Administering cytotoxic medicines and caring for patients

How to set up an area for administration and patient care

Employers must take precautions to keep safe those employees who administer cytotoxic medicines to patients. After administration, patients mainly eliminate cytotoxic medicines in their urine or bile. But all bodily substances can be contaminated with either the:

• unchanged drug
• active drug metabolites.

How long bodily substances are contaminated with cytotoxic medicines will differ for individual drugs and patients. Cancer Institute NSW (eviQ) recommends following cytotoxic precautions for a standard period of seven days after treatment. Additional care should be taken to identify drugs with extended excretion.

Exposure to cytotoxic medicines can occur through:

• handling cytotoxic medicines or related waste
• handling bodily substances from people treated with cytotoxic medicines
• managing spills of cytotoxic medicines or contaminated body fluids
• splashes to the skin or eyes
• inhaling airborne contaminants, which can be generated when air is expelled from a drug-filled syringe
• sharps injuries.

To ensure that cytotoxic medicines are provided safely, employers should consider:

• workplace design
• specialist equipment
• safe work practices, including education, training, supervised practice and competency assessment as required
• personal protective equipment (PPE).

Workplace procedures should be available for:

• all areas where cytotoxic medicines are administered
• where patients receiving cytotoxic medicines are cared for.

Use available controls

When designing and setting up an area to administer cytotoxic medicine and care for patients in a healthcare setting, employers should consider the following controls:

• A process to identify which patients have had cytotoxic medicines and if cytotoxic precautions are needed.
• Ensuring that:
  • there is sufficient room to move in the area
  • flooring is liquid-resistant, rather than carpet or mats, and can be hygienically cleaned.
• Providing: 
  • washable chairs and other furnishings
  • hand-washing facilities
  • a spill kit
  • a toilet with a lid
  • an emergency shower
  • secure storage of cytotoxic waste and sharps containers
  • secure storage for cytotoxic waste ready for disposal.
• Storing equipment for disposal of cytotoxic waste near the patient care area, including:
  • a purple cytotoxic waste disposal bin appropriate for sharps
  • a cytotoxic waste bin for safe disposal of body waste such as dressing materials, colostomy or urostomy bags, and incontinence aids such as nappies
  • bags to safely manage contaminated laundry
  • a hot pan flusher.
• Using closed systems where possible for handling body fluids. For example, if the patient has an indwelling catheter, use a sealed bag and weigh content for measurement.
• Keeping health and safety information, such as a Safety Data Sheet (SDS), in a place accessible to employees.
• Labelling any specimens of body fluid to be sent to pathology with the pictogram shown
  
  (see Labelling of cytotoxic medicines).
• Having PPE available near the patient care area.

For patients who need cytotoxic precautions at home, these controls should be in place where reasonably practicable. Patients should be given information on what controls they could consider and how to follow them at home. This may depend on the individual circumstances. Also see the following sections:

• 'Administration in the home'
• 'When patients leave a treating facility'

How to administer cytotoxic medicines safely

All employees involved with administering cytotoxic medicines must be given the information, instruction, training or supervision they need to work safely.

For all routes

Provide drug administration equipment

Equipment that helps to administer cytotoxic medicines can greatly reduce the risk of exposure. This equipment can include:

• needle-less administration systems
• closed administration systems
• Luer Lock syringes
• solid injection trays to contain and carry medicines to the patient
• plastic-backed absorbent sheets or pads to capture any potential spill associated at the injection site
• portable trolleys to store administration equipment and allow movement from patient to patient
• plastic, rigid-walled, wide-necked cytotoxic waste containers with a securable lid that are readily accessible to all operators
• spill kits (see Managing cytotoxic medicine spills)
• PPE (see Personal protective equipment for handling cytotoxic medicines).

Follow standard work procedures

As an employer, you should ensure that standard work procedures for administering cytotoxic medicines clearly detail how to:

• Follow the recommended procedures from suppliers and the pharmacy to administer specific cytotoxic medicines.
• Protect employee safety during administration. For example, using back-priming techniques and connecting bags at waist level where possible.
• Determine and manage for how long a patient requires cytotoxic precautions. For example, avoiding contact with all bodily fluids after administration.
• Manage extravasation incidents promptly.
• Appropriately dispose of cytotoxic waste. For example, not recapping needles, disposing of the administration set as a closed system.
• Use and dispose of appropriate PPE.

For intravesical administration

The intravesical route is used to treat bladder cancer. The chemotherapy drugs are administered via a urinary catheter, which is inserted into the bladder via the urethra. There are specific risk control measures to consider when this treatment is offered. These include:

• Monitoring and limiting leakage from the site of insertion of the urinary catheter. This may include work procedures for catheter insertion and removal.
• Limiting environmental contamination and spills of fluid from the bladder. This may include:
  • educating patients about urinating after treatment
  • ensuring there is extra cleaning of toilets used.
• Ensuring the personal hygiene of the patient.

For topical cytotoxic agents

Topical cytotoxic agents may be in the form of ointments, lotions or eyedrops. Control measures when administering topical agents include:

• avoiding unnecessary contact with topical cytotoxic agents
• applying ointments and lotions as a film, using a disposable spatula and wearing gloves
• educating patients on the correct way to apply medication
• minimising contact with clothing by wearing appropriate PPE, such as gloves
• disposing of all contaminated equipment and PPE as cytotoxic waste.

For oral cytotoxic medicines

Oral cytotoxic medicines are generally given as tablets and capsules. Control measures when administering oral medicines include:

• transferring tablets and capsules from their container into a disposable medication cup, to avoid direct handling
• returning tablets and capsules to the pharmacy when loose powder is observed
• contacting the pharmacy if it is necessary to produce a cytotoxic medicine mixture
• discarding used medication cups as cytotoxic waste.

Oral dose forms should only be manipulated if a pharmacist recommends it. This includes tablets and capsules. Manipulation may be needed when a patient is:

• nasogastric fed
• fed by PEG.

Crushing or breaking should only happen:

• in a specifically designed workplace
• using special equipment and safe work practices.

Pharmacy can advise on other forms or dosing strategies (including dissolution). This will help to minimise chances of exposure and environmental contamination.

For more information, see:

• ‘Preparing cytotoxic medicines’ in Storing, preparing and transporting cytotoxic medicines
• Society of Hospital Pharmacists of Australia, Don’t rush to crush, 4th edition.

Administration in the home

Employees may sometimes administer cytotoxic medicines in a patient's home. To minimise the risk of clinical employees and others being exposed to cytotoxic medicines and waste, consider:

• Storing medicines such as tablets, capsules or injections in a safe and secure place.
• Disposing of needles, syringes and other administration equipment in the purple cytotoxic waste bin. This should be returned to the hospital or pharmacy for safe disposal.
• Returning any unused medicine to the hospital or pharmacy for safe disposal.
• Setting up an administration area that can be thoroughly cleaned if there is a cytotoxic spill. For example, a wipeable chair positioned on a liquid-resistant surface (not carpet) close to a wash basin.

Spills in home and community care settings

Patients treated at home or in a community care setting should be given the means to help them safely deal with a cytotoxic spill for up to seven days after treatment. This should include:

• equipment including:
  • disposable gloves
  • absorbent material such as paper towel
  • disposable cloths
  • sturdy plastic bags that can be sealed or tied
• a list of contents
• easy-to-read instructions on how to manage the spill, including how to replace and dispose of used items.

Spill containment instructions for the home setting may be as follows:

• Wear disposable gloves and use paper towel to soak up spill.
• Use disposable cloths and soapy water to wash down surfaces the spill is on.
• Wipe dry with paper towel.
• Place used paper towel, cloths and gloves in the plastic bag, tie it securely and dispose in the general waste bin.
• Where linen is involved, use gloves to place in washing machine. Wash them on their own on the longest cycle in either hot or cold water with detergent. Run the full wash cycle a second time. Dry the washed items outside if possible. The items can then be used as normal.

How to safely care for patients

Exposure to cytotoxic waste can occur through:

• Handling any bodily fluid from a patient treated with cytotoxic medicines. For example:
  • vomitus
  • saliva
  • blood
  • excreta
  • sweat/thioepa
  • fluid drained from body cavities.

This includes handling any vessel used to receive bodily fluids, such as:

• bedpans or urinals
• emptying catheter, colostomy or urostomy bags
• vomitus bowls.
• Handling bed linen or clothing soiled with patient waste.
• Handling bed linen or clothing potentially contaminated with unchanged drug or active metabolites.
• Cleaning spills.

Identifying patients who need cytotoxic precautions

Whenever cytotoxic medicine is administered, employees should note:

• its name
• its route of administration
• the time it was administered
• if it is continuously administered – for example, by ambulatory pump/IV infusion.

This formal process will help employees to work out if any body fluids from the patient may be contaminated, requiring cytotoxic-specific precautions.

When patients leave a treating facility

When patients leave a treatment facility, they often still need cytotoxic-specific precautions. This includes for their body fluids. Treating facilities should explain to patients and their carers:

• which drugs they have been given
• special care requirements while they may excrete the drug
• the time frame for these precautions.

It is important that the treating facility:

• appropriately packages and labels any cytotoxic medicines the patient is taking with them
• makes available to the patient any equipment needed to manage cytotoxic waste, including a spill kit (see Managing cytotoxic medicine spills )
• gives written instruction to patients or carers.

If a patient is being transferred to another ward or facility after receiving cytotoxic medicines, the treating facility should ensure:

• availability of required facilities, equipment and appropriately trained employees
• necessary information is passed on to the receiving ward or facility.

The treating facility should develop procedures for:

• avoiding skin contact with patient body substances
• preventing the generation of aerosols when handling patients' body waste
• managing contaminated linen
• disposing of waste such as
  • urine
  • faeces
  • vomitus
  • the contents of colostomy/urostomy bags
  • incontinence aids such as disposable nappies or stoma bags
• containing waste generated from drug administration in a dedicated sharps container
• keeping waste containers secure and appropriately labelled
• cleaning up spills immediately
• providing written instructions on how to manage a spill in home or community settings.

How to safely transport patients

When moving a patient to another area within a hospital or treating centre, employers need to ensure the following control measures are in place:

• constant clinical supervision of the patient during the relocation if cytotoxic medicine administration is in progress
• immediate access to equipment and required help in the event of a spill of cytotoxic medicine or waste (a spill kit) 
• appropriate PPE
• handover and communication.

Employers must give employees the information, instruction, training or supervision they need to work safely. For example, employees at the patient’s new destination should be:

• trained in cytotoxic medicine safety
• made aware of the patient’s cytotoxic status. 

The same requirements apply to transport by ambulance if required.