I think Melanie is right on target.  Lab abnormalities and adverse outcomes of pregnancy (or difficulty conceiving) are common and confounded by multiple other factors beside occupational exposures.  I have always thought that the most useful way to monitor this population of workers exposed to hazardous drugs was by giving them the option of completing a confidential health/exposure survey online using the medical center’s intranet and feeding that data into a database.  That would allow us to look at trends in exposed groups (pharmacists, inpatient and outpatient oncology nurses) who were exposed over time to various agents to try and determine if there are unusual patterns of adverse outcomes of pregnancy or illness.  That might yield more information than chasing down individual lab abnormalities or symptoms.

 

Unfortunately, this was never a high enough priority for the IT department to set it up at my last place of employment, and we haven’t even begun to discuss it in any serious way at the health system where I currently consult.  Perhaps someone else has developed and implemented this type of approach.  

 

Jim

 

James Garb, MD FACOEM

Medical Director Occupational Health Services

Cape Cod Healthcare

Hyannis, MA

 

 

What a frustrating topic. This would be lovely if there was a biomarker for exposure that would be sensitive and specific for adverse effects from the drugs being handled, but this does not exist. Beth Baker did an MCOH survey several years back and found that some places do health and reproductive surveys, others add basic labs like a CBC, U/A and LFTs, while others do not do any routine medical surveillance except for acute exposures. Of those who did symptom surveys or labs, none reported this being effective or informative. (This is probably in the MCOH listserv archives somewhere, if anyone has time to search…)

 

Laboratory abnormalities are very common in the general population (estimates roughly 50% of the unexposed population would have some abnormal value if you do random CBC, U/A and LFTs) and if you find it in the course of a medical surveillance program, then you have some obligation to work it up or refer the patient further. Malignancy is the main concern with most chemotherapeutic agents, and CBC, U/A and LFTs are not recommended as screening tests for any malignancy.

 

Furthermore, reproductive surveys run the very real risk of implying to the workers that every miscarriage is work-related, even if  the rate of miscarriage is the same or lower than the general population.

 

We do acute and f/u evaluations after a spill or identified exposure, targeted to the specific drug and the findings one might expect at the timing indicated for that drug.

 

We do have a policy that allows workers who are pregnant or attempting pregnancy to request temporary reassignment.

 

Our safety colleagues do regular formal environmental monitoring with wipes in the pharmacy rooms with BSCs where chemo is mixed. This has been the most important thing to monitor for exposure risk and helps greatly to reassure staff of their safety.

 

 

 

Hi, all, OSHA is interested in that letter, too, as we are trying to consider / updating our web work.  Melanie and Mark, would you send that to OSHA, too?

1.      It would be really interesting to know whether anyone does “surveillance” , i.e., whether you collect a CBC, whether you collect anything more, whether you collect information on reproductive efforts or outcomes, and whether you ever collect biological monitoring samples, for example after spills and other unexpected exposures (like ventilation system failures in pharmacies)

2.      Do people formally acknowledge and follow Oncology Nursing Society procedures?  Are those acknowledged and supported by your pharmacy and nursing leadership?

3.      Do people have a formal policy on managing workers of reproductive age who are considering / planning active reproduction?  Would this group be willing to answer whether

a.      You offer people a chance to transfer to a job without exposure? (men too?)

b.      Let people transfer out of an exposed job once they are pregnant?

c.       Mandate that people transfer out of an exposed job once pregnancy is known?

4.      Does anyone do formal exposure assessment, i.e., wipe samples outside of pharmacy cabinets?

 

Exposed here means simply working with cytotoxic agents…

 

Michael Hodgson, MD

OSHA Office of Occupational Medicine and Nursing

 

 

Our esteemed colleague Dr. Russi at Yale drafted a letter to NIOSH on this subject last summer which encapsulates this quagmire nicely.

Mark, would you to share this with the list or do you mind if I share it (I have it handy, I read it often…)

 

 

 

I am an Employee Health Nurse at a hospital in Oregon. Do any of you do medical surveillance for staff administering or handling chemo drugs?

If so, can you please describe your policy. If not, can you please provide reasons why.

Thank you in advance for your answer.

 

Kit Schweitzer, RN, BSN, COHN

Employee Health Nurse

Employee Health and Safety

Sacred Heart Medical Center

(541) 222-2544 Office   

(541) 434-3140 e-Fax

3333 RiverBend Drive, Springfield, OR 97477

www.peacehealth.org

           

 

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