Doing the dirty work: Who handles antineoplastic drug contaminated excreta and do they do it safely?

Antineoplastic drugs (ADs) given to combat cancer, can increase the risk of secondary cancers in those that receive them. ADs are also a hazard to those health-care workers who have long-term exposure to the agents. 1Department of Health and Human Services Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings.Centers for Disease Control and Prevention ed. NIOSH- Publications Dissemination, Cincinnati, OH2004Google Scholar Health-care workers can become exposed to ADs through spills and splashes, during the administration of the agents and even during exposure to the excreta of patients (most commonly urine and stool). 1Department of Health and Human Services Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings.Centers for Disease Control and Prevention ed. NIOSH- Publications Dissemination, Cincinnati, OH2004Google Scholar Levels of AD retained in urine, stool, and vomit of patients vary in amount and duration based on the agent, and personal characteristics of the patient. The active drug can be found in bodily fluids for at least 48 hours and up to 7 days post-administration. 2Oncology Nursing Society Safe Handling of Hazardous Drugs.2nd ed. Oncology Nursing Scoiety Publications Department, Pittsburgh, PA2011Google Scholar Recent research is also beginning to document that ADs are in the work environment and being metabolized by health-care workers who are not coming into direct contact with the agents or the bodily fluids of patients receiving them such as unit clerks, volunteers, and dieticians. 3Hon CY, Teschke K, Shen H, Demers PA, Venners S. Antineoplastic drug contamination in the urine of Canadian healthcare workers. Int Arch Occup Environ Health 933–41.Google Scholar Prior research has documented adverse effects of exposure to ADs for health-care workers including skin rashes, infertility, birth defects, miscarriage, and an increased risk for cancer, notably leukemia. 4Rogers B, Emmett EA. Handling antineoplastic agents: Urine mutagenicity in nurses. Image J Nurs Sch 108–13.Google Scholar, 5Connor TH, Lawson CC, Polovich M, McDiarmid MA. Reproductive health risks associated with occupational exposures to antineoplastic drugs in health care settings: A review of the evidence. J Occup Environ Med 901–10.Google Scholar, 6Lawson CC Rocheleau CM Whelan EA Lividoti Hibert EN Grajewski B Spiegelman D et al.Occupational exposures among nurses and risk of spontaneous abortion.Am J Obstet Gynecol. 2012; 206: 327e1-327e8Abstract Full Text Full Text PDF Scopus (131) Google Scholar, 7McDiarmid MA, Oliver MS, Roth TS, Rogers B, Escalante C. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. J Occup Environ Med 1028–34.Google Scholar The research that has been done to date has primarily focused on pharmacists and nurses who are preparing and administering these agents and less on nursing assistants (NAs) who are handling the excreta of patients receiving them. In the United States alone, it is estimated that more than 1,420,570 people work as NAs. 8Bureau of Labor Statistics. May, 2015 National Industry Specific Occupational Employment and Wage Estimates; 2016Google Scholar NAs provide care under the direction of a licensed health-care provider. They are often responsible for the majority of assistance with activities of daily living for patients which includes feeding, bathing, toileting, dressing, repositioning patients, and changing their linens. Nurses often delegate tasks like assistance with toileting to NAs. As suggested in an ethnographic study by Jervis, because of their frequent contact with excreta, NAs are at risk of being viewed as “polluted people” who do tasks that are unpleasant to nurses. 9Jervis LL The pollution of incontinence and the dirty work of caregiving in a US nursing home.Med Anthropol Q. 2001; 15: 84-99Crossref PubMed Scopus (73) Google Scholar However, do NAs know how to safely handle the excreta of patients receiving ADs? In the U.S., federal regulations mandate that Certified NAs receive at least 75 hours of training and 16 hours of clinical training, 10Wright B In Brief: Training Programs for Certified Nursing Assistants. AARP Public Policy Institute, Washington DC2006Google Scholar but when it comes to oncology-specific education for NAs, such as the hazards involved in exposure to ADs, recommendations for safe handling of excreta contaminated with ADs or even required provision of personal protective equipment (PPE) by employers, no mandates exist. Recommendations for safe handling of hazardous drugs and the excreta of patients receiving them exist from the National Institute for Occupational Safety and Health (NIOSH) 1Department of Health and Human Services Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings.Centers for Disease Control and Prevention ed. NIOSH- Publications Dissemination, Cincinnati, OH2004Google Scholar and are based on the results of research. A single case study described the effects experienced by one NA exposure to ADs from contact with patient excreta, 11Kusnetz E, Condon M. Acute effects from occupational exposure to antineoplastic drugs in a para-professional health care worker. Am J Ind Med 107–9.Google Scholar but few studies have included NAs in their sampling frame. 12Hon CY, Teschke K, Demers PA, Venners S. Antineoplastic drug contamination on the hands of employees working throughout the hospital medication system. Ann Occup Hyg 761–70.Google Scholar, 13Hon CY, Teschke K, Shen H. Health care workers' knowledge, perceptions, and behaviors regarding antineoplastic drugs: Survey from British Columbia, Canada. J Occup Environ Hyg 669–77.Google Scholar No study has been specifically focused on AD exposure for this large sector of the health-care workforce. Based on these limited findings, NIOSH recommends that NAs use chemoprotective PPE when handling excreta or linens of patients who have received ADs within the last 48 hours. 1Department of Health and Human Services Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings.Centers for Disease Control and Prevention ed. NIOSH- Publications Dissemination, Cincinnati, OH2004Google Scholar These behaviors include two pairs of chemotherapy rated gloves, a disposable gown, and a face shield if splashing is nonabsorbent. 1Department of Health and Human Services Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings.Centers for Disease Control and Prevention ed. NIOSH- Publications Dissemination, Cincinnati, OH2004Google Scholar The actual practice of NAs with regard to the handling of excreta has not been examined. While factors that influence the use of PPE when handling chemotherapy have been examined among nurses, 14Polovich M, Clark PC. Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. Oncol Nurs Forum E299–309.Google Scholar NAs have never been queried about what influences their use of PPE. We need to begin to think about exposures for NAs who have less education and training than nurses and are often doing “the dirty work.” Who handles the excreta of patients receiving ADs? How do they do so? Were they trained? By whom? Can you think of how their practice could be safer? Do you have any best practices to share with others when it comes to training assistive personnel to handle AD contaminated excreta safely? We have garnered a basic understanding from the literature, but there is much more to learn from what and who is missing. It's time to begin to critically examine exposures for those handling AD contaminated excreta in our practice settings. Dr. Walton was funded by a training grant (T32NR007091) from the National Institutes of Nursing Research, National Institutes of Health. There are no conflicts of interest.

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