[MCOH-EH] Hazardous Drug Surveillance

[Newcomb, Richard D., M.D., M.P.H.]

As Dr. Hudson notes, many medical centers are not currently providing medical surveillance programs for hazardous drugs.  We hopefully will have a couple of papers pending publication on the topic, the first involving qualitative research exploring the topic in general, and reviewing the barriers and benefits to proceeding with a medical surveillance program.  The second paper is a survey of approximately 100 respondents from the MCOH listserv, and also included members of the National Comprehensive Cancer Network centers. From that survey, we found that just over 50% of respondents offer medical surveillance.

As you may know, or gather from some of the other postings on the subject, medical surveillance is recommended by OSHA, NIOSH, EPA and various professional organizations, but is not currently a legal requirement.

However, there is a major change looming on the horizon, with the USP 800.  This is guidance from the U.S. Pharmacopeia association, a trade organization that makes recommendations to pharmacies regarding safety and function.  Although it has no legal binding on medical centers directly, each state board of pharmacy typically requires a pharmacy to follow the USP guidance, or risk loss of state certification and/or possibly accreditation by the joint commission, so this would indirectly affect any medical centers that utilize pharmacies to prepare and disseminate chemotherapy and other hazardous drugs.  The USP 800 is extending its reach to indicate that any healthcare employees handling hazardous drugs be involved in medical surveillance, in addition to recommendations regarding safe handling in pharmacies with closed system drug transfer devices, ventilated cabinets/ hoods designed to redirect flow away from workers, etc.  USP 800 will be in full effect by summer 2018. This would cover all workers with possible contact to hazardous drugs, including shipping/receiving through to end use with nurses administering, and environmental services for spills, contaminated excrement, etc.

It will be very interesting to see how this plays out.

Regarding the question of what to do with positive test results, some will follow these more frequently, or over time if minor changes, or refer for further evaluation when the changes are suspected to be related to the hazardous drug handling.  Others who find abnormalities that are not thought to be obviously related to hazardous drug contact may be referred to primary care for further evaluation.  For example,  if a CBC is done to monitor for leukemia, but anemia is found, the person is referred to primary care.  As Dr. Hudson points out, and Dr. Russi addressed at the Denver AOHC, increased testing increases the opportunities for false positives and negatives.  Dr. McDiarmid has also contributed much to the research on this subject, and spoke at the same session.

Of the institutions that do provide medical surveillance, the components vary widely.  Some have periodical questionnaires, some inquire regarding reproductive health, some have periodical testing, most are voluntary for employees, thus far no respondents were doing routine physical examinations, and no one does biological monitoring (for drugs or metabolites in question).  It seems that the subject and institutional approaches may evolve quite a bit over the next several years.

Richard Newcomb MD, MPH
Assistant Professor Mayo Medical School
Division of Preventive, Occupational and Aerospace Medicine
Mayo Clinic
Rochester, Minnesota

Laura Breeher, MD, MPH
Section Chief, Occupational Medicine
Associate Medical Director, Occupational Health Services
Division of Preventive, Occupational and Aerospace Medicine
Mayo Clinic
Rochester, Minnesota

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Today's Topics:

   1. Re:  [EXTERNAL]  hazardous drug administration (Giovannetti, Mary)


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Message: 1
Date: Wed, 13 Sep 2017 11:57:47 +0000
From: "Giovannetti, Mary" <MGiovannetti at srhs.com>
To: 'MCOH/EH' <mcoh-eh at mylist.net>
Subject: Re: [MCOH-EH] [EXTERNAL]  hazardous drug administration
Message-ID:
	<CD1347D378235449A04FA403AFD0170B9E43223B at SWMSX0002.srhs.com>
Content-Type: text/plain; charset="us-ascii"


So do they fill out a questionnaire at all?

Mary C Giovannetti, DNP, APRN, BC-FNP
Manager/Nurse Practitioner | Employee Health

[cid:image001.png at 01CFD7E5.AFEE0CD0]

853 North Church St, Suite 400 | Spartanburg, SC 29303
o: 864-560-6514 | f: 864-560-6509
e: mgiovannetti at srhs.com<mailto:mgiovannetti at srhs.com> | w: SpartanburgRegional.com<http://www.spartanburgregional.com/>

From: MCOH-EH [mailto:mcoh-eh-bounces+mgiovannetti=srhs.com at mylist.net] On Behalf Of Hudson, T. Warner
Sent: Friday, September 01, 2017 11:11 AM
To: MCOH/EH
Subject: Re: [MCOH-EH] [EXTERNAL] hazardous drug administration

Be aware: [This message came from outside of Spartanburg Regional Network]

At AOHC 2017 in Denver there was a long session on this with several excellent speakers. And several of the UC OH Medical directors attended, me among them, and so with 5 of the UCs having medical centers we too are all interested in doing the right thing.  Mark Russi, MD Medical Director of Occupational Health at Yale Hospitals presented a fantastic segment of the Denver sessions on this and among other things reviewed the published data on what you find if you do lab tests (CBC, U/A, BUN/creat, AST/ALT) on 1000 healthy non exposed individuals, and you will have over 900 abnormal results to chase down.  So consensus among the medical directors all trained in USPSTF and first do not harm is that doing physicals and labs as part of this surveillance will generate so much chasing of incidental personal health findings like the lab tests just noted at significant time, expense and hazard to these individual with no evidence based medicine evidence of benefit, that we at UC are going on  the minimalist end of this "surveillance" spectrum; education, review of use of PPE and exposure history and potentially more if exposure occurs depending on the exposure.  Warner

T. Warner Hudson, MD FACOEM, FAAFP
Medical Director, Occupational and Employee Health UCLA Health System and Campus Office 310.825.9146 Fax 310.206.4585 Pager 800.233.7231  ID 27132 E-mail twhudson at mednet.ucla.edu<mailto:twhudson at mednet.ucla.edu>
Website www.ohs.uclahealth.org<http://www.ohs.uclahealth.org>

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Morelli, Karen J
Sent: Friday, September 01, 2017 5:39 AM
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: Re: [MCOH-EH] [EXTERNAL] hazardous drug administration

I, too, would love to see if anyone has a hazardous drug surveillance program in place as our system is looking at this as well.

Karen Morelli RN, BSN
Clinical Manager
WorkHealth LLC
Eastern Maine Healthcare Systems

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Angeli Mancuso
Sent: Thursday, August 31, 2017 4:59 PM
To: MCOH/EH
Subject: Re: [MCOH-EH] [EXTERNAL] hazardous drug administration





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Hi all,

I sincerely appreciate the input and perspectives from this group. I have some follow up questions that I'm curious how others are handling:

1)     For current employees, how are you getting folks into compliance with this regulation? Are you asking them to complete the questionnaire and lab work (CBC, metabolic panel, UA) now and considering this a baseline?

2)     What are you doing with abnormal lab results for these current employees? Referring to their own physician? Doing follow up and more extensive testing through Occupational Medicine to determine other underlying health conditions and then referring to PCPs?
I've really appreciated the shared policies and forms from everyone! Thanks for being such a great community!


Angeli Mancuso, RN, COHN-S/CM
Manager, Employee Health & Safety | Cottage Health P.O Box 689 | 400 W. Pueblo St | Santa Barbara, CA 93102-0689
Office: (805) 569-7866 |  Fax: (805) 569-8271 a1mancus at sbch.org<mailto:a1mancus at sbch.org> | cottagehealth.org<https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.cottagehealth.org%2F&data=02%7C01%7Ctwhudson%40mednet.ucla.edu%7C852615c6b227407d8a4008d4f1366894%7C39c3716b64714fd5ac04a7dbaa32782b%7C0%7C0%7C636398663373387984&sdata=0L8ZaTfrawbr58rRlFlj7jVGrbM21VaFx762WzLPjm8%3D&reserved=0>
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From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Allen-Hardy, Blythe
Sent: Tuesday, August 01, 2017 3:39 PM
To: MCOH/EH
Subject: Re: [MCOH-EH] [EXTERNAL] hazardous drug administration

I'm fairly new to the organization so still learning how it is determined who's in the program. I'm assuming that a list is giving to occur health by the director of oncology nursing. I can respond back once I get further clarification.

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Blythe Allen-Hardy, MD, FACOEM
Medical Director, Employee Health
Texas Medical Center
6411 Fannin, JB500
Houston, Texas, 77030
W: 713-704-2792
C: 720-840-9593
F: 713-704-6350
Blythe.allen-hardy at memorialhermann.org<mailto:Blythe.allen-hardy at memorialhermann.org>

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Thrasher, Terri
Sent: Tuesday, August 01, 2017 1:34 PM
To: MCOH/EH
Subject: Re: [MCOH-EH] [EXTERNAL] hazardous drug administration

How do you determine who to place in surveillance and how many employees are you running through the surveillance labs?
Terri

Kindest regards,

Terri

Terri L. Thrasher RN MSN
Sr. Director HR
Employee Health, Occupational Safety, Environmental Health, Employee Relations, Leave Management  HR Compliance/Policy, Workers Compensation, 803-SAFE, Injury Management, Non CCHMC Badging, Early Education and Childcare Center
3333 Burnet Ave
Cincinnati Ohio 45229  MLC 9006
513-636-6240



From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Allen-Hardy, Blythe
Sent: Tuesday, August 01, 2017 2:22 PM
To: 'MCOH/EH' <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: Re: [MCOH-EH] [EXTERNAL] hazardous drug administration

Cathy,

At Memorial Hermann we have a surveillance program that I am in the process of updating due to the USP 800 requirements. We have a policy in place in our hospitals on how the drugs are handled etc and it is fairly comprehensive. The medical surveillance I believe as involved checking a CBC, UA and completing an annual questionnaire. I am developing a medical surveillance guideline that will addl laboratory tests such as LFT's, BUN/Cr to the CBC w/diff and UA. Will also add a focused exam component for post exposures.

That may be overkill but I want to make sure we have a comprehensive program. Feel free to contact me for further questions.

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Blythe Allen-Hardy, MD, FACOEM
Medical Director, Employee Health
Texas Medical Center
6411 Fannin, JB500
Houston, Texas, 77030
W: 713-704-2792
C: 720-840-9593
F: 713-704-6350
Blythe.allen-hardy at memorialhermann.org<mailto:Blythe.allen-hardy at memorialhermann.org>

From: MCOH-EH [mailto:mcoh-eh-bounces+blythe.allen-hardy=memorialhermann.org at mylist.net] On Behalf Of Senior, Cathy (Employee Health)
Sent: Tuesday, August 01, 2017 11:42 AM
To: 'MCOH/EH'
Subject: [EXTERNAL] [MCOH-EH] hazardous drug administration



Does anyone have a medical surveillance plan for employees who handle hazardous drugs. We are seeing more administration of these hazardous drugs between starting the intravesical therapy and the biologics that are administered. We follow the ONS guidelines for safe handling of hazardous drugs as outlined in our policy. We already have the appropriate work practice in place including proper use of PPE and education for the staff that handle these drugs. There has been a concern voiced by one of our educators that institutions such as NIOSH have recommendations for medical surveillance to make it a comprehensive prevention program that we do not have in place.  Some of the drugs we administer is  Carboplatin, VP-16, Taxol, Cisplatin, Cytoxan, Erbitux, 5-FU, Abraxane, Gemzar, Herceptin, Parieto and Rituxan to name a few. We also give biologics to out-patients in our short stay unit. Any help would be much appreciated.  Thanks


Cathy Senior RN BSN CDE
Employee Health Director
Penn Highlands DuBois
100 Hospital Avenue
P.O. Box 447
DuBois Pa 15801
Phone 814-375-3392
Fax 814-372-2610
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