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Identifying patients receiving outpatient HDs (and urine PPE)

  • 1.  Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 04-30-2019 10:26
    Hi all
    I'd like to get a feel from those outpatient departments who administer HDs and non-HDs, specifically how you are identifying which patients require ancillary staff to wear PPE when emptying urinals. One issue/example: patients who are receiving hydration post chemotherapy; there is no visible indicator on an IV pole that this patient's urine should be handled with PPE. While the RN caring for the patient has this information, the nursing assistant does not.

    Really appreciate all ideas.

    Thanks in advance,

    Seth


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    Seth Eisenberg RN ASN OCN BMTCN
    PROFESSIONAL PRACTICE COORDINATOR, INFUSION SERVIC
    Seattle Cancer Care Alliance
    Federal Way WA
    ------------------------------


  • 2.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 03:33
    We stock the floor with chemo gloves so they are utilized for everything on all patients.

    Sent from Dee's iPhone😊




  • 3.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 09:18
    Hi Dee
    Let me clarify:
    I am looking specifically at outpatient infusion.
    Are you saying you treat all infusions as hazardous? Also, you mention gloves but did not mention gowns; are those being utilized?

    Thanks,
    Seth


    We stock the floor with chemo gloves so they are utilized for everything on all patients.

    Sent from Dee's iPhone😊
    Dee Ann Omatsu,  05-01-2019 03:32


    ------------------------------
    Seth Eisenberg RN ASN OCN BMTCN
    PROFESSIONAL PRACTICE COORDINATOR, INFUSION SERVIC
    Seattle Cancer Care Alliance
    Federal Way WA
    ------------------------------



  • 4.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 12:13
    Hi Seth,
    In outpatient when disposing of urine chemo gloves (which is what is stocked on unit) are used, no gowns. Is everyone also using gowns when emptying urinals?
    Dee Ann Omatsu




  • 5.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 07:48
    Hi Seth!
    We use laminated hazard precaution signs for any patient room who is actively receiving HD or in the up to 72 hour post window (we opted for 72 hours for variety of reasons). We train staff on signage and precautions on hire and annually.
    Anna

    ------------------------------
    Anna Vioral [PhD MEd RN OCN BMTCN)
    [Director Oncology Practice and Professional Development)
    [CompanyName]
    Gibsonia PA
    DIRECTOR ONCOLOGY EDUCATION AND RESEARCHPhD RN
    ------------------------------



  • 6.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 09:14

    Hi Anna

    Appreciate for the response.

    Are you referring to inpatient or outpatient?

    If the latter, how are you identifying patients who may come in for hydration or other supportive medications 2 or 3 days after having received their chemotherapy? Does this responsibility fall on the RN caring for the patient?


    Thanks,

    Seth






  • 7.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 20:19
    Hi Seth!
    I should have provided more details.

    For inpatient - all clinical and non- clinical staff complete mandatory training on HDs. This includes signage, gowns, gloves etc

    For outpatient - our infusion areas are trained RN staff only . The entire ambulatory outpatient offices receive the exact same HD training on hire and annually as inpatient employees.

    If the patients are ambulatory they are assigned chairs . If they are at risk for excretion concerns we place them in a room. We have 1-3 rooms in each of our centers .

    We do not gown and glove to walk patients to the br. If there is any spill of chemo or excreta we complete the 4-step cleaning process.

    We do not have nursing or medical assistants in the active infusion areas.

    Hope this clarifies more
    Anna




    ------------------------------
    Anna Vioral [PhD MEd RN OCN BMTCN)
    [Director Oncology Practice and Professional Development)
    [CompanyName]
    Gibsonia PA
    DIRECTOR ONCOLOGY EDUCATION AND RESEARCHPhD RN
    ------------------------------



  • 8.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-01-2019 14:18
    Seth,
    In our clinic, patient are required / expected to be able to void independently.  Therefore, there are no urinals.  There have been a couple of 'accidents', but that is a different discussion.
    Our outpatient chemotherapy patients that require 'inpatient room' (some for ADL support), come to the oncology floor where we utilize the laminated signs similar to what was discussed earlier.  HOWEVER, your bring up a good point as our nurse aids do not always use a gown.  We continue to try to reinforce, and our manager has taken that responsibility and offering education specifically to our nurse aids/ secretaries in June.  We delayed to make sure our policies were updated to the USP-800 standards before we implemented.  Also, we checked that our gowns were NOT to USP-800 standards, so that is also a new teaching update.

    I don't mean to divert your original question, but do you recommend the 'chemo gowns' for the splash protection?  I honestly did not think of changing their gowns as the chemotherapy has been metabolized, but now I am re-thinking that situation.

    Kristy

    ------------------------------
    Kristy Robinson APRN, AGACNP, OCN
    Clinical Oncology Coordinator

    O: 817-551-2545 F: 817-551-2536
    Kristy.Robinson@adventhealth.com
    ------------------------------



  • 9.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-14-2019 16:39
      |   view attached
    Seth,

    We use EPIC and embedded into all chemotherapy drugs regardless of route is cytotoxic precautions for 48 hours post administration of last dose.  It is a green banner populates to the patient chart regardless of encounter type (inpatient or outpatient).  It works to alert staff to use precautions, I have attached an example of this.  I believe a system such as this would support your needs.

    ------------------------------
    Brenda Wolles, MS, RN, CNL, OCN
    Clinical Nurse Leader, Oncology
    Sanford Health System
    1305 W 18th St
    PO Box 5039
    Sioux Falls, SD 57117
    Phone: office - 605-312-0044, cell - 605-940-9221
    ------------------------------



  • 10.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-14-2019 17:49

    Thanks for the information.

    I suspect that your normal workflow would be for the person emptying the urine to first log into the patient's chart before proceeding? Just looking at the details.


    Seth






  • 11.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-19-2019 18:27
    Hi Seth-
    If a patient on a rare occasion requests a urinal in the ambulatory setting I will encourage them to ambulate to the bathroom.  If they need help ambulating we require a caregiver and/or family member to be present.  Also if a patient has a urine collection bag/catheter I have the patient empty it out themselves in the bathroom.  But honestly, we don't run into this problem very much because patients must be ambulatory to receive their chemo in the outpatient setting.  Most ambulatory settings do not have ancillary staff that would be available for tasks such as emptying patient urinals.

    The only thing similar to your mentioned situation in my many years in the ambulatory setting is there is often incontinent episodes especially in relation to a Reactions and/or taxane infusions (just my observation r/t taxanes not sure if there is any science to it : ).  In this case patient will change clothes in the bathroom and we will give them a pair of scrubs to wear and help them bag their clothes and treat any contaminated or visibly wet areas similar to a spill response (requiring full PPE).

    Keep in mind these patients go directly home after their infusion (some without any home support) so if they are unable to ambulate independently to a certain extent then discharging them home is unsafe and it would be best for them to receive inpatient treatment.

    But to answer your inquiry we discourage urinal use and would not have an reason to measure output and also ancillary staff is not available to most ambulatory settings.  Not to mention that sometimes just ambulating to the bathroom and back is essential in reducing immobility consequences, especially since most are at high risk for blood clots.  And usually this explanation when given to a patient requesting urinal use is accepted and agreeable for the patient.

    Hope that helps!
    -Ali

    ------------------------------
    Ali Jackson RN BSN OCN
    ------------------------------



  • 12.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-19-2019 18:51

    Hi Ali

    Appreciate the input. We are indeed fortunate to have ancillary staff who assist in many aspects of patient care.

     

    For clarification, all of our patients are indeed ambulatory. We do offer urinals as one method of fall prevention so patients do not have to negotiate tight quarters with an IV pole, bags and pumps. (In the past, the overwhelming majority of patient falls were at the bathroom doors.)

     

    Seth






  • 13.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-19-2019 19:12
    Interesting.  I'd like to know your take on the risks related to exposure of urine receiving HDs.  As I overheard our EH&S department leader describe it as less of an issue because the urine is so diluted.  This statement bothered me especially coming from the person in charge of our environmental safety.  : )

    - Should respiratory protection be available when emptying and/or cleaning up urine from patients who recently received Cytoxan for example?

    - Also, I was reading USP<800> language closely and believe it mentions PAPR for voliatle spills are a "should" and not a "must?"

    thank you
    -Ali

    ------------------------------
    Ali Jackson RN BSN OCN
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  • 14.  RE: Identifying patients receiving outpatient HDs (and urine PPE)

    Posted 05-20-2019 09:03
    HI Ali
    Technically, the EH&S employee is correct, but less of a risk does not equate to no risk! And you have reason to be bothered if the context of that statement means we should not be worried.

    There is ample evidence that many (though not all) HDs are excreted in urine; there is also evidence that contact with urine can lead to absorption of HD (and subsequent excretion again). So anyone who wants to argue that urine does not pose a danger should be looking at the literature.

    Of course, that does not make it easy to manage in the clinical environment. Hence the original question I posed in this post.

    As for respiratory protection, I have not seen any studies that have looked at vaporization of urine containing HDs. Since vaporization in general is a very tricky area of research (difficult to ascertain levels due to numerous variables), I would argue that a PAPR would not be needed for a urine spill (nor is it recommended in any of the guidelines). This is separate from face protection.

    Regarding PAPRs, you are correct in that the wording is "should" and not "must." Of course, USP uses that same language for CSTDs for compounding. However, I will tell you from my own personal experience cleaning an etoposide spill many years ago, that I could definitely "smell" the drug on the floor the entire time. And if you can smell it, you've already inhaled it!

    Seth

    ------------------------------
    Seth Eisenberg RN ASN OCN BMTCN
    PROFESSIONAL PRACTICE COORDINATOR, INFUSION SERVIC
    Seattle Cancer Care Alliance
    Federal Way WA
    ------------------------------