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The Handling of Anticancer Drugs in Riyadh and the Eastern Province

1997; King Faisal Specialist Hospital and Research Centre; Volume: 17; Issue: 2 Linguagem: Inglês

10.5144/0256-4947.1997.257

0975-4466

Mastour S. Al‐Ghamdi, Zaki H. Al‐Mustafa,

Chemical Safety and Risk Management

Brief ReportsThe Handling of Anticancer Drugs in Riyadh and the Eastern Province Mastour S. Al-Ghamdi and PhD Zaki H. Al-MustafaPhD Mastour S. Al-Ghamdi Address reprint requests and correspondence to Dr. Al-Ghamdi: CMMS, King Faisal University, P.O. Box 2114, Dammam 31451, Saudi Arabia. From the Department of Pharmacology, King Faisal University, Dammam and Zaki H. Al-Mustafa From the Department of Pharmacology, King Faisal University, Dammam Published Online:24 Apr 2019https://doi.org/10.5144/0256-4947.1997.257SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionThere is increasing evidence that exposure to cytotoxic drugs in the workplace carries a definite hazard to the health of workers. The International Agency for Research on Cancer of the World Health Organization1 has identified at least five anticancer drugs with sufficient evidence of carcinogenicity. Urine mutagenicity in pharmacists2 and damaged chromosomes3 as well as fetal loss in nurses after exposure to antineoplastic drugs during the first trimester of pregnancy4 were reported. Exposure of workers to cytotoxic drugs may occur mainly by inhalation of airborne particles or direct skin contact.5 In response to the potential hazards to health care personnel, a number of organizations such as the National Institutes of Health (NIH),6 American Society of Hospital Pharmacists (ASHP),7 Clinical Oncological Society of Australia8 and Occupational Safety and Health Administration (OSHA)9 have developed guidelines for the safe handling of parenteral antineoplastic drugs during both preparation and administration. These guidelines are summarized in Table 1.Table 1. Summary of guidelines for safe handling of cytotoxic drugs, published by various international organizations.*Table 1. Summary of guidelines for safe handling of cytotoxic drugs, published by various international organizations.*Until recently, only King Faisal Specialist Hospital and Research Centre in Riyadh treated cancer patients with cytotoxic agents, but now almost all the referral hospitals in Saudi Arabia provide this service. It was our concern that some hospitals have neither a policy nor the necessary equipment and training for handling such hazardous drugs. This study, therefore, was aimed at investigating the conditions and proficiency of handling cytotoxic drugs in Saudi Arabia.METHODSTwelve referral hospitals known to offer cancer chemotherapy service in the Eastern Province and Riyadh City were investigated. They included four hospitals in the Ministry of Health (MOH) (Riyadh Central Hospital, Riyadh Maternity and Children's Hospital, Dammam Central Hospital and Qatif Central Hospital), two for the Armed Forces, one for the National Guard, one for the Ministry of Interior, two teaching hospitals, King Faisal Specialist Hospital and Research Centre and Aramco Hospital. A random visit was made to each site by one of the authors without prior knowledge of any of the professional workers involved. The study was conducted through a detailed questionnaire to pharmacists, nurses and physicians and all questions were answered at the time of the visit. The questionnaire was aimed at investigating the adherence to internationally recommended guidelines summarized in Table 1. The unannounced visit was made to ensure accurate and complete response.RESULTSOnly seven (58%) of the 12 hospitals investigated had a written policy for handling such hazardous chemicals (Table 2). Staff nurses were involved in preparation of cytotoxic drugs in three (25%) hospitals, while domestic staff were involved in cleaning up spillage in five (42%) hospitals. Administration of these drugs was mainly carried out by nursing staff.Table 2. Current practices relating to cytotoxic drug administration.Table 2. Current practices relating to cytotoxic drug administration.The site of preparation was considered unsuitable in five hospitals (42%), due to either lack of essential equipment such as vertical laminar flow cabinet (33%) or use of the site for preparing other drugs (42%) or both (Table 2). The area of preparation was not closed off and aseptic conditions were not maintained in three hospitals. In one hospital, even a wash basin was not available at the site of preparation.Gloves were used during preparation in all of these hospitals, while eye spectacles and surgical face masks were used in six (50%) hospitals, and gowns or aprons were used in 9 (75%). Special trays or absorbent sheets for preparation were used in 75%, while a special pad to break open ampoules was used in 50% of investigated hospitals. A vertical laminar flow cabinet was used in 67%, and Luer lock syringe fittings in 75%. Only in one hospital was air expelled from syringes into a special pad.Disposable boxes were used to keep sharps, needles and ampoules of cytotoxic drugs in nine hospitals (75%). Special bags or double plastic bags were used for other disposable materials in nine hospitals (75%) before being sent for incineration, which was the method used to eliminate the residuals of cytotoxic drugs in 10 hospitals (83%). A chemical kit, or disposable absorbent material to clean up spillage, was available in eight hospitals (67%).DISCUSSIONOur survey shows that all the investigated referral hospitals are dispensing parenteral cytotoxic drugs and that a high proportion of them were dispensing more than 40 injections/week. Furthermore, different professionals were involved in preparation, administration and cleaning up of cytotoxic drugs (Table 2). This would lead to a greater risk of exposure to these extremely hazardous drugs if safety policies are not implemented. It has been recommended5–9 that a comprehensive written policy describing all the procedures of safe handling during the various stages of preparation, administration, cleaning up of spillage and disposal of contaminated material is kept by each hospital dispensing cytotoxic drugs. Personnel should be aware of its existence and trained to implement it. This represents an essential step toward improving and maintaining high safety standards.10 Our results showed that only 58% of investigated hospitals had a written policy for handling antineoplastic drugs.Despite the fact that occupational risk could be minimized by strict adherence to safety measures and the use of protective equipment such as vertical laminar flow cabinet (biological safety cabinet) and full apparel, which consists of gloves, apron or gown, eye spectacles and surgical face mask or respirator,7–12 our findings suggest that most protective measures during preparation were not stringently enforced in some hospitals. While most items of protective clothing were ignored in some hospitals, gloves were the only consistently used method for self-protection. This finding is consistent with that reported by Wiseman and Wachs.12Systemic absorption of antineoplastic agents in hospital workers results mainly from the inhalation of airborne drugs.5 Preparation of cytotoxic drugs in a vertical laminar flow cabinet significantly reduces the risk of inhalation of drug particles and has been strongly recommended for this purpose.5,7,8,13 The cabinet should be continuously turned on and should be decontaminated once a week.13 A vertical laminar flow cabinet was used during preparation in only 67% of investigated hospitals, while the remaining four hospitals were not equipped with this important cabinet. Unfortunately, use of a surgical mask or even horizontal laminar flow cabinet does not provide sufficient protection.2The awareness of all staff involved in cytotoxic drug handling of the hazards posed by such chemicals is also important in raising standards of safety.13 It is the pharmacist's responsibility to instruct nurses, physicians, and domestic staff on safe handling of hazardous drugs.13 Furthermore, the pharmacist should educate patients on safety aspects when handling cytotoxic drugs in home chemotherapy.14In conclusion, our study revealed serious inadequacies in equipment and expertise in handling cytotoxic agents in some of the investigated hospitals. These range from absence of written policies to lack of essential facilities and proper training and practice. Although some effort has been made to promote the standard of safety handling of cytotoxic drugs,15,16 the authors are of the opinion that a center for training personnel in the proper handling of cytotoxic agents should be created in each region of the country. Major hospitals with appropriate facilities and proper administration of handling policy may serve as such centers. The Saudi Council for Health Specialties and the Saudi Pharmaceutical Society should be the organizing bodies for such training programs. Different methods of instruction, such as organizing workshops and group discussions13 or implementing self-learning exercises,17 may be used. In addition, the safety committee in each hospital should ensure appropriate implementation of safety policies for handling cytotoxic drugs. Meanwhile, employees' apprehension about handling cytotoxic drugs could be reduced by keeping them informed about hospital plans, listening to their concerns, and involving them in developing procedures for safe handling of these agents.18ARTICLE REFERENCES:1. International Agency for Research on Cancer, World Health Organization. "Evaluation of carcinogenic risk of chemicals to humans: some antineoplastic and immunosuppressive agents" . IARC Monographs. 1981; 26:370–84. Google Scholar2. Anderson RW, Puckett WH, Dana WJ, et al.. "Risk of handling injectable antineoplastic agents" . Am J Hosp Pharm. 1982; 39:1881–7. Google Scholar3. Waksvik H, Klepp O, Brogger A. "Chromosome analysis of nurses handling cytotoxic agents" . Cancer Treat Rep. 1981; 65:607–10. Google Scholar4. Selevan GS, Lindbohm ML, Hornbung RW, Hemminki K. "A study of occupational exposure to antineoplastic drugs and fetal loss in nurses" . N Engl J Med. 1985; 313:1173–8. Google Scholar5. Neal AW, Wadden RA, Chiou WL. "Exposure of hospital workers to airborne antineoplastic agents" . Am J Hosp Pharm. 1983; 40:597–601. Google Scholar6. Recommendation for the safe handling of parenteral antineoplastic drugs. Dept. of Health and Human Services Publication (NIH) 83-2621. Bethesda, MD: National Institutes of Health, 1982. Google Scholar7. American Society of Hospital Pharmacy. "ASHP Technical Assistance Bulletin on handling cytotoxic and hazardous drugs" . 1990; 47:1033–49. Google Scholar8. Clinical Oncological Society of Australia: guidelines and recommendations for safe handling of antineoplastic agents. Med J Aust. 1983; 1:426–8. Google Scholar9. Occupational Safety and Health Administration work practice guidelines for personnel dealing with cytotoxic (antineoplastic) drugs. "Occupational Safety and Health Administration Instruction Publication 8-1.1, Office of Occupational Medicine, Washington, D.C" . 1986. Google Scholar10. Council on Scientific Affairs: Guidelines for handing parenteral antineoplastics. JAMA. 1985; 253:1590–2. Google Scholar11. Medkova J. "On the problems of agents with mutagenic and carcinogenic efforts in health care. Cytostatic drugs" . Acta-Univ-Palaki-Olomuc-Fac-Med. 1990; 26:107–15. Google Scholar12. Wiseman KC, Wachs JE. "Policies and practices used for the safe handling of antineoplastic drugs" . AAOHN-J. 1990; 38:517–23. Google Scholar13. Power LA, Anderson RW, Cortopasi R, Gera JR, Lewis RM. "Update on safe handling of hazardous drugs: the advice of experts" . Am J Hosp Pharm. 1990; 47:1050–60. Google Scholar14. Steven KR. "Safe handling of cytotoxic drugs in home chemotherapy" . Semin-Oncol-Nurs. 1989; 5(suppl 1):15–20. Google Scholar15. Al-Ghamdi MS, Al-Mustafa ZH. Safe handling of cytotoxic drugs. 3rd symposium on drugs and poisons: uses and hazards. Jeddah, Saudi Arabia, April 1994. Google Scholar16. Bradley C, El-Fadil NB. Safe handling of antineoplastic agents. Saudi Oncology Symposium, Riyadh, Saudi Arabia, October1994. Google Scholar17. Dunne CF. "Safe handling of antineoplastic agents. Self-learning module" . Cancer Nurs. 1989; 12:120–7. Google Scholar18. Moore TD, Hale KM, Cortese LM, et al.. "Managing employee apprehension toward handling cytotoxic drugs" . Am J Hosp Pharm. 1985; 142:826–31. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 17, Issue 2March 1997 Metrics History Received27 March 1996Accepted7 September 1996Published online24 April 2019 InformationCopyright © 1997, Annals of Saudi MedicinePDF download