Category: ASSOCHEALTH
POLICY & PROCEDURE
Subject:
Medical Surveillance Of Associates Handling Cytotoxic (Antineoplastic) Drugs
Classification:
Management Approved
Policy Owner:
Senior Vice President, Human Resources and Organization Development
Approved by:
WFH President and CEO
Medical Director, Associate Health & Wellness
POLICY:
It is the policy of Wheaton Franciscan Healthcare (WFH) to offer routine medical
surveillance to all associates handling cytotoxic/antineoplastic agents.
RATIONALE:
This policy is designed to be in accordance with WFH’s Mission, Vision and Values:
Effective: May 15, 2007
Value of Respect - Our Value of Respect calls us to ensure that we respect an associate’s
right to privacy of his/her own health information.
Value of Integrity - Our Value of Integrity requires us to understand and comply with state
and federal laws and regulations that apply to the health status of associates in our
organization.
Value of Stewardship -Our Value of Stewardship calls for us to maintain health and safety
in the workplace.
SCOPE:
This policy applies to all WFH associates in the owned and managed regions.
PROCEDURE:
A. TRAINING AND INFORMATION DISSEMINATION
All associates involved in any aspect of the handling of cytotoxic/antineoplastic drugs
will receive instruction including known risks, relevant techniques and procedures for
handling, the proper use of protective equipment and materials, spill procedures, and
medical surveillance/concerns (including those dealing with pregnancy and with staff
actively trying to conceive children) as part their departmental orientation.
Knowledge and competence of associates will be evaluated in their department after
the initial orientation or training session, and then yearly or more often if a need is
perceived.
B. EXPOSURE LOG
All associates handling cytotoxic agents in the course of their job duties (preparing or
administering) shall maintain an Exposure Log in their department. The numbers of
each drug the individual has prepared or administered shall be recorded. The
Exposure Registry/Log for each associate shall be routed to Associate Health &
Wellness annually (at the end of the calendar year) for entry into the associate’s health
record.
C. PRE-PLACEMENT HEALTH ASSESSMENT
A pre-placement health assessment is conducted on all candidates for employment.
ASSOCHEALTH
Medical Surveillance of Associates
Handling Cytotoxic (Antineoplastic) Drugs
Page 1 of 3
This assessment provides baseline health data for new associates. See Preplacement Health Assessment Policy.
D. PERIODIC HEALTH ASSESSMENT
1. Associates are encouraged to complete a Periodic Health Assessment form
annually. See Periodic Health Assessment Policy.
2. All associates with potential exposure to cytotoxic drugs through preparation,
administration, housekeeping, waste disposal, transport or storage will be offered a
complete blood count with differential, SGOT, ALT (SGPT), creatinine, blood urea
nitrogen, and urinalysis for blood annually, post acute exposure, and upon job
termination or transfer.
3. Associates will be referred to a physician if further medical evaluation/treatment is
indicated.
E. PERSONNEL CONTAMINATION
1. Any accidental or unforeseen contamination of persons or property with
cytotoxic/antineoplastic drugs shall be considered an incident and reported
accordingly. See Occupational Injury / Illness policy.
2. Overt contamination of gloves or gowns, or direct skin or eye contact will be treated
as follows:
a. Immediately remove personal protective equipment and/or clothing that has
been contaminated;
b. Wash the affected skin area immediately with soap (not germicidal cleaner)
and water. For eye exposure, immediately flood the affected eye with water or
isotonic eyewash designated for that purpose for at least 5 minutes.
3. Acute exposures also include needle-sticks from needles attached to syringes
containing the drugs.
4. However, needle-sticks received by laboratory personnel dealing with the blood of
patients being treated with Cytotoxic Drugs do not constitute a special hazard and
require ordinary needle-stick procedures. See Associate Blood or Body Fluid
Exposure policy.
5. The exposed health care worker reports to Associate Health & Wellness. If
Associate Health & Wellness is closed, the associate shall receive treatment at an
Emergency Department or Urgent/Convenient Care Center. WFH
owned/managed locations are preferred.
6. The Associate Health Nurse, or nurse designee, will assess personnel subjected to
acute, direct exposure to cytotoxic agents, with particular attention to the eyes,
buccal and nasal mucous membranes, and the skin.
7. Associates will be referred to a physician if medical evaluation and/or treatment is
indicated.
F. PREGNANCY
On the basis of the available evidence, it seems reasonable to assume that if
procedures are followed, and proper equipment and protection are used, reproductive
ASSOCHEALTH
Medical Surveillance of Associates
Handling Cytotoxic (Antineoplastic) Drugs
Page 2 of 3
hazards will be reduced.
1. Associates handling these chemicals in the course of their employment will be fully
informed of the potential reproductive hazard through departmental training and, if
they so request, staff members who are pregnant or breast-feeding will be excused
from handling cytotoxic drugs.
2. Male or female associates who are actively trying to conceive a child may also
voluntarily request a transfer to jobs that do not involve handling cytotoxic drugs.
Replaces:
Medical Surveillance of the Associate that Handles or Administers Antineoplastic
Agents, WFH – All Saints
Medical Surveillance of Employees Handling Cytotoxic (Antineoplastic) Drugs – WFH
– Milwaukee, Employee Health Services Procedure 18.0
Cross reference:
Associate Blood or Body Fluid Exposure policy (TO COME)
Occupational Injury / Illness policy
Periodic Health Assessment policy
Pre-placement Health Assessment policy
Review Period:
Two (2) years
Original Policy Date:
May 15, 2007
Dates Updated:
ASSOCHEALTH
Medical Surveillance of Associates
Handling Cytotoxic (Antineoplastic) Drugs
Page 3 of 3