Staff health monitoring & training

An essential part of the risk management strategy is dealing with issues of staff health surveillance, counselling, reporting and record keeping. Health surveillance is part of a comprehensive prevention program that also minimize worker exposure through the implementation of control measures. For example, engineering controls, good work practices, and personal protective equipment, and provides education about working with hazardous drugs. Health surveillance is the monitoring of a person to identify changes in the person’s health status because of exposure to certain substances; this includes health and biological monitoring but does not include atmospheric or environmental monitoring.

Exposure standards for acceptable levels of exposure to cytotoxic drugs have not been developed and are not available to date, therefore adoption of standard precautions and the principle of as low as reasonably achievable is recommended. Health monitoring includes the implementation of a health surveillance program that monitors an individual’s health status pre-employment or pre-placement and on an ongoing basis to determine any adverse effects to health following exposure to cytotoxic drugs. The program must include counselling of workers on the potential risks to health and reproductive risks, how exposures might occur and risk control measures in place.

It is recommended that complete blood count with differential and liver function tests are completed at baseline for staff who are assessed to be at a greater risk of exposure following a risk assessment based on duties performed; for example, pharmacy production staff and cytotoxic drug administration nurses. Biological monitoring is the measurement and evaluation of a substance or its metabolites in the body tissue fluids or exhaled air of exposed persons. The need for biological monitoring to detect exposure to a scheduled carcinogenic substance or tests to detect health effects caused by exposure should be carefully considered when the risk assessment is carried out. In particular, information must be obtained about methods that can detect the early signs of health effects or disease.

Many methods have been used to investigate potential health effects of exposure to cytotoxic drugs. These methods have given results that are often inconclusive and difficult to interpret. The ideal test should meet several requirements, it should be sensitive, specific, quantitative, rapid, reproducible and inexpensive. Importantly, the procedures of taking a sample should be non-invasive and should not cause unnecessary duress or anxiety to the individual. Several cytotoxic drugs are known to cause bladder damage and blood in the urine of treated patient leading some international standards to recommend monitoring the urine of workers who handle hazardous drugs with a urine dipstick or a microscopic examination of the urine for blood. The robustness of this testing is unclear.

Unfortunately, there is currently no test that meets all these requirements, nor is there one test that can used to detect the presence of all cytotoxic drugs and or metabolites. As a consequence, there is conflicting information and opinion about the value of routine biological tests in monitoring the health of workers handling cytotoxic drugs and related waste. Persons conducting a business or undertaking and or responsible agencies, have a duty of care to provide information, instruction, training and supervision to all workers handling cytotoxic drugs and related waste. A strategy of continuous education should be developed and implemented to keep all workers up-to-date with policies and procedures for handling cytotoxic drugs and related waste.

Health Services must ensure that only workers who have received appropriate training, and have attained the required level of competency and proficiency, handle cytotoxic drugs and related waste.

Training should be undertaken at induction or prior to commencement of duties where cytotoxic drugs or related waste are involved. Or it could be undertaken when new equipment or substances are introduced, or procedures change. Lastly, it could occur on an ongoing basis with annual review via Performance Review and Development processes or similar function.

So, who should be trained? The risk assessment results are used to identify all workers requiring specific training. Different level of training are recommended, depending on the level of potential risk of exposure to cytotoxic drugs and related waste.

Workers at greater risk of exposure to

cytotoxic drugs are following: pharmacy personnel, nursing personnel, laboratory staff, and animal handler in research area or medical personnel. The following are the workers at lower risk of exposure to cytotoxic drugs. Supervisors and managers they’re not clinical. Maintenance personnel, stores, procurement personnel, cleaners, on-site waste transporters, couriers and porters, waste handlers, carers, ambulance officers, and patient transport personnel. Training provided should be tailored to the needs of each individual after consideration of number one, the role description, number two, previous level of education, number three, specific responsibility relating to cytotoxic drugs.

Training and information in relation to

cytotoxic drugs and related waste should cover: Number one, work hazards and potential risk of exposure to cytotoxic drugs and related waste. Number two, the risk management process. Number three, the risk control measures, safe work procedures and work practices to be adopted when handling cytotoxic drug and related waste. Training and information in relation to cytotoxic drugs and related waste

should cover: legislative requirements for work health and safety, legislative requirements for cytotoxic waste management, safe preparation of cytotoxic drugs, safe administration of cytotoxic drugs, pre maintenance cleaning and maintenance of equipment, cleaning and laundering procedures, correct selection, use, cleaning and disposal of personal protective equipment. Procedures to be adopted in the event of incident, injury or spill, including reporting and recording, access to first aid resources, storage, transport, treatment and disposal of cytotoxic drugs and related waste, health surveillance and reporting, written safe work procedures. Training program should be evaluated to assess the effectiveness of the training, by monitoring how work is being performed and whether risk control measure are used correctly.

Could also evaluate it to incorporate review of reported incidents for continual practice improvement. And regularly, could be annually monitor workers’ performance to ensure continued competency. Monitoring performance will determine if further training is required, for example, through PR and D processes. Ensure modules and topics included in training are applicable to the work being carried out; this should be done regularly and each time there is a relevant change such as change of equipment, chemical, safe work procedure, work practice or risk control measure. Lastly, following all incidents and injury, the training program should be reviewed to ensure its adequacy. Health Services must keep record of workers’ training for at least five years after the date the record was created.

Training record should include: date of training, topics covered, name of the person who conducted the training, names and attendance validation, for example, signature, of the workers who attended the training, course evaluations, competency and proficiencies assessed.