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Management of Chemotherapy Drugs

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Preamble• The purpose of this training is to increase

awareness among first responders regarding the health risks posed by working around hazardous drugs or patients receiving treatment, and to provide you with measures for protecting your health.

• Training is a direct result of exposures to spilled drugs or toxic bodily fluids by local first responders.

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Course Content:

• Definitions• Health Risks: short, long term exposures and entry

routes• Life time of drug toxicity• Chemo administration process/techniques/equipment• Hazard and risk assessment of the scene• Overview of patient care considerations• PPE• Spill management and sources of contamination• Accidental exposure• Items within the spill kit

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Discovery of Chemotherapy

• The first chemotherapy drugs to be used on patients were based on nitrogen mustard.

• When soldiers were exposed to this gas doctors found;• Bone marrows and lymph nodes had been affected• Cells in bone marrow and lymph nodes had been reduced

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• In 1946 two scientist named Gilman and Philips published an article on the chemical compounds related to this gas

• Further studies showed that these drugs caused lymphomas to shrink• There was also huge toxic effects to the digestive system and also to

the blood and bone marrow.• These drugs became the first to be used by doctors to treat cancer

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• In 1947 another research doctor called Farber published data on another group of chemotherapy drugs called antifolates.

• It was known from research that folic acid caused leukemia cells to increase.

• Drugs created to block the cell’s use of folic acid• This led to the development of methotrexate in 1949• This was the first drug to treat leukemia

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Chemotherapy

• Chemo – is the treatment of cancer with one or more cytotoxic/ antineoplastic drugs as part of a regime.

• Chemotherapy may be given to cure, aim to prolong life or to lessen symptoms in a dying patient (palliative).

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Definitions• Cytotoxic: a pharmacological compound that is detrimental or

destructive to cells within the body.A drug can be harmful to cells in different ways:

• Genotoxic – a substance that damages DNA, damage can lead to growth of malignant tumors.

• Carcinogenetic – a substance that may cause mutations leading to the development of tumors in otherwise healthy cells

• Mutagenic – a substance that alters the DNA of a living being• Teratogenic – a substance that may cause malformations of an

embryo or fetus (birth defects).

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• Antineoplastic: chemotherapeutic agent that controls or kills cancer cells. Are cytotoxic but are generally more damaging to dividing cells than to resting cells.

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How Chemotherapy Works

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Cancer Care Ontario

• They reviewed how chemotherapy was being delivered in 2007 (specifically out of hospital tx)

• Results of the review introduced guidelines and policies on PPE and spills• As a result of this, the training today is attributed to the review from CCO

and the guidance set out by the CDC/NIOSH.

• ***There are no exposure limits set for cytotoxic drugs and therefor no exposure is safe***

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Potential Health Risks – Short Term

• Nausea• Headache• Dizziness• Hair Loss• Sores in the mouth• Liver damage – Jaundice• Abdominal Pain• Contact Dermatitis• Both Skin and Eye injuries

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Potential Health Risks – Long Term Effects

• Not well documented but some information does exist• Genetic mutations• Reproductive issues such as: Menstrual dysfunction, Infertility,

Spontaneous abortion• Developmental: Offspring, Low birth weight, Premature birth, learning

disabilities• Cancer: Leukemia, Lymphoma• Organ Damage

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Entry Routes• These hazardous drugs may enter the body

through:

• Absorption – is route most frequently reported

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• Inhalation – as an exposure route has not been clearly established but cannot be ruled out.

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• Injection

• Ingestion

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Exposure Contact

Chemotherapy drugs• Capsules, tablets or IV fluid

Waste products• Needles, waste container, used spill kit, gown, gloves, etc

The patients bodily fluids

• Vomit, diarrhea, blood, urine, semen, and vaginal fluid. • Patient’s bodily fluid may contain a small amount of the

chemotherapy drug up to 7 days post treatment.

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Sources of Contamination

Direct Care

Vehicle Exposure area

• In-patient LTC facilities• Home care residences• Out patient

• Door handles• Inside passenger compartment

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Vehicle Exposure area

• Bags, handles, zippers• Monitors• Stretcher

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Chemo Administration• IV chemotherapy can be administered through a bottle

called an Infusor pump. It is made of hard plastic and looks like a baby bottle.

• Oral chemotherapy drugs and medications for side effects are delivered from the pharmacy in a package similar to this.

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IV Chemotherapy• The small white section on the tubing

is called a flow restrictor. It controls how fast the chemo runs. It is to be taped against the skin at all times.

• This is a closed system. This system is safe. Gloves are needed to attend to this patient. If the line was detached or punctured, this could result in a leak and full PPE is required.

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Portacath Access

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PICC LinePeripherally Inserted Central Catheter

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Infusor Pump• Inside the bottle there is a balloon

which holds the chemo drug. The balloon gently pushes the chemo down the tubing into the IV. Chemo can run over 2, 5, or 7 days.

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• The pump is working when the balloon becomes smaller or changes size. There may not be a lot of change in the first few hours.

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Cytotoxic• The IV pump labelled “cytotoxic” can

be carried in a pouch strapped to the patient.

• Some patients choose to carry it in a purse, under the shirt, and pants or shirt pocket.

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Drug Toxicity and Time• 24 hours after a dose given, drug is changing inside the patient and

starts to become less toxic

• Some drugs become neutral after 48 hours

• Up to 14 days after the last dose given, residue of the drug may be detected in patient excreta.

• Upon initial contact, until otherwise indicated, we will assume that the patient is within the 7 day window

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• Within the 7 day period, body fluids are to be considered toxic and PPE precautions are to be adhered to.

• Because we cannot determine the time rated toxicity of any drug we will follow the 7 day rule.

(ASSTSAS table 8 pg 11-5) Adobe Acrobat Document

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Hazard and Risk Assessment

Prior to rendering patient care, be sure to complete an assessment of potential hazards and risks on scene. Scene size up is the primary step to identifying operational hazards and exposure risks.

- Check out the scene

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Key observations will include:

• Signage or notice of the use of antineoplastic drugs• May not be visible

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• Look for spill kits within the home or patient environment• Medical consumables(syringes, bandages), IV poles or infusion vials in

the patient’s home could be an indication of some kind of drug use• When entering the home, be sure to observe floor areas for any spills• Be aware of body waste control items: bed pans, urinals, toilets, waste

baskets

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Assessment – Establishing a treatment timeline

Upon making patient contact, the Paramedics will elicit a S.A.M.P.L.E. survey in order to determine if the patient is being treated with chemotherapeutic medication as well as when the last treatment was given.

This time line will help to identify how toxic the patient may be!

Try to elicit the following and use lay terminology:• What is the medical Dx?• Are you being treated for cancer?• When was the last known dose given?

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History Assessment -S.A.M.P.L.E.

S: Symptoms – SOB, nauseated, CPA: Allergies – Does the patient have any drug allergiesM: Medications – Antineoplastic (chemotherapy) drugsP: Past medical history – Cancers, etc.L: Last known oral intakeE: Events leading up to the call

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Incidents That Can Lead To Exposure

Spills

Bodily fluid at scene or enroute

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Spills Management Fire Response

We are currently working with fire services to establish a protocol with them regarding Cytotoxic spills:

• They will have all required PPE to deal with a spill (do you?)• They will be versed in what a Cytotoxic spill is and what precautions

need to be taken. (looking after this today)

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Spills ManagementThe following will help you in determining the best approach to managing fluids on scene.

• Perform a scene size up, identify exposure risks or operational hazards upon entering the area.

• Responders will make every reasonable effort to control bio hazardous/cytotoxic material if there is a need to make the scene safe to extricate the patient.

• If needed, call for additional resources to aid with the decontamination or patient care process.

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Spills Management Cont’d• Consider a safe path to extricate patient and crews. Be sure to relay this

information to other responders.

• Responders will identify areas that are suspected of containing cytotoxic waste or hazardous medications.

• Move patient away from spill area if possible.

• Open spill kit and place absorbent padding components on human waste, medication in an attempt to isolate and control the area. Ensure that the absorbent pads are used with the blue side down on the spill area. (100mls of absorption per pad)

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Spills Management Cont’d

• Prepare a red biohazard bag to receive waste by rolling open each bag.

• Ensure all waste is placed into the red biohazard bag.

• Bring the sealed bag with you to the closest base or hospital and dispose of bag into the provided red pails.

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On Scene Contamination – Bodily Fluids• Don proper PPE.• Move patient away from contaminated area if possible.• Place absorbent padding, from the spill kit, on medication or human waste.• Remove contaminated clothing if possible, if not wrap patient in yellow

disposable blanket.• Use the red biohazard bags to receive the waste by rolling open bag. All

contaminated waste is to go into these bags.• Transport and provide patient care while in full PPE.• Decontaminate at the hospital.• Bring the sealed bag with you to the closest base and dispose of bag into

your provided red pail.

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En-route Contamination

• Stop vehicle in a safe location, get out and don your proper PPE.• Place absorbent pads, from spill kit, on medication or human waste.• Use the red biohazard bags to receive the waste by rolling open bag. All

contaminated waste is to go into these bags.• Continue transport and provide care.• Decontaminate at hospital.• Bring the sealed bag with you to the closest base and dispose of bag into your

provided red pail.

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Spills at Scene• Don’t enter contaminated area- if you have entered, leave and assess

situation.• Don proper PPE.• If patient is not contaminated remove them to a safe area.• Call fire/Superintendent to attend scene.• Remove contaminated clothing, if possible, wrap patient in yellow disposable

blanket.• Continue with transport and provide care.• Fire/Superintendent may also have to attend hospital to decontaminate

vehicle.• Place all contaminated items into red biohazard bags.• Bring the sealed bag with you to the closest base and dispose of bag into your

provided red pail.

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Spills En-route• Pull over into a safe location and get out.• Don proper PPE.• Place absorbent pads over spill area to contain.• Turn exhaust vent on within back of vehicle.• Continue with transport and provide care.• Notify CACC to have Fire/Superintendent to attend hospital to assist

decontaminate of vehicle.• Place all contaminated items into red biohazard bags.• Bring the sealed bag with you to the closest base and dispose of bag into your

provided red pail.

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Transporting the Patient involved in a Spill or Leak of Chemotherapy Drugs

Advise the ED prior to arrival at the hospital about the patient and the risks

• If there was a leak/spill that is now contained.• If the patient is contaminated.• Or crew/stretcher contaminated.

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Accidental Exposure• Any skin will require the responder to remove him/herself from the area and

wash with soap and water.• If a hazardous drug accidentally comes into contact with a worker’s clothing,

the worker must immediately remove the contaminated clothing and thoroughly wash the affected area with soap and water.

• Any splashes to the eyes will require flushing with water for at least 15 minutes.

• Drugs can be harmful to contact lens wearers, who must remove their lenses immediately in the event of accidental exposure.

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• Needle stick injury will require the responder to squeeze and milk the poked area.

• If injury is sustained, report to the nearest hospital for treatment.• Ensure that your Duty Superintendent has been notified.• City Guelph Employee Incident report will need to be filled out.• If excreta and or drug has breeched PPE, it is best practice to register as a

patient and be interviewed by a physician post exposure.

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Cleaning Up Equipment

• Wear PPE.• Proper disposal of linen and any other soiled material into a red bag.• Special cleaning solutions are needed to break down the chemo drugs on

a surface rendering them safe. (Surface Safe).• Initially clean affected areas with detergent and water, then cleaning

solution (Surface Safe). Use regular soap and water TWICE after this.• All cleaning items, cloths, etc. need to be placed into a red bio hazard

bag.

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P.P.E. Donning and DoffingIt is important to adhere to the procedures outlined in the ASSTSAS prevention guide, on the Donning and Doffing sequences when working with/near hazardous medications.

Donning Procedure

1. Apply the first pair of appropriately sized chemo specific gloves.2. Apply the disposable Tyvek suit ensuring that the cuff of the suit goes

over the glove.3. Apply a second pair of chemo gloves over top of the Tyvek suit cuff.4. Apply the P100 respirator and ensure a seal test is performed.5. Apply face shield.

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Doffing

Doffing Procedure

1. Perform contact exposure prior to removal of PPE.2. Remove the outer pair of medical gloves following proper glove removal

and place in the red biohazard bag.3. Remove Tyvek suit ensuring that it is turned into itself, place it into the

red biohazard bag .

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Doffing Con’tDoffing Procedure

5. Leave eye protection/face shield and mask on when closing the red bio hazard bags.

6. Close the red biohazard bag by un-rolling the edges up and closing with a nylon tie.

7. Remove the remaining pair of gloves, P100 mask and eye protection. Place these items into the 2nd red bio hazard bag and seal it with a nylon tie.

8. Perform hand hygiene practices by using soap and water after PPE removal.

9. Sealed red biohazard bags need to be placed into a red pail, lid sealed and a Cytotoxic waste label adhered to the pail.

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Spill Kit

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Spill Kit ContentsGuelph-Wellington Paramedic Service kit will contain the following:

Two part system:

First Kit• 2 large red biohazard bags• 4 nylon ties• 4 Surface Safe (or equivalent) wipes• 4 Chemo absorbent pads• Chemo rated gloves with extra long cuffs• P100/N95 masks• Face Shield

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Spill Kit ContentsGuelph-Wellington Paramedic Service kit will contain the following:

Two part system:

Second Kit

• 2 ea Lg, XL, 2XL, 3XL, and 4XL coveralls• Each coverall is equipped with a hood as well as boots

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RecapAccidental exposure to cytoxic drug by a health caregiver must be managed as an urgent or emergency situation with immediate measures to remove drug contact with the worker.

• If clothing is contaminated remove ASAP. Flush skin with copious amounts of water, wash well with soap and water. This may require a decontamination shower. Wash uniform separate from other clothing.

• Flush eyes with copious amounts of water at a sink or eyewash station or with isotonic (0.9% NaCl) for 20 minutes. Seek medical attention.

• If accidentally pricked or injected with a needle containing any cytoxic drug, flush area with running water. Milk the puncture area to encourage bleeding and flush out any drug that may have been injected accidentally.

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Recap

• Personnel exposed to cytoxic/antineoplastic agents must visit the Emergency Department for additional medical care and complete a City of Guelph – Incident Investigation Report

• Pre-alert the ED to receive further directions. They may require you and your patient to remain in the garage until the patient and equipment is safe to proceed into the ED.

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