ONS Interim Guidelines during the COVID-19 Pandemic

PPE Shortages, Patient Care and Safe Handling of Hazardous Cancer Drugs

The COVID-19 pandemic is creating a growing shortage of personal protective equipment (PPE). Oncology nurses are caring for people with cancer during treatment and survivorship. Although ONS supports full protection of healthcare workers handling drugs for cancer treatment that the National Institute for Occupational Safety and Health (NIOSH) has deemed hazardous, nurses in clinical settings are facing difficult choices if recommended PPE supplies are not available. In addition, they are making choices regarding the protection of themselves and their patients from potential COVID-19 infection and use of PPE for safe handling of hazardous cancer drugs.

ONS supports recommendations that the first priority when allocating PPE supplies is maintaining the protection of patients and healthcare providers from COVID-19 infection. For care of patients with COVID-positive infections, follow the Centers for Disease Control and Prevention guidelines for prevention of infection and optimizing use of PPE.

Please note that these guidelines were written as many were facing supply chain issues at the beginning of the Covid-19 pandemic. ONS recommends that all practice settings return to established PPE use procedures as supplies are available.

PPE and Administering Cancer Drugs

The following ONS interim recommendations are for the use of PPE during clinical oncology care and for safe handling and administration of hazardous cancer drugs based on the Table 1 NIOSH list. The options are presented in descending order from highest-level recommended practice based on supplies of available PPE. Although ONS recognizes that these are not ideal, they are interim guidelines to support decision making and staff and patient safety in clinical care during the COVID-19 pandemic.


  • ONS Recommended: Disposable poly-coated gown
  • Regular disposable gown (water resistant)
  • Cloth gown (facility laundered) for infection control and nonhazardous drugs


  • ONS Recommended: Mask with face and eye protection required only if splashing is likely and for spill cleanup
  • Reserve N95 masks for symptomatic or COVID-positive patients, hazardous drug spills and cleanup.
  • Use powered air purifying respirators (PAPRs).

Eye Protection

  • ONS Recommended: Mask with eye protection or googles if splashing is likely or spill cleanup
  • Can also use full facepiece air purifying respirators or PAPRs.


  • ONS Recommended: Double chemotherapy-tested gloves
  • Single chemotherapy-tested glove
  • Double standard exam gloves
  • Single standard exam glove

Shoe Covers

  • ONS Recommended: Use only in area for compounding hazardous drugs.
  • Work-only, washable shoes


Processes for Practice

Evaluate workflows and processes to maximize efficiency and decrease waste of PPE supplies.
Cluster care activities as much as possible and avoid touch contamination of surfaces.

Options for General Work Processes

  • Follow hospital emergency policies regarding screening of patients and visitors.
  • Consider using already-garbed staff for facility cleaning and disinfecting activities.
  • Limit training of new staff and ­exclude students in cancer care areas.
  • Restrict those with symptoms of illness (e.g., fever, cough) from entering the clinical area.
  • Consider using facility-laundered scrubs under gowns.

Options for Safe Handling of Table 1 NIOSH Drugs

  • Recommended: Per ONS and Hematology/Oncology Pharmacy Association guidelines (2019), use one poly-coated gown to hang or take down chemotherapy and double chemotherapy-tested gloves.
  • Use one gown for one patient. Between uses, hang gown inside out near patient and away from surfaces where it could become contaminated.
  • One nurse performs all takedowns of chemotherapy.
  • Use gloves only and no gown for lower hazardous–risk drugs (e.g., rituximab).


The Interim Guidelines on PPE are also available in Spanish.


Visit our comprehensive COVID-19 page to find more information and resources relating to the pandemic.