Download National Nursing Standards for Antineoplastic Drug Administration

National Nursing Standards for
Antineoplastic Drug Administration in
New Zealand
National Nursing Standards Working Group
National standards for Chemotherapy Administration Version 10
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Contents
Introduction
Background
Process
How to use
3
4
4
Standard 1.0
Informed consent
5
Standards 2.0
Patient Education
6
Standard 3.0
Patient Assessment
7
Standard 4.0
Administration
8
Standard 5.0
Staff Education
10
Standard 6.0
Staff safety
11
Standard 7.0
Waste Management
11
Appendix I
Working Group
Appendix II
References
14
Appendix III
Patient Assessment Tool
Time out tool
15
16
Appendix IV
Glossary
17
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INTRODUCTION
Background
The New Zealand Nurses Organisation Cancer Nurses College (CNC) has recognised
the need to develop a national certification process for anti-neoplastic drug
administration since 2009. In 2014, in collaboration with Nursing in Cancer Care
Collaborative Steering Group (now disestablished) a proposal for a nationwide
chemotherapy education programme for nurses was discussed with the Medical
Oncology Working Group (MOWG). It was acknowledged that there are difficulties
implementing a national education programme and national certification process in
the absence of nationally agreed, evidenced based practice standards for antineoplastic drug administration. In June 2015, under CNC leadership, a national
working group was formed to develop national standards for antineoplastic drug
administration (now known as The Standards).
It is well recognised that antineoplastic drugs are complex, with a narrow therapeutic
window, and are associated with significant risk for those people receiving them.
They also have mutagenic, teratogenic and carcinogenic properties which have the
potential to cause harm to those handling and administering these drugs. In New
Zealand, most antineoplastic drugs will be administered by nurses. It is essential to
ensure adequate precautions are in place to protect people both administering and
receiving antineoplastic drugs.
New Zealand has six tertiary cancer centres but a significant amount of antineoplastic
agents are administered in regional and rural centres across the country. The
Standards will ensure that all staff administering chemotherapy have achieved a
minimum level of training and education.
The Standards Working Group (refer Appendix I) agreed The Standards should:

Reflect nursing involvement in antineoplastic drug administration. The
working group acknowledge that standards encompassing prescribing,
dispensing, storage and transportation should be developed. However given
the time frame of this project it was decided that the scope should be focused
on anti-neoplastic administration. The Standards are designed to fit within a
larger, multi-disciplinary document.

The Standards will be an overview of best and/or evidenced based practice. It
is not intended to replace policies and procedures within each antineoplastic
drug administration area but provide a tool to guide practice.
The Standards are applicable to all anti neoplastic and immunotherapy
modalities within cancer care. These will now be referred to as antineoplastic
drugs.
The Standards will be applicable to all cancer treatment areas in New Zealand
regardless of geographic location and/or sub-speciality groups within cancer
care.


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Process
Cancer nurses throughout New Zealand were asked to volunteer to be part of this
working group to ensure a geographic representation. This has resulted in most
District Health Board’s (DHB’s) being represented. Colleagues in private cancer
care, the New Zealand Hospital Pharmacist Association and the New Zealand Society
of Oncology were also invited to be involved in developing The Standards.
The reference group identified five (Refer Appendix 2) published international
standards for antineoplastic administration. The Standards were developed from
these.
A literature review was also undertaken.
How to use the standards
These standards are to be utilised when developing and auditing the current policies
and procedures within each clinical area. They are not designed to replace current
policies but to inform practice, and ensure a safe minimal standard is maintained
while providing the opportunity to use best practice points to develop an even higher
quality of delivery of antineoplastic drugs.
An assessment tool is provided (to be included when document finalised), which can
be used to measure your current policy against The Standard. It is recommended that
each clinical area (DHB and private care delivery centres) review their current
policies against the standard.
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Standard 1.0 Informed consent
Standard 1.1
All patients must sign informed written consent prior to
initiation of a chemotherapy regime. The consent process
should follow appropriate professional and legal
guidelines and meet requirements within their DHB.
Standard 1.2
Although nursing is not legally accountable for informed
consent, nurses play an integral role within the consent
process. Nurses have a professional and ethical
responsibility to ensure patients are appropriately
informed and aware of their rights under the NZ Health
and Disability code.
Good Practice Points
1.1
Informed consent is a continuous process of communication between
healthcare providers and people affected by cancer (principle of Te
Whai Mana Painga). This is not limited to the completion of a consent
form.
1.2
Consent is central to the relationship between patients, whanau and
healthcare providers because it allows people affected by cancer to
make autonomous decisions about their treatment. Healthcare
providers need to be open, receptive, and responsive to patient
questions.
People affected by cancer should receive a copy of signed consent.
1.3
1.4
People affected by cancer should receive written information when
consenting to treatment
1.5
Changes to treatment regimen require a re-consent.
1.6
Consent can be withdrawn by people affected by cancer at any point in
their treatment.
The consent process should include:
 Diagnostic information
 Treatment options, including no treatment and other therapeutic
modalities (e.g. radiation)
 Treatment intent
 Prognosis
 Planned duration of treatment
 Drugs/ regimen specific information
 Schedule of treatment administration
 Information on possible short and long-term adverse effects,
 When and how to notify health care team
Standards 2.0 Patient Education
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Standard 2.1
Before initiation of an antineoplastic regimen, each
person affected by cancer is provided an opportunity for
a formal education session supported by written
information. Where desired by the people affected by
cancer this should include whanau/family. Education
should be tailored to the individual – taking into account
age, language, culture and health literacy.
Good Practice points
2.1
Consideration should be given to using multiple media methods to
support principles of effective learning.
2.2
Nurses should have an understanding of health literacy and its
relevance to health equity in New Zealand.
Key components of chemotherapy education for people affected by cancer should
include:

An assessment of patient/family/whanau prior knowledge and
experience supporting the principle of Ako

Family/whanau or significant others

Short term side effects specific to drug regime

Long term and delayed side effects of drug regime

Access to supportive care including NGO e.g. Cancer Society

Eating, nutrition and hydration

Maintaining healthy life choices

Sexuality and intimacy; relationship changes

Toxicities and an action plan in event of emergency

Waste and spill management

How Complementary and Alternative Medicine (CAM) can affect
chemotherapy
Education is an initial planned event however education should be a
continuous process of reviewing people affected by cancer understanding and
providing information throughout treatment and beyond.
Standard 3.0 Patient Assessment
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Standard 3.1
Prior to the administration of anti-neoplastic drug
therapy nurses should complete a comprehensive
holistic assessment. Assessment findings should be
documented within the permanent health record. Refer
to Appendix III
Good Practice points
3.1
Assessment should be tailored to the individual – taking into
account the age, language, culture and health literacy of people
affected by cancer and their whanau.
Assessment should include:









Holistic assessment including physical, psychological and social
assessment
Review of the patient’s diagnosis, treatment plan, health history
(including allergies/sensitivities)
Height, weight and body surface area – changes in weight should be
evaluated in relation to the impact upon Body Surface Area (BSA),
where used, and drug dose calculation.
Physical and Performance status e.g. Eastern Cooperative Oncology
Group performance status (ECOG)
Response to previous treatment including toxicities and complications
and adverse reactions
Current medication being taken to manage symptoms and side effects
including both supportive medications and complementary
medications.
Evaluation of educational needs – the understanding of provided
information by people affected by cancer should also be assessed.
Other medications (not treatment related) and CAM
Baseline observations, tests or investigations specific to the treatment
protocol
Standard 4.0 Administration
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Standard 4.1
The nurse who is administering the antineoplastic drugs
confirms with the person affected by cancer his/her
planned treatment prior to each cycle.
Two nurses certified to administer antineoplastic drugs
should check medication as per local policy. This should
include a “Time Out” procedure and verify all critical
information including:
•
Identify the patient using name and one other
identifier (preferably NHI)
•
Drug
•
Dose, including BSA check
•
Volume and rate
•
Route
This is to be checked against the medication order and
the label on the antineoplastic syringe/bag
See Appendix III
Prior to administering an intravenous antineoplastic,
the intravenous access device in use must be assessed
for patency i.e. flushes freely and blood return present.
Standard 4.2
Standard 4.3
Standard 4.4
Extravasation management procedures, including
antidotes are defined and aligned with current literature
and guidelines. Antidotes are accessible.
Standard 4.5
Emergency equipment and spill kits should be available
within the administration area.
Standard 4.6
Any incidents where antineoplastic medication were
used incorrectly should be documented as an incident as
per local policy.
Best Practice points
4.1
Prior
to
administration
the
nurse
should
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review
the
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documentation ensuring the cancer diagnosis and treatment plan
confirms appropriate treatment is being administered. Consent
should also be sighted.
4.2
Documentation of a comprehensive assessment (as per Standard
3.1) should be reviewed and relevant interventions completed
prior to administration of treatment.
4.3
When administering bolus vesicant antineoplastic drugs, it is
advisable to:
•
Administer with fast flowing compatible fluids
•
Administer vesicants first unless otherwise indicated
•
Wherever possible, use a newly inserted cannula for
peripheral administrations
4.4
For people affected by cancer who are enrolled on a clinical trial,
clinical trial information should be available within the clinical
treatment area.
4.5
Electronic or printed prescriptions of neoplastic medications are
gold standard and are known to reduce administration errors.
Where possible these should be used.
4.6
Administration of oral antineoplastic medications
Refer to Standard 2.1 Patient Education for required information.
Patients receiving oral antineoplastic drugs should also receive
information on:
•
How and when to take each medicine
•
What to do if doses are missed
•
What to do if patient vomits after taking a dose.
•
The need to swallow tablets/capsules whole and not
chew
•
Risks of crushing tablets and mixing with food or
emptying the contents of capsules into food or drink
•
To store all medications appropriately i.e. refrigeration
as needed and secure away from children
•
Avoid or minimise the handling of tablets/capsules by
family members/carers i.e. using a non-touch
technique
•
Where to return empty anti-neoplastic medication
containers or any left-over medication
•
How to manage waste
•
How to manage a spill
Standards 5.0 Staff Education
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Standard 5.1
All staff engaged in the administration and management
of antineoplastic therapy must be certified to do so by
completion of an appropriate training program.
Competency should be a measurable indicator of an
individual's ability to perform the associated clinical
duties.
___________________________________________________________________________________________
Good practice points
5.1
Each health care facility should have a documented training program
which is evidenced based and includes competency assessment tools
based on effective learning methodology.
5.2
The training programme should undergo a robust review for
relevancy every 2 – 3 years.
5.3
Each program should have a mechanism for competency evaluation.
This could be a competency reassessment or an audit process which
documents outcomes.
5.4
Competency includes the professional expectation that certified staff
maintain ongoing competence within the reassessment timeframe by
recognizing their own ongoing education needs and demonstrating a
commitment to evidence based practice and legislative updates.
5.5
Nurses who are novice at antineoplastic drug administration should
be working under the appropriate supervision (either
indirect/direct) of an allocated preceptor who is fully certified in
antineoplastic drug administration and management.
The components within an education program for developing nursing staff to be competent
handling antineoplastic drugs should include:
•
The basic principles of antineoplastic therapy including mechanism of action,
dosing methods, scheduling and administration and treatment intent
•
Antineoplastic protocols commonly used and how to access and refer to the
protocols
•
Adverse effects and toxicities associated with antineoplastic therapy including,
early identification, ongoing monitoring, principles of prevention and management
•
Principles of safe handling and waste management of antineoplastic drugs.
•
Antineoplastic medication preparation, storage and transportation
•
Information and support needs of patients and their families including
psychological support for persons receiving treatment for cancer
•
Ethical and legal issues associated with the use of antineoplastic therapy
•
Local policy and procedures as they relate to cancer treatment
•
Managing infusion reactions, extravasation and spills
•
Principles
content of education for the person affected by cancer.
Standard
6.0 Staffand
safety
•
Assessment of IV access considerations
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Standard 6.1
Staff should be aware of relevant legislation and guidelines
pertaining to administration of anti-neoplastic drugs and
associated waste management.
Standard 6.2
Closed system administration sets should be utilised to minimise
drug exposure.
Standard 6.3
Personal Protective Equipment (PPE) is mandatory for
personnel administrating antineoplastic drugs. PPE consists of
chemotherapy approved gloves and gowns.
N95/P2 Respirators, face shields and/or goggles can be worn as
per legislation or local policy. PPE must be available in each
administration area.
Standard 6.4
All clinical areas administering antineoplastic agents should
have a process to ensure that staff unfamiliar to the clinical area
is aware who is receiving chemotherapy.
Standard 6.5
Staff who are pregnant, actively trying to get pregnant or
breastfeeding should not be handling antineoplastic drugs
Standard 7.0 Waste Management
Standards 7.1
All clinical areas administering antineoplastic agents must have
a waste management policy
Standard 7.2
All clinical areas administering antineoplastic agents must have
access to a spill kit and be appropriately trained in how to
manage a spill
Standard 7.3
All clinical areas administering antineoplastic agents must have
a documented policy on managing accidental exposure to
antineoplastic agents
Standard 7.4
A cytotoxic spill must be regarded as a clinical incident and
documentation completed as per the local health care facility
policy.
Best Practice Points
7.1
Personal protective equipment should be worn when dealing with any
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potentially contaminated body fluid waste.
7.2
All waste and non-reusable equipment/products should be disposed
of in a designated cytotoxic waste bin or bag.
7.3
Transporting patients between areas/services with intravenous
chemotherapy infusing should be avoided. However, if this is
necessary, they must be accompanied by a cytotoxic certified person
and a spill kit.
7.4
If a staff member or carer is accidentally exposed to antineoplastic
drugs:
•
Remove contaminated clothing
•
Wash the affected area with copious amounts of soap and
water for 10-15 minutes. Consider doing this in a shower
•
If eyes have been contaminated, irrigate them with copious
amounts of water or saline.
•
For needlestick injuries, follow local procedure
•
Inform appropriate personnel and complete documentation
as per local area
•
Medical attention may be required
7.5
A shower should be available within the clinical areas for staff /carers
in the event of accidental exposure
7.6
All clinical areas should have a policy of surveillance for staff and/or
visitors who are accidentally exposed to antineoplastic drugs.
APPENDIX I
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Chair
Angela Knox, Clinical Nurse Specialist – Counties Manukau District Health Board
Members
Cathie Teague, Clinical Nurse Specialist Oncology, Capital and Coast District Health Board
Kathryn McWatt, Cancer Nurse Educator – Counties Manukau District Health Board
Amber Conley, Charge Nurse- paediatrics, Auckland District Health Board
Bridget Smith, CNE paediatrics - Auckland District Health Board
Karen Palmer, Clinical Nurse Specialist Oncology – Northland District Health Board
Paul Smith, Charge Nurse Manager, Capital and Coast District Health Board
Theresa MacKenzie, Nurse Manager, Auckland District Health Board
Wendy Jar, Clinical Nurse Specialist Bone Marrow Transplant, Canterbury District Health Board
Sarah Ellery, Clinical Nurse Specialist CNS Oncology, Canterbury District Health Board
Sharyn Pilkington, Registered Nurse Haematology, Waikato District Health Board
Anita Wootton, Clinical Nurse Specialist – Hawkes Bay District Health Board
Anna Saua, Cancer Nurse Educator -Mid Central District Health Board
Annie Walker,
Clinical Speciality Nurse – Oncology, Nelson Marlborough District Health Board
Bronwyn Ward, Charge Nurse Manager– St George’s Cancer Care Centre, Christchurch
Advisors and Stakeholders
Karyn Sangster Director of Nursing – Cancer- New Zealand Nurse Executives
Andrew Simpson , National Clinical Director Cancer Ministry of Health
Garry Forgeson, Chair - Medical Oncology Working Group
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Appendix II
References
Clinical Oncology Society of Australia. 2008. Guidelines for the safe prescribing,
dispensing and administration of cancer chemotherapy.
https://www.cosa.org.au/media/1093/cosa_guidelines_safeprescribingchemo2
008.pdf
National Cancer Action Team: National Health Service (2011) National cancer
peer review programme. Manual for cancer Service: Chemotherapy measures.
http://www.mycancertreatment.nhs.uk/wpcontent/themes/mct/uploads/2012/09/resources_measures_Chemotherapy_M
easures_June2011.pdf
Neuss, N. Polovich, M. McNiff, K. Esper, P.Gilmore, T. LeFebvre, K. Schulmeister, L.
Jacobson, J. 2013. 2013 updated American Society of Clinical Oncology/Oncology
Nursing Society Chemotherapy Administration safety standards including the
standards for the safe administration and management of oral chemotherapy.
www.jop.ascopubs.org
The Quality Unit: Scottish Government. 2012. Guideline for the safe delivery of
systemic anti-cancer therapy. http://www.scotland.gov.uk
Canadian Association of Nurses in Oncology. 2011. Standards and competencies
for cancer chemotherapy nursing practice.
https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=156524
Safe Handling of Cytotoxic Drugs and Related Wastes:
Guidelines for South Australian Health Services 2012
http://www.sahealth.sa.gov.au/wps/wcm/connect/f8aa68004b3f6cf6a340afe7
9043faf0/SafeHandlingOfCytotoxicDrugsRelatedWastesGuideline-PHCS120515.pdf?MOD=AJPERES
Jacobson, J. Polovich, M. McNiff, K. LeFebvre, K. Cumming, C. Galioto, M. Bonelli, K.
McCorkle, M. 2009. American Society of clinical Oncology, Oncology Nursing
Society Chemotherapy administration standards. Oncology Nursing Forum. 36
(6).
Kullberg, A. Larsen, J. Sharp, L. 2013. Why is another person’s name on my
infusion bag? Patient safety in chemotherapy care – a review of the literature.
European Journal of Oncology Nursing. 17: 228 – 235.
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Lester, L. 2012. Safe handling and administration consideration of oral
anticancer agent in the clinical and home setting. Clinical Journal of Oncology
16(6): E192 – E197.
Treleaven, J. Gadd, J. Cullis, J. Favre, A. McLeod, A. Meller, S. Milligan, D. Neilson, R.
Quinn, B. Webb, A. Wimperis, J. 2012. Guidelines on obtaining consent for
systemic anticancer therapy in adults. Haematology 17(5): 249-254
Vioral, A. Kenniham, H. (2012). Implementation of the American Society of
Clinical Oncology and Oncology Nursing Society chemotherapy safety standards:
A multidisciplinary approach. Clinical Journal of Oncology Nursing 16(6): E226E230.
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Appendix III
Assessment tool
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Timeout Checklist
Appendix IV
Glossary
Antineoplastic therapy - Encompasses biological therapies and cytotoxic
chemotherapy
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Ako - The concept of ako describes a teaching and learning relationship, where
the educator is also learning from the student and where educators’ practices are
informed by the latest research and are both deliberate and reflective. Ako is
grounded in the principle of reciprocity and also recognises that the learner and
whānau cannot be separated
Certified Staff – where a nurse has been professionally certified as being able to
competently complete a task or skill.
Cytotoxic spills - Involve any formulation of the drug and can occur wherever
cytotoxic drugs and waste are being handled, stored, transported or disposed.
Spills may result in the contamination of the environment including floors, work
surfaces, equipment, bedding and clothing as well as the patient and carer/staff
member
Accidental exposure - to cytotoxic drugs can occur at any time during and after
the administration process. This includes both direct drug exposure and
exposure to contaminated body fluid waste.
Health literacy - The capacity to find, interpret and use information and health
services to make effective decisions for health and wellbeing.
Te Whai Mana Painga - Empowerment of knowledge, skills and resources, to
make an informed choice of care and treatment.
NGO - Non government Organisation offering supportive services, in this case for
people affected by cancer e.g. Cancer Society, Leukaemia and Blood Cancer New
Zealand.
People affected by cancer - People affected by all types of cancer, including those
at risk of developing cancer, people living with cancer, cancer survivors, carers,
family and whānau members and significant others.
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