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SAFE MANAGEMENT OF CYTOTOXIC SPILLS

GONG Cancer Care Guidelines

Next Review Date: Feb 2010


Responsibility: Gippsland Oncology Nurses Group.
Purpose: Provide comprehensive, current, evidence based guidelines for
management of cytotoxic spills to inform standardized policy and
procedure development across Gippsland. This guideline gives a brief
overview of the principles for safe management of cytotoxic spills and
follows the WorkSafe Victoria guide (see references).
Desired Outcome: Raise awareness of the topic of management of cytotoxic spills in
everyday assessment of cancer care and thereby promote best practice.

1. DEFINITION OF Spillage of cytotoxic medications or any body fluids of a patient


which are still deemed to be contaminated with the cytotoxic
CYTOTOXIC WASTE medication or less active metabolites of treatment. Cytotoxic
medications are primarily eliminated from the patient by renal
The GONG Guideline Safe and hepatic excretion. All body substances may be
Handling of Cytotoxic contaminated with either the unchanged drug or active drug
Substances should be read metabolites. Exposure to cytotoxic waste can occur through
in conjunction with this handling vomitus, blood excreta and fluid drained from body
guideline. cavities; handling bedpans, urinals, emptying urinary catheter
www.gha.net.au/GRICS bags, colostomy/urosotomy bags and vomitus bowls; handling
bed linen or clothing soiled with patient waste, or potentially
contaminated with unchanged drug metabolites; cleaning spills.

2. RISK POTENTIAL Any person handling cytotoxic medications and related waste
might be involved in dealing with a spill, which may occur:
The period during which When preparing, storing and transporting packaged drugs.
body substances may be
contaminated with cytotoxic During administration or transport of patients with
medications WILL DIFFER chemotherapy in-situ.
for individual drugs and Handling patient body substances contaminated with
patients. See appendix 1 cytotoxic medications.
for excretion times of
cytotoxic medications. Any time any cytotoxic waste is handled.

3. HEALTH SERVICE Health services should develop a spill policy and procedure for
in-patient and home visits, that is understood, implemented
POLICY and maintained by all personnel who handle cytotoxic
medications and waste, and those who may be involved in
managing spills.

4. STAFF EDUCATION Employers should ensure that all employees who handle
cytotoxic medications and waste have received appropriate
training, and have obtained the required level of proficiency for
spill management. Those personnel deemed safe to provide
appropriate spill containment include: all hospital staff that may
deal with the potential risk listed in point 2 Risk Potential.

5. PATIENT EDUCATION Patients and carers should be provided with written health and
safety information such as the GRICS Chemotherapy Safety at
- SPILL MANAGEMENT Home patient information brochure available on
AT HOME www.gha.net.au/GRICS

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6. SPILL EQUIPMENT All areas where cytotoxic medications and related waste are
handled should have the following readily available:
- HOSPITAL SETTING
Spill kit containing (minimum) instructions for use,
personal protective equipment, disposable gown, head
covering, over-shoes, protective gloves, protective
eyewear, respiratory protective device.
Adequate supplies of disposable absorbent material.
Cleansing material including strong alkaline detergent
pH>10 (eg. Decon).
Disposable mop head.
Approved container for cytotoxic spill waste.
Approved container for sharps where required.
A disposable brush and shovel should be available in case a
glass container has been broken.
Spill pillows may be necessary for larger spills.

7. LAUNDERING Special precautions are required for the laundering of non-


disposable personal protective equipment and linen
- HOSPITAL SETTING contaminated with cytotoxic waste.
This is to protect the laundry personnel from cytotoxic waste.
This is achieved by:
Preventing contamination of the materials being laundered.
Contaminated linen should be placed in plastic bags
appropriately labelled with cytotoxic labels at the point of
contamination for subsequent laundering. Alginate bags
may be used.
Bed mattresses should be cleaned after a spill with a
cleansing material including strong alkaline detergent
pH>10 (eg. Decon).

8. EQUIPMENT For patients receiving a continuous infusion of chemotherapy at


home, the equipment available for the visiting nurse should
- HOME SETTING include:
Spill kit containing (minimum) instructions for use,
personal protective equipment, disposable gown, head
covering, over-shoes, protective gloves, protective
eyewear, respiratory protective device.
Adequate supplies of absorbent material.
Cleansing material including strong alkaline detergent
pH>10 (eg. Decon).
Approved container for sharps where required.
Appropriate cytotoxic waste containers.
Patients who experience a cytotoxic spill at home should refer
to their GRICS Chemotherapy Safety at Home Patient
information brochure.

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9. STAFF OR PATIENT Use a spill kit.

CONTAMINATION Wash area with copious amounts of water or shower if


possible.
Notify medical officer.
Notify manager.
Fill out appropriate health service documentation.

10. DOCUMENTATION Complete relevant Health Service incident reporting, eg.


Spill registry where appropriate.
Notify treating doctor if spill was associated with
interruption to treatment or loss of chemotherapy dosage.
Document event in patients medical record.

REFERENCES
1. American Society of Health-System Pharmacists. (2002). ASHP guidelines on preventing medication
errors with antineoplastic medications. Am J Health-Syst Pharm. 59:1648-68.
2. Austin Health. (2004). Procedure for cytotoxic chemotherapy spill management. Austin Health.
3. British Columbia Cancer Agency. (2006). Policy: Chemotherapy process. British Columbia Cancer
Agency.
4. Cancer Nurses Society of Australia ( 2006) Position statement on the minimum education and safety
requirements for nurses involved in the administration of cytotoxic drugs
5. Bayside Health. (2005). Guidelines for safe handling of cytotoxic drugs. Bayside Health.
6. Cancer Institute NSW. (2005). Cytotoxic spill management. http://www.cancerinstitute.org.au/
7. Cancer Institute NSW. (2005). Excretion Times of Cytotoxic Medications.
http://www.cancerinstitute.org.au/
8. Cancer Nurses Society of Australia. (2003). Chemotherapy Position Statement on the minimum
education and safety requirements for nurses involved in the administration of cytotoxic drugs. CNSA.
9. Latrobe Regional Hospital. (2006). Cytotoxic substances-safe handling policy. Latrobe Regional
Hospital.
10. Peter MacCallum Cancer Centre. (2004). Management of cytotoxic spill. Peter MacCallum Cancer
Centre.
11. SHPA Committee of Specialty Practice in Oncology. (2005). SHPA Standards of practice for the safe
handling of cytotoxic drugs in pharmacy departments. Journal of Pharmacy Practice and Research.
Vol 35 (1): 44-52.
12. WorkSafe Victoria. (2003). Handling cytotoxic drugs in the workplace. WorkSafe Victoria. Website:
http://www.worksafe.vic.gov.au

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APPENDIX 1 - EXCRETION TIMES OF
CYTOTOXIC MEDICATIONS
Clinical Summary DRUG URINE STOOL Notes
Length of time that Amsacrine 2 days
safe handling Asparaginase Trace
precautions should amounts
be taken with urine
Bleomycin 3 days
and stools after the
Busulphan 12-24hrs Trace
administration of
amounts
cytotoxic
Capecitebine 1 day
medication.
Carboplatin 1-2 days
These excretion Carmustine 4 days 10% as C0
times are a guide Chlorambucil 2 days
for when to wear Cisplatin 7 days > 10% excreted in bile
the appropriate Cyclophospha 3 days (IV) 5 days after In sweat and saliva for 3 days
Personal Protective mide PO dose
Equipment. Cytarabine 1 day
Standard Universal Dacarbazine 1 day
Precautions will Dactinomycin 5 days 7 days
suffice at all other Daunorubicin 2 days 7 days 20% elimination via gall
times. bladder in first 24hrs
Source: Cancer Docetaxel 7 days 7 days
Institute NSW. Doxorubicin 6 days 7 days
(2005). Excretion Epirubicin 7 days 5 days
Times of Cytotoxic Etoposide 4 days 7 days
Medications. phosphate
http://www.cancer Etoposide 4 days 7 days
institute.org.au/ Fludarabine 2 days
Fluorouracil 2 days
Fotemustine 4 days
Gemcitabine 7 days
Hydroxyurea 2 days
Idarubicin 4 days 7 days
Ifosfamide 2 days
Irinotecan 2 days
Liposomal Extended Biphasic elimination; half life
Doxorubicin elimination of 5hr & 55hrs.
Lomustine 4 days
Melphalan 2 days 7 days
Mercatopurine 2-3 days 5 days
Methotrexate 3 days 7 days
Mitomycin 1 day Small amount in bile
Mitoxantrone 6 days 7 days
Oxaliplatin 3 days
Paclitaxel 1 day 5 days
Pemetrexed 3 days
Procarbazine 2 days
Temozolomide Unknown
Teniposide 5 days 2 days
Thioguanine 1 day
Thiotepa 3 days
Topotecan 2 days
Vinblastine 4 days 7 days
Vincristine 4 days 7 days
Vindesine 4 days 7 days
Vinorelbine 4 days 7 days

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