Aside from compounding, chemotherapy spill represents the biggest opportunity for HD exposure. It is not known how many spills occur each year as there is no centralized database for this information and institutions typically do not make the data public. Instead, we rely upon published surveys and anecdotal evidence.

 

Surveys

The largest survey to date was published by Boiano and colleagues in 2014 and included 1,954 nurses. 12% reported experiencing a spill or leak within the week prior to the survey. Almost 10% stated that spills had not been properly cleaned. No data is available for the number of spills that occurred during the prior 6 or 12 months, although multiple spills during the 7 day period were reported (Boiano, Steege & Sweeney, 2014, Journal of Occupational and Environmental Hygiene, 11.)

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A study published in 2017 by He et al, which included nurses from California, Michigan and Georgia (n=252), indicated that 26% had experienced a spill within 6 months. Only 17 nurses reported using a CSTD; however, 62% cited a device malfunction. (See discussion on CSTDs for more information.) Also of interest, only 57% used chemotherapy tested gloves and only 39% used double-gloves (He, Mendelshon-Victor, McCullagh, & Friese, Oncology Nursing Forum, 2017, 44(1).

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In 2015, Chris Freise and colleagues reported on a pilot study (n=40) in an ambulatory infusion center. During a 6 month period, 9 employees were involved in 4 spills. More significantly, HD was detected in the urine of employees who did not report or were not involved with a spill, indicating likely environmental contamination. This study resulted in changes being made to spill cleaning procedures (Friese, McArdle, Zhao, Sun, Spasojevik, Polovich and McCullagh, 2015. Cancer Nursing, 38(2).

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Absorption

The primary route of HD absorption is dermal (Fransman, Roeleveld, Peelen, de Kort, Kromhout, & Heederik, 2007, Epidemiology, 18.) and dermal contact in the environment can lead to absorption. This is one rationale for performing regular surface wipe testing. Considerably less information is available about inhalation of vapors. (See section on respiratory protection.) And despite the use of components to prevent spills (e.g., Luer Lok connections and CSTDs), spills still occur. So while we must do everything possible to prevent them, the reality is that at some point a spill will happen.

 

Just as organizations do everything possible to prevent fires, drills and safety protocols are a normal part of the healthcare workplace. This same approach must apply to spills, and is discussed throughout USP <800>.

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USP <800> does not specifically discuss how nurses should clean a spill at the bedside, but information is included in the section I authored in the ONS Safe Handling of Hazardous Drugs (2018). Readers are encouraged to review this material.

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USP <800> also does not specify who should respond to spills, but section 16 requires that they must be trained. As with fires and code blue events, it might be years before someone has to respond to a spill, thus providing the rationale and requirement for annual training.

 

Spill Kits

A number of manufacturers offer HD spill kits. Nurses should be familiar with what is in their kit (similar to knowing what's in the crash cart), and with the institution's spill policy. It should be recognized that not everything in a kit may be useful or effective as there are no regulations requiring manufacturers to test the items in their kits. Many contain surgical masks or N95 respirators that are completely useless for vapors, and may not provide an airtight fit against the employee's face. (OSHA 29 CFR 1910.134(f) requires fit testing for respirators.) Shoe covers in some kits may not be impervious to HDs, providing a false sense of security.