. 

     

    It is the responsibility of the clinical lead or departmental head in each area to ensure not only that this kit is available and maintained but also that all staff in these areas have read and understood this protocol.  It is the responsibility of the oncology pharmacist to review this protocol on an annual basis.  Safety data sheets for all currently stocked cytotoxic chemotherapy medications are held in Pharmacy ext 4443 or 4275 (file in aseptics office) and in the emergency drug cupboard.  Please note that either spectacles must be removed prior to wearing protective eyewear or the eyewear must be worn over the spectacles.  Staff unable to see clearly without spectacles if removed should not manage cytotoxic spills.  Staff who are allergic or sensitive to latex should wear either vinyl or nitrile gloves under the latex gloves contained in the spill kit.

     

    Spillage kit includes:

    Protective eyewear (goggles)                                                                   Dust/mist respirator

    Latex gloves (one pair each of inner gloves and blue outer gloves)   Plastic scoop

    Absorbent towels                                                                                   Overshoes

    Two yellow plastic bags                                                                          ChemoPlus gown

    Chemo spill sign                                                                                    Incident report card

    ChemoSorb spill pads (chemotherapy absorbent gel pads)                        Plastic bag seals

     

    2.2 Method/procedure

     

    NEVER LEAVE A CYTOTOXIC SPILL UNATTENDED.

     

    Management of spills: surface spills

    1                     If the spill was onto a person, treat them first and then clear up the spill.

    2                     Arrange for patients to be moved away from the area of spillage and restrict access.  Minimise air flow to area by shutting doors and windows.

    3                     Call for help to get the nearest cytotoxic spill kit and a sharps box.

    4                     Open the kit and display the "Cytotoxic spillage" sign near the spill area.

    5                     Put on the following from the kit in this order: a pair of gloves (inner), mask, goggles (spectacles may not be used instead of goggles), the gown, overshoes, and a pair of blue gloves (outer).

    6                     A) For small volume spills (less than 5ml or 5g)

    i) Cover liquid spill with absorbent towels but avoid splashing.

    ii) Pick up solids with a moistened absorbent towel (wet with water or sodium chloride 0.9%).

    B) For large volume spills (more than 5ml or 5g)

    i) For liquids, cover the spill with chemotherapy absorbent gel pads. 

    ii) For solids, place an absorbent towel moistened with water or sodium chloride 0.9% on top of the cytotoxic material.  Then cover with chemotherapy absorbent gel pads.  Wait for the pad to be transformed into a gel and scoop up using plastic scoop.  Ensure all of the residual gel is removed.

    7                     Scoop up any sharps using either the plastic scoop or swabs and place in a sharps box.

    8                     Work from the outside inwards, clean the spill area with soap and water at least three times.  Place all used absorbent towels in one of the yellow bags.  Take care to avoid contamination of the bucket of water by only placing new absorbent towels in the water.  If contamination does occur rinse the bucket thoroughly.

    9                     Place all contaminated material (including gown, outer gloves, mask, goggles and overshoes) in yellow bag.  Then place filled bag and inner gloves in the other yellow bag.  Please ensure that the outer bag is a Trust cytotoxic yellow bag with a purple stripe. Label all material as cytotoxic waste and dispose of according to SDH Waste Management Policy.

    10                 Wash hands.

    11                 Fill in adverse event form, inform Occupational Health Department and record spill in departmental records.  Fill out incident report card in spill kit and return to Oncology Pharmacist.  These reports will be audited on an annual basis in order to identify potential areas for the improvement in practice.  On receipt of a report card a new spill kit will be sent to the area concerned.  A spare spillage kit is kept in the emergency drug cupboard for use out of hours.  If any member of staff experiences skin contact with a cytotoxic agent they should have a full blood count on the day of the incident and 7 –10 days later.

    12                 Inform lead nurse for Oncology/Haematology of incidents in clinical areas.

     

    Management of spills: Spills involving patients and staff

     

    ·        Arrange for patients to be moved away from the area of spillage and restrict access to the area. 

    ·        Minimise air flow to the area by shutting doors and windows.

    ·        If the spill was onto a patient or staff member, treat them first and then clear up the spill. 

    ·        If any cytotoxic has spilled onto the body, the area should be rinsed thoroughly with water. 

    ·        For contact with eyes, irrigate with plenty of water or sodium chloride 0.9%.

    ·        Members of staff who have had skin exposure should contact Occupational Health.  They should have a full blood count on the day of the incident and 7-10 days later.  If immediate medical attention is required then the member of staff should report to Accident and Emergency.  If possible take a copy of the relevant safety data sheet when attending Accident and Emergency.  Follow up will be carried out by Occupational Health. 

    ·        Patients should be reviewed by their medical team.

    ·        Spillage onto clothing: wearing the protective clothing in the spill kit, remove the persons contaminated clothing to minimise skin exposure.  If possible discard the contaminated clothing as cytotoxic waste.  If this is impracticable then, whilst wearing two pairs of gloves place clothing in a red alginate bag and then place inside a yellow cytotoxic bag.  For patient clothing, a relative or the patient should be provided with two pairs of gloves and instructed to place the red alginate bag in a domestic washing machine whilst wearing both pairs of gloves.  The clothing should be washed separately on a boiled wash programme.  Staff should wash their contaminated clothing in a similar manner.  Do not send contaminated clothing to hospital laundry for washing.  Contaminated bedding should be discarded as cytotoxic waste.  Inform the Laundry Manager of any discarded bedding.

    ·        Inform the appropriate medical team of incidents involving patients.

    ·        Follow instructions for points 10 through 12 as described above for the management of surface spills.

     

    Spillage onto equipment

    1          Remove any visible surface spill following the instructions for the management of surface spills. 

    2          Quarantine any equipment onto which cytotoxic chemotherapy has been spilt.  If possible, place this equipment inside two yellow cytotoxic chemotherapy bags.  Please ensure that the outer bag is a Trust cytotoxic yellow bag with apurple stripe. Clearly mark the equipment as contaminated with cytotoxic chemotherapy.

    3          Seek specialist advice from Medical Equipment or Pharmacy about the possible decontamination of the contaminated equipment.

    4          Follow instructions for points 10 through 12 as described above for the management of surface spills.

    Summary flowchart for Cytotoxic Chemotherapy Spillage

    2.3 Potential complications

    Failure to manage a spillage of cytotoxic chemotherapy in the appropriate manner may result in systemic absorption of the agent.  The exact nature of the exposure will depend on the drug involved.

     

    2.4 After care

    Staff members who have experienced skin exposure to cytotoxic medications should have a full blood count immediately following exposure and 7-10 days later.  Any further action should be discussed with the Occupational Health department (or Accident and Emergency department if needing immediate treatment).  Medical follow up will be carried out by the Occupational Health department.  Following skin exposure to cytotoxic medications, patients should be reviewed by their medical team.  The report card in the spill kit should be returned to Pharmacy.  Both patients and staff who have experienced skin exposure should be reassured about the incident and should receive standard first aid care.  If the patient did not receive the prescribed dose of cytotoxic chemotherapy then, arrangements should be made with Pharmacy to provide an additional dose.  Where part but not the whole dose of the drug has been administered, the prescriber should be contacted and if necessary the drug re-prescribed.


    3. Patient Information

    There are currently no patient information sheets covering this topic.  Management by patients of cytotoxic chemotherapy spillage is out with the scope of this protocol.  Separate guidance is being developed for care of patients in the community.


    4. Audit

    4.1 Standards

    Standard Statement:   All spillages involving cytotoxic chemotherapy will be managed in the manner outlined in this protocol.

     

    Structure

    1                     All personnel involved in the handling of cytotoxic chemotherapy will receive this protocol.

    2                     Each area where the storage, preparation or administration of cytotoxic chemotherapy takes place will have access to the Protocol for the Management of Cytotoxic Chemotherapy Spillage.

    3                     Each area where the storage, preparation or administration of cytotoxic chemotherapy takes place will have access to a spillage kit.

     

    Process

    1                     All staff who administer cytotoxic chemotherapy should have undergone the specified Trust training which includes the management of cytotoxic chemotherapy spillage.

    2                     All staff who prepare cytotoxic chemotherapy should have undergone the specified pharmacy training which includes the management of cytotoxic chemotherapy spillage.

    3                     All staff who are involved with the storage of cytotoxic chemotherapy should have undergone training in the management of cytotoxic chemotherapy spillage.

    4                     All staff who are involved with the storage, preparation or administration of cytotoxic chemotherapy should be familiar with and have access to the Protocol for the Management of Cytotoxic Chemotherapy Spillage and the contents plus location of spillage kits.

    5                     The Lead Nurse and Departmental heads will monitor their departments to ensure staff working in their area are complying with the standard.

    6                     Cytotoxic chemotherapy spillages that occur should be recorded on the report forms within the spillage pack and a clinical incident report form completed.  Any skin exposure should be recorded in patient's notes and departmental records as appropriate.

     

    Outcome

    1         Cytotoxic chemotherapy spillage is managed by competent staff who have been appropriately trained.

    2                     All cytotoxic chemotherapy spillages have been managed according to the protocol.

    3                     Patients and staff involved in cytotoxic chemotherapy spillage are satisfied with the care that they have received with regard to the management of the spillage.

     

    4.2 Audit tool

    Audit Reference No.:

    Topic:                           Spillage of Cytotoxic Chemotherapy Drugs

    Sub-topic:                     Management of Cytotoxic Chemotherapy Spillage.

    Care Group:                   Staff and patients involved with the preparation or administration of cytotoxic chemotherapy.

    Standard Statement:      All spillages involving cytotoxic chemotherapy will be managed in the manner outlined in these guidelines.

     

    1                     Each member of staff involved with the handling of cytotoxic chemotherapy will have received a copy of this standard and Protocol for the Management of Cytotoxic Chemotherapy Spillage.

    2                     Each nurse who has undergone Trust Cytotoxic Chemotherapy Drug Administration Training will have received specific training for the management of cytotoxic chemotherapy spillage.

    3                     Each member of Pharmacy involved in the preparation of cytotoxic chemotherapy will have received specific training for the management of cytotoxic chemotherapy spillage.

    4                     Each member of Pharmacy involved with the storage of cytotoxic chemotherapy will have received training for the management of cytotoxic chemotherapy spillage.

    5                     Each clinical area where the administration of chemotherapy takes place has access to a spillage kit and a copy of the Protocol for the Management of Cytotoxic Chemotherapy Spillage.

    6                     Each area where cytotoxic chemotherapy is stored or prepared has access to a spillage kit and a copy of the Protocol for the Management of Cytotoxic Chemotherapy Spillage.

    7                     The Departmental/Ward Head monitors their staff to ensure compliance with the standard.

     

    4.3 Patient survey

    No formal patient survey will be carried out.  Both patients and staff will, where possible, be interviewed by either the Oncology Pharmacist or Lead Oncology/Haematology Nurse to provide feedback on

    i) ease of use of both the spillage kit and this protocol,

    ii) the manner in which the spillage was dealt with.  

    Pharmacy will review reports of cytotoxic spillages on an annual basis.

     

    4.4 Risk management

    Risks to members of staff associated with the handling of cytotoxic chemotherapy are dealt with in the Policy for the Administration of Prepared Cytotoxic Drugs.

    Factors associated with an increased risk of cytotoxic chemotherapy spillage

    Factors

    Risk Management

    Storage factors

     

    Pharmacy staff inexperienced in the storage of cytotoxic chemotherapy.

    Pharmacy staff to have appropriate training in the safe handling of cytotoxic chemotherapy.

    Preparation factors

     

    Pharmacy staff inexperienced in the preparation of cytotoxic chemotherapy.

    Pharmacy staff to have appropriate training in the safe handling of cytotoxic chemotherapy.

    Environment conducive with the preparation of cytotoxic chemotherapy.

    Appropriate workspace and workload for the preparation of cytotoxic chemotherapy.

    Administration factors

     

    Nursing staff inexperienced in the administration of cytotoxic chemotherapy.

    Nursing staff to have appropriate orientation to services and Trust training in the Administration of Cytotoxic Chemotherapy.

    Environment conducive with the administration of cytotoxic chemotherapy.

    Appropriate workspace available for the preparation and administration of cytotoxic chemotherapy.

    Infusion pump not switched off before disconnecting infusion reservoir from infusion line.

    Switch off infusion pump before disconnecting infusion reservoir from infusion line.

     

    5. Evidence Base

    5.1 Sources of information

    1.         Anon.  ASHP technical assistance bulletin on handling cytotoxic and hazardous drugs.  Am. J. Hosp. Pharm.  1990; 47: 1033-1049.

    2.         'www.marcguidelines.com'- a peer reviewed website.

    3.         Allwood, M, Stanley, A and Wright, P.  The Cytotoxics Handbook, 4th edition.  2002  Radcliffe Medical Press, Oxon, UK.

     

    5.2 Summary of literature review and recommendations

    Spillages involving cytotoxic chemotherapy must be promptly managed by appropriately trained staff wearing personal protective equipment1,2,3. 

     

    It has been recommended that cytotoxic chemotherapy spillage kits should contain: goggles, two pairs of gloves, a low permeability gown, a small scoop for collection of broken glass, a sharps container and two waste-disposal bags in addition to sheets of chemo-absorbent material for managing large volume spills1.  Spillages have been categorised not only by size, large or small volume, but also based on the type of material involved, i.e., liquid or solid.  Gloves used during decontamination should be of suitable thickness: gloves should be greater then 0.45mm thick3.  After removal of the spilled cytotoxic material, the area concerned must be further decontaminated to remove residues.  For general decontamination, soap and water should be used as there is no single decontamination agent available.  If however, a decontamination agent specific to the spilled cytotoxic material is used, then following this decontamination the area should in addition be washed with soap and water.

     

    All materials and equipment used in the management of cytotoxic chemotherapy spills should be discarded as cytotoxic waste.

     

    5.3 Evidence review

    The information contained in this protocol has been collated from the published peer reviews and is the best evidence available to date.

     


    6. Appendices



    Document Owner Debra Robertson 
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