POLICY Title: Surface Wipe Sampling Number: V-50 Effective Date: Revision Date:

Transcription

1 Page 1 of 8 RATIONALE Contamination of work areas with hazardous drugs poses a health risk to BCCA staff. Surface wipe sampling measures levels of contamination allowing BCCA to assess risk levels and take appropriate action. DIRECTIVE To ensure levels of hazardous drugs are at the low risk or non-detectable level, surface wipe sampling for cyclophosphamide levels (and other hazardous drugs as deemed appropriate) will occur in the pharmacy and the chemotherapy treatment areas. PROCEDURES 1. Wipe samples will be taken 6 months after implementing a Closed System Drug Transfer Device (CSDTD) and then annually. Follow actions in Table Surface wipe samples will be taken by two designated staff members (one each from pharmacy and nursing) (see BCCA Works Standard Wipe Sample Procedure located at H:\EVERYONE\Pharmacy\Surface Wipe Sampling ). Samples are to be taken at the end of the workday before housekeeping and pharmacy have cleaned any surfaces (including the biological safety cabinet). Surface wipe samples will be performed on the same location and the same area of the location each time. Six samples will be taken in the pharmacy department and six in the chemotherapy treatment areas. Locations to be sampled are indicated in Appendix1. 3. If levels are low or medium (see Table 1 BCCA risk Levels) the Pharmacy PPL or Clinical Nurse Leader will estimate the risk based on the affected surface. Steps will be taken to identify, document, and contain the source of contamination. Actions may include reevaluating work practices, re-training personnel, performing thorough deactivation, decontamination, cleaning and improving engineering controls. 3 Decontaminate and repeat wipe sampling as per Table If levels are in the prohibitory risk level (see Table 1) stop work in area then follow the steps and actions in point 3.

2 Page 2 of 8 TABLE 1 BCCA Risk Levels 4 Risk Level Not Detectable Surface Contamination cyclophosphamide (ng/cm2) Action (affected areas) None Estimate risk based on affected surface; investigate and evaluate cleaning process and work practices Monitoring (affected areas) Low Medium Prohibitory Risk Level < > 10 Annual Repeat wipe sampling in 6 months Estimate risk based on affected surface; investigate and evaluate cleaning process and work practices; decontaminate as soon as possible Repeat wipe sampling after decontamination and in 6 months Stop work in area investigate and evaluate cleaning practice, work practices; decontaminate Repeat wipe sampling after decontamination and in 2 months

3 Page 3 of 8 APPENDICES Appendix 1 Wipe Sampling Worksheets Pharmacy 6 month 1 year 2 year Sampling Location Record further details of your sampling location may take photos to further identify wipe sampling locations Center of work surface inside BSC Which hood was sampled? Airfoil BSC (front grill) Which hood was sampled? Floor in front of BSC Which BSC? Left side arm rest or foot rest of chair used by chemo mixing staff Which chair was sampled? Color or labels on it? IV checking counter Which counter exactly? Handle of IV pass through door (final product checking side) Where on handle? Pharmacy PPL to retain copy of worksheet

4 Page 4 of 8 Patient Treatment Area 6 month 1 year 2 year Sampling Location Floor area of chair where pump usually stands Pump touch pad Record further details of your sampling location may take photos to further identify wipe sampling locations Beside which chair? Which pump?(number on pump) Right side arm of a patient treatment chair Surface where HD preparations rest prior to administration Floor near chemo waste bucket Mouse of most commonly used computer in nursing station area Which chair sampled? Tag the chair which was sampled. Describe where Chemo bucket beside which chair? Hardware number of computer terminal? Clinical Nurse Leader to retain copy of worksheet

5 Page 5 of 8 Appendix 2 Decontamination Procedure Decontamination involves the inactivation, neutralization, and/or removal of toxic agents, usually by chemical means. 1 There is no single process that has been found to deactivate all currently available hazardous drugs, and therefore the procedure involves multiple surface wipes with different agents, as outlined in the table below. 2 The table describes cleaning for all areas of the pharmacy and patient treatment areas when surface wipe sampling results indicate a medium or prohibitory risk level of cyclophosphamide contamination was measured. Pharmacy Area Examples of Surfaces Decontamination Steps Pharmacy HD Sterile Preparation Room (SPR) Pharmacy areas outside the SPR Inside the BSC (by pharmacy staff) Floors, countertops, carts, drug bins, shelving, outside surfaces of the BSC, doors, door handles, inside pass throughs Walls, window blinds, chairs Telephones, computer keyboards, intercom switches Windows Window blinds, walls Floors, countertops, carts, drug bins, shelving, outside surfaces of the BSC, doors, door handles, outside pass throughs Telephones, computer keyboards, intercom switches Step 2 - Sodium Thiosulfate 1% Step 3 - Sterile water for irrigation (Remove residue) Step 4 - Sterile 70% alcohol Step 2 - Sodium Thiosulfate 1% Step 3 - Sterile water for irrigation (Remove residue) Step 1 - Accelerated Hydrogen Peroxide 0.5% solution (see Note 2) Step 2 - Dilute solution of dilute alkaline (ph 8-9) Step 3 - Water for Irrigation Do not pour or spray solution onto the surfaces; moisten a cloth and wipe Step 1 - Dilute solution of alkaline (ph 8-9) Step 1 - Accelerated Hydrogen Peroxide 0.5% solution (see Note 2) Step 2 - Dilute solution of dilute alkaline (ph 8-9) Step 3 - Water for Irrigation Step 2 - Sodium Thiosulfate 1% Step 3 - Sterile water for irrigation (Remove residue) Do not pour or spray solution onto the surfaces;

6 Page 6 of 8 Windows moisten a cloth and wipe Step 1 - Dilute solution of dilute alkaline (ph 8-9) Patient Treatment Area Area Examples of Surfaces Decontamination Steps Walls, window blinds, chairs, beds Step 1 - Accelerated Hydrogen Peroxide 0.5% solution (see Note 2) Step 2 - Dilute solution of dilute alkaline (ph 8-9) Step 3 - Water for Irrigation Floors, countertops, pass throughs, shelving, outside pass throughs Step 2 - Sodium Thiosulfate 1% Step 3 - Remove residue with Sterile water for irrigation Patient Treatment area Telephones, computer keyboards, DERS Alaris pumps Do not pour or spray solution onto the surfaces; dampen a cloth and wipe For Alaris pump cleaning see H:\EVERYONE\nursing\EDUCATION\Alaris Infusion Pump\Pump Cleaning\BCCA STANDARD PUMPCLEANING June2015 (2).docm Windows Step 1- Dilute solution of dilute alkaline (ph 8-9) Step 2- Water for Irrigation Notes: 1. Accelerated Hydrogen Peroxide 0.5% and Sodium Hypochlorite 2% can NOT be used on the same surface because of a possible chemical reaction.

7 Page 7 of 8 2. Accelerated Hydrogen Peroxide is available as Virox 5 (a 1:14 dilution will provide a 0.5% concentration with a ph of 1.8)

8 Page 8 of 8 REFERENCES 1. NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings. (Accessed Nov 19, 2012: 2. American Society of Health-System Pharmacists. ASHP guidelines on handling hazardous drugs. Am J Health-Syst Pharm 2006;63: USP 800: USP Compounding Compendium Sessink PJ. Environmental contamination with cytotoxic drugs: past present and future. Safety Consideration in Oncology Pharmacy; Special Edition. Pharma Publishing and Media Europe; 2011.