Disposal of chemotherapy waste in the community

Introduction

With the introduction of new drugs and the overall increase in the use of chemotherapy, a growing number of non-complex chemotherapy treatments are now being delivered either close to, or in patients’ own homes.

Because patients undergoing such treatments are extremely vulnerable to life-threatening infections the opportunity to deliver care at home within an agreed guideline will not only increase capacity and flexibility in service provision but may also be more appropriate in terms of reducing the risk of health care associated infection. Additionally, treatment that is delivered in the patient’s own home is convenient and timely thereby improving the patients overall experience of their healthcare journey.

It must be acknowledged however, that the use of cytotoxic chemotherapy drugs in the management of malignancy can be potentially hazardous to both the health care personnel involved in their preparation and administration and to the patient receiving them. Therefore whatever the setting, chemotherapy needs to be administered by staff who are aware of the hazards and who are competent and confident to deliver and discontinue the treatment.

This document presents guidance for the disposal of cytotoxic chemotherapy waste in NHS Ayrshire and Arran. Adherence to the guidance will minimise risk to all staff who handle cytotoxic chemotherapy. The document should be used in conjunction with other relevant clinical guidelines.

Purpose of the guideline

Under Control of substances hazardous to health (COSHH) regulations 2002, all staff must be made and kept aware of the risks and circumstances under which they may be exposed to a carcinogenic agent. The purpose of this document therefore is to safeguard patients, relatives/visitors and staff by setting out general guidance for the safe handling and administration and disposal of cytotoxic chemotherapy in the community setting.

Scope of the guideline

The guideline will advise and support community nursing staff in the disposal procedure for cytotoxic chemotherapy in the community setting.

Definition of terms

Cytotoxic drug - The term ‘cytotoxic drug’ is generally used to refer to any agent that may be genotoxic, oncogenic, mutagenic or teratogenic.

Equality and diversity impact assessment

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

Health and safety is not an individual issue but a team issue whereby each member ensures safety for themselves, their colleagues, their patients and the environment in which they are working. Effective communication of all written and verbal instructions relating to the patient’s treatment must be conveyed to all those involved and recorded / filed in the patient held notes.

N.B. Handling of cytotoxic drugs is an activity that should not be rushed thereby aiming to ensure that practice remains safe at all times.

All community staff working with cytotoxic drugs in the community must undertake the community chemotherapy e-learning module on LearnPro. The certificate generated on completion should be given to the individual's line manager to be kept within their personal file. This e-learning module must be completed on an annual basis.

For disconnection procedure, refer to relevant sections of this guideline below.

The sealed, locked and labelled cytotoxic waste bin MUST be transported directly back to the nurse’s base in the boot of the car in an upright position or left in a safe place in the patient’s home for collection by the district nurse after a weekend/public holiday.

Cytotoxic chemotherapy will be labelled in a way to identify the contents as being “cytotoxic” and give instructions on safe storage, and information on what to do in the event of a spill.

Wherever cytotoxic chemotherapy must be stored in a fridge it must be identified that sufficient storage space in a suitable fridge is available before the patient is discharged. It is advised that the cytotoxic drugs be stored in a sealed perspex box and stored on a low shelf in the fridge.

Wherever cytotoxic chemotherapy is stored, gloves, apron and sharps bin marked cytotoxic waste must be available together with instructions on how to manage a spill should this occur.

The correct use of personal protective equipment can shield staff from exposure to cytotoxic drugs and minimise the health risks. However, no protective clothing or equipment will afford total protection to the operator.

Safe handling procedures should always be followed, even in the presence of protective equipment. The following recommendations are considered to be the absolute minimum protective clothing/equipment that should be worn for the defined work tasks including the delivery of chemotherapy. Local policy must be followed if there has been a spillage of systemic anti-cancer therapy (SACT).

Protective equipment recommended for administration of cytotoxic drugs:

• gloves: see table 1. Consideration needs to be given as to whether the procedure requires sterile or non-sterile protective gloves depending on whether an aseptic technique is required.
• plastic apron.

Table 1. Recommended Gloves for Use in Handling Cytotoxics (Administration, Patient Waste, Spillage Handling).

1. Put on appropriate personal protective equipment.
2. Prepare equipment to disconnect central venous access device (CVAD) pump following Guideline G004:
   Care and Maintenance of Central Venous Access Devices Guideline (excluding permcaths - renal lines)
3. On disconnection of the pump place a Non PVC Dual Function white leur lok cap (order no. MX49 1P1) on to the end of the completed pump to ensure that no fluid can leak into the cytotoxic sharps waste bin.
4. Place the pump directly into the cytotoxic sharps waste bin. The cytotoxic sharps waste bin will be provided by the oncology unit or can be ordered via the community stores.
5. Seal, label and return the cytotoxic sharps waste bin to the district nurse base or health centre for collection.
6. In the event of a late or an evening visit where the nurse is not returning to base, the nurse must arrange a morning visit with the patient the next day to collect the cytotoxic sharps waste bin and return it to base in the boot of the nurses’ car.

• Needles and syringes that are actually or potentially contaminated with cytotoxic/cytostatic drugs or hazardous medication must be disposed of in a cytotoxic sharps waste bin. The cytotoxic sharps bin will be provided by the oncology unit or can be ordered via the community stores.
• Place the syringe directly into the cytotoxic sharps waste bin.
• On completion of the last dose of systemic anti-cancer therapy (SACT), seal, label and return the cytotoxic sharps waste bin to the district nurse base or health centre for collection.
• In the event of a late or an evening visit where the nurse is not returning to base, the nurse must arrange a morning visit with the patient the next day. The cytotoxic sharps waste bin is placed in the boot of the nurse’s car and transported to the nurse’s base for disposal.

Patient waste e.g. urine, faeces, vomit, effusion drainage may contain concentrations of cytotoxic drugs or active metabolites both during administration and up to seven days after treatment has ceased. It has been shown that these unchanged cytotoxic drugs or active metabolites can be irritant to the skin, eyes and mucous membranes. Although evidence of long-term toxicity is inconclusive and conflicting, all staff handling waste should take reasonable precautions to limit exposure and ensure absorption does not occur.

The use of universal precautions applies here as with all body fluids.

Wear appropriate gloves e.g. nitrile x-tra and protective aprons.

Staff are advised to follow the precautions described in NHS Ayrshire & Arran Control of Infection Policy.

Ideally patients should use separate toilet facilities to staff. Men should be advised to void sitting down to minimise splashing. Following voiding, toilets should be flushed twice, with the lid down (again to minimise splashing).

All staff that handle cytotoxic chemotherapy or waste, or work in areas where they are used must be trained appropriately in the risks and appropriate practices for handling and disposal of waste. Training is provided via e-learning and should be completed annually. Their understanding of, and adherence to, local policies and protocols should be monitored by their line manager annually.

1. If a patient is on an ambulatory 5FU pump that has not fully infused contact the oncology day unit to advise them (there will normally be about 25mls i.e. 10% of the volume left in the pump to avoid the pump completely emptying).
2. The oncology nursing staff will ask the community nurse to check that there are no kinks in the line and to ensure that no clamps are on.
3. Once this is confirmed the community nurse will be advised to leave the pump insitu for a further 24hrs and return the following day.
4. If the pump has completed disconnect following the normal process.
5. If the pump has still not completely infused contact the oncology day unit to advise them.
6. The Oncology Day Unit will arrange for the patient to attend the unit for review, establish the approximate remaining volume and disconnect / dispose of the pump as advised by the oncology team.

If a patient, member of staff or visitor is involved in a spillage of cytotoxic drugs or potentially contaminated patient waste the following procedures must be followed. All such events/accidents should be reported to a senior member of staff and fully documented on the DATIX system. Advice for patients and carers can be found within the SACT in Ayrshire & Arran Booklet – A guide for patients and carers, this is given and explained to all patients prior to commencing systemic anti-cancer therapy (SACT).

A cytotoxic spillage kit must be available at all times where cytotoxic drugs are administered, one will be provided for each patient on commencing SACT in the community. All staff must know how to use it and where it is stored. If a kit is used it must be replaced immediately.

District nursing teams wishing additional cytotoxic spillage kits for their team bases can order these from University Ayr and Crosshouse Hospitals pharmacy departments.

Immediate action

• Restrict access to the spillage area.
• If you have been injured or contaminated, another member of staff (if possible) must deal with the spillage while you receive attention for the injury or contamination.
• New and expectant mothers should not have direct involvement in the management of a cytotoxic spillage.
• Turn off all fans and reduce any draughts.
• Open a Cytotoxic Spillage Kit.
• If protective clothing has been contaminated during the spillage, remove the contaminated items and put on fresh protective clothing from the spillage kit. Place all contaminated items in the cytotoxic waste bin.
• Before dealing with the spillage ensure you have:
  • Put on a disposable protective gown.
  • Put on a pair of gloves, a mask, and protective eye wear.

Liquid spillages

• Put paper towels in a ring around the spill to contain the fluid so that it cannot spread to a larger area.
• Cover the liquid spillage with paper towel until all the fluid has been absorbed.
• Keep adding paper towels until the fluid has distributed itself throughout the towel and the towel is just moist i.e. when the towel is picked up the fluid will not drip out of the towel.
• Pick up the moist towel and place it into the appropriate plastic bag. Seal the bag and place in the cytotoxic sharps bin. Take care not to contaminate the outside of the sharps bin.
• Use water for irrigation and paper towel to clean the contaminated area and place used paper towel in a self-seal bag. Repeat this at least five times working from the outside of the contaminated area inwards to prevent spreading the contamination.
• Place all the self-seal bags and protective clothing in the cytotoxic 'sharps' bin.
• Put the lid on the cytotoxic 'sharps' bin and seal completely.
• The floor and all other contaminated surfaces should be given a routine clean a minimum of three times with a general purpose detergent as soon as possible.
• A DATIX report should be completed and the Head of Department and Occupational Health informed.
• The district nurse must remove the sealed cytotoxic sharps bin and take back to base in the boot of the nurse’s car for collection.
• Ensure the cytotoxic spillage kit is replaced in the home.

Skin contamination

• Remove any contaminated clothing immediately.
• The contaminant must be removed as rapidly as possible by flushing the affected area with a large volume of cold water. If running water is not immediately available, bottles or bags of sterile water or normal saline should be kept as an alternative.
• After initial copious flushing with water, the contaminated skin should be thoroughly washed with liquid soap or antiseptic scrub and water. After rinsing, the process should be repeated.
• Do not use hand creams and emollients as these may aid absorption of the drug.

Eye contamination

• The contaminant must be removed as rapidly as possible by flushing the eyes and surrounding areas with a large volume of sterile normal saline. Alternatively cold tap water can be used if necessary.
• Medical attention must be sought immediately from the nearest Eye Clinic or Accident & Emergency Department.

Needle stick injuries

• Allow the wound to bleed freely.
• Wash the puncture site/wound thoroughly with copious amounts of cold water.
• Report the incident immediately to a senior member of staff.
• Follow the procedure PN38: Safe Management and Handling of Sharps, and consider seeking advice from the Accident & Emergency Department or Occupational Health, especially if the needle had been in contact with a patient.
• Complete a Datix incident form.

Clothing

• Any contaminated clothing must be removed immediately and placed in a plastic bag. At the earliest opportunity put on gloves and an apron and rinse the clothing under running tap water. Squeeze dry and place in a plastic bag to take home for laundering.
• Personal clothing should be taken home for laundering. Such items should be laundered twice where possible. The first wash should be separate from other clothing at the highest temperature possible. They may be laundered with other items for the second wash.
• Dispose of gloves and apron into the waste bag provided in the spillage kit.

Related documents

Scottish Government. [Revised] guidance for the safe delivery of systemic anti-cancer therapy. CEL30 (2012)
NHS Ayrshire & Arran. Code of practice for the management of medicines. 
NHS Ayrshire & Arran. G004. Care and maintenance of central venous access devices guideline.
NHS Ayrshire & Arran. Guide for the administration of subcutaneous low dose cytarabine in the domestic setting.

References

1. Health and Safety Manual, Waste Management Procedure (2011), NHS Ayrshire & Arran Health Care Waste Management Committee.
2. Code of Practice section 12.2, Cytotoxic Chemotherapy, specialist guidance (2014).NHS Ayrshire & Arran Area Drugs and Therapeutics Committee.
3. Chief Executive Letter (CEL) 30, Guidance for the safe delivery of systemic anti cancer treatment (2012) Scottish Government.

Heath & safety risk assessment form