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
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.
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.