Decades ago, nurses mixed chemotherapy drugs on the countertop in medication rooms, without the benefit of primary engineering controls. Later, horizontal flow hoods gained in popularity, followed by several permutations of vertical flow BSCs. At that time, many oncology professionals believed that the newer BSCs, with or without use of PPE, were sufficient protection for compounding HDs. Based on CDC, ASHP, and NIOSH publications, the Oncology Nursing Society (ONS) issued guidelines for wearing PPE for all HD handling activities. However, more recent studies have proven that even with these engineering controls and PPE, contamination and absorption continued to occur.
The first closed system drug-transfer device (CSTD), designed to reduce occupational exposure to HDs, became available in the US in 1999. While extremely effective, considerable resistance to CSTD adoption remained; hospitals were not yet convinced that CSTDs were necessary, so justifying the additional cost often was challenging. Since that time, a half-dozen CSTDs have been developed, all designed to protect health care workers during all phases of HD handling, from compounding through disconnecting the IV tubing once the infusion has been completed.
Despite the availability of multiple devices, choosing the appropriate CSTD is not as simple as choosing another commodity, such as the right car. To identify which car to purchase, numerous magazines and Web sites can provide specifications, head-to-head comparisons, crashworthiness ratings, and reliability data. It is easy to visit car dealerships and test-drive the vehicles. And after the ideal make and model has been identified, obtaining cost comparisons from multiple dealers is straightforward. Conversely, comparing CSTDs in a real-world environment is significantly more complex. The lack of a standardized CSTD containment protocol has made it difficult to determine the best device for a facility’s needs. This challenge will likely become simpler when NIOSH releases the final version of its CSTD testing procedure.
All CSTDs essentially have the same basic components designed to access the vial for compounding, add a medication to an IV bag, and administer the drug at the patient’s bedside. However, the various devices employ a number of significantly different approaches, which affect the device’s effectiveness, ease of use, compatibility, and cost. For example, not all CSTDs are compatible with all tubing and pump equipment, so an organization first must evaluate any incompatibility issues and then choose at least two devices to compare based on the above criteria.
The key to a CSTD evaluation is providing detailed education to all the staff members who will be involved in the testing. Failure to ensure that all staff members participating in the evaluation are competent at manipulating the devices could result in spills, which then risks biasing the staff against the product—that is, judging it as ineffective rather than recognizing that the problem was related to improper training.
Consider utilizing wipe testing as part of the CSTD evaluation. When conducted in both the pharmacy and in nursing areas, wipe testing is not only an excellent method of identifying contamination, but also can be performed before and after the evaluation to demonstrate the effectiveness of the device in reducing or eliminating contamination. In-house wipe testing has become considerably more accessible in recent years; several US companies now offer kits that enable in-house testing. However, check with the CSTD manufacturer, as they may be willing to perform these tests at their own expense.
Should the device evaluation determine that the best device for pharmacy is not ideal for nursing, consider using two brands of CSTDs; this hybrid system is one possible solution when a consensus cannot be achieved. Once the device has been chosen, education for all staff outside of the pilot group must occur. An education program also must be in place for new staff.
The issues surrounding HD safety are complex. While tremendous work is being undertaken to develop newer, targeted therapies, HDs continue to dominate oncology treatment regimens. Therefore, taking steps to ensure health care workers handle these drugs safely, including employing CSTDs, is vital.
Seth Eisenberg, RN, OCN, BMTCN, is the professional practice coordinator for infusion services at the Seattle Cancer Care Alliance Ambulatory Clinic.