Reply To: Hazardous Drug Surveillance Labs, Surface Monitoring and PPE Compliance in the Outpatient Setting

  • Mindy Bibart

    Member
    January 25, 2021 at 6:46 am

    Responding for Nationwide Children’s Hospital

    1. Does your facility offer voluntary or require mandatory hazardous drug surveillance labs? How often are they collected? Does your manager receive the results of the labs? Have these results lead to any process changes?

    We plan to monitor levels in a few high risk areas, including our hem/onc/bmt areas and the general infusion clinic. Our employee health department needed to pivot with Covid-19, so we haven’t started yet. My understanding is that there will be levels drawn at the time of hire (or project start date). Employees deemed at high risk will be screened annually via a survey. Anyone who reaches a threshold response will have labs collected. Additionally, hazardous spills will be assessed and anything reaching a particular threshold will require sampling for employees exposed. 

    2.Does your facility perform any surface monitoring for hazardous drug material on counter tops, nurses stations, door handles, check out desks, etc? Who collects and performs this testing and how frequently is it done? Have the results of this surface monitoring lead to any process change?

    We complete quarterly swipe testing, highlighting different areas to monitor each session. We have had one instance of very minor contamination outside of the hood in our chemotherapy pharmacy. It was traced back to a contaminated bag that was taken out of the hood and into the pharmacy staging areas. All other clinical areas, including medication rooms and patients rooms have tested negative. We will likely decrease our testing at some point since we are not finding contaminants.  

    3. Does your facility have any issues with PPE compliance? If staff are not compliant with PPE use, how is it handled? i.e. verbal counseling

    We have good compliance with PPE. If there were opportunities identified, we would likely follow our corrective action policy which begins with verbal counseling and progresses through more punitive actions.

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    Mindy Bibart, MSN RN CPHON NE-BC CSSBB
    Director of Patient Care Services, Hematology/Oncology/Blood and Marrow Transplant
    Nationwide Children’s Hospital
    Columbus, OH
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    Original Message:
    Sent: 01-24-2021 04:15 PM
    From: Kristen Ammon
    Subject: Hazardous Drug Surveillance Labs, Surface Monitoring and PPE Compliance in the Outpatient Setting

    Hi there-
    See my answers for Duke Children’s (Durham, NC) below!

    1. Does your facility offer voluntary or require mandatory hazardous drug surveillance labs? How often are they collected? Does your manager receive the results of the labs? Have these results lead to any process changes?- We do not require this at Duke.

    2.Does your facility perform any surface monitoring for hazardous drug material on counter tops, nurses stations, door handles, check out desks, etc? Who collects and performs this testing and how frequently is it done? Have the results of this surface monitoring lead to any process change? – Our Pharmacy and Occupational Safety Office has begun surface monitoring in a few of the adult areas as directed by USP 800.  So far, they have only done before CSTD implementation (August 2019) and then recently.  So far, the results have not led to any process changes that I am aware of. 

    3. Does your facility have any issues with PPE compliance? If staff are not compliant with PPE use, how is it handled? i.e. verbal counseling, written warning, termination- We are still working on full implementation on our PPE policy for hazardous drugs (delay due to COVID PPE usage). Our Infection Prevention department does Hand Hygiene/PPE audits and issues warning “tickets” that go to the charge nurse, but they are auditing for Infection Prevention, not hazardous drug handling.  So far, we haven’t escalated to corrective action. 

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    Kristen Ammon, MSN, RN
    Nurse Manager
    Pediatric BMT/Onc inpatient unit and clinic/Valvano Day Hospital
    Duke Children’s
    Durham, NC
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    Original Message:
    Sent: 01-15-2021 07:37 AM
    From: Nicole Rafalko
    Subject: Hazardous Drug Surveillance Labs, Surface Monitoring and PPE Compliance in the Outpatient Setting

    Hello all,

    Reaching out to my outpatient heme/onc colleagues to inquire about processes and practice regarding Hazardous Drug use.

    1. Does your facility offer voluntary or require mandatory hazardous drug surveillance labs? How often are they collected? Does your manager receive the results of the labs? Have these results lead to any process changes?

    2.Does your facility perform any surface monitoring for hazardous drug material on counter tops, nurses stations, door handles, check out desks, etc? Who collects and performs this testing and how frequently is it done? Have the results of this surface monitoring lead to any process change?

    3. Does your facility have any issues with PPE compliance? If staff are not compliant with PPE use, how is it handled? i.e. verbal counseling, written warning, termination

    Many thanks,
    Nicole Rafalko

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    Nicole Rafalko, RN
    Greensburg, PA
    United States
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