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C- 7.1 Administration of Intravenous Chemotherapy KENNEDY UNIVERSITY HOSPITALS (KUH) POLICY: Administration of Intravenous MANUAL: Generic Nursing Standards Chemotherapy FUNCTION: Care of Patients POLICY NUMBER: C-7.1 IMPLEMENTATION DATE: December 1994 LAST REVISION: September 2011 September 2012 AUTHOR: Patient Care Committee PAGE(s): 6 DISTRIBUTION: System Wide POLICY: It is the policy of Kennedy University Hospitals to safely administer intravenous chemotherapy per physician’s orders to patients. PURPOSE: To promote patient and staff safety through current handling, administration and disposal of chemotherapeutic agents. SCOPE: POPULATION SERVED: Adult patients receiving chemotherapeutic agents. Patients receiving chemotherapy will be assigned to designated nursing units (GI Infusion Suite & MS1). If a patient is unable to be admitted to a designated unit, then a chemotherapy competent registered nurse will be assigned to that patient/unit for the duration of the therapy including administration and monitoring. PHYSICIAN ORDER REQUIREMENT: Yes CONSENT REQUIREMENT: Yes for administration of chemotherapy medications. RESPONSIBILITIES: Chemotherapy Competent RN. Pregnant associates will not administer chemotherapy. DEFINITION OF TERMS: 1. Chemotherapeutic agents are categorized into two different classes: Antineoplastic/Cytotoxic and Biologic/Molecularly target agents. Antineoplastic/Cytotoxic: an agent that prevents the development, growth or proliferation of malignant cells. Biologic/Molecularly: an agent that prevents the development, growth or proliferation of malignant cells by targeting a specific pathway. These include antibodies, interleukins, vaccines and other oral agents. 2. High Risk Medications: medications that bear a higher risk of causing significant harm when they are used in error. 3. Chemotherapy Competent Nurse: a RN who has successfully completed the KUH’s Basic Chemotherapy Course to include competency every two years and Note: Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the online version of the manual for the most current policy. C- 7.1 Administration of Intravenous Chemotherapy an annual Chemotherapy update regarding safety, spills, PPE, and review of policies. EQUIPMENT: Personal Protective Equipment (PPE) Infusion Pump Rigid biohazard container Chemotherapy cart, where available, or these items separately: - Ziploc biohazard bag - Chemotherapy stickers - Biohazard sign: “Caution Chemotherapy” (5510.197) - Chemo gloves (2 pair-non-sterile) - Chemo gown (non-sterile) - Chemo spill kit (available) - Disposable plastic backed liners - Sterile gauze pads (approximately 2-3) Medications and IV fluids/equipment as ordered PROCEDURE: STEPS KEY POINTS PRIOR TO ADMINISTRATION OF A CHEMOTHERAPEUTIC AGENT, THE CHEMO-COMPETENT RN 1. Will obtain and review baseline data from 1. Safe administration of chemotherapy physician, which includes the following: may depend on adequate laboratory values, especially RBC’s, WBC’s and Problem focused H&P/Note to include: platelets. allergies current medications NOTE: If a patient is unable to be admitted problem focused to a designated unit, then a chemo proficient physical examination nurse will be assigned to that patient/unit pertinent co-morbid for the duration of the therapy including complications administration and monitoring therapeutic plan duration of care Results of diagnostic studies (CBC & blood chemistry, etc.) if applicable Patient’s actual weight/height/BSA Signed consent 2. Notify the ordering physician of any missing 2. The ordering physician is responsible to data or abnormality in above data. determine if chemotherapy is continued or held based on patient information. 3. RN completes initial RN assessment form. 4. Initiate &/or update the interdisciplinary Patient Care Plan with patient-specific goals and interventions. 5. Place a Caution Chemotherapy sign in the 5. Identification of patients receiving Note: Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the online version of the manual for the most current policy. C- 7.1 Administration of Intravenous Chemotherapy STEPS immediate patient care area. 6. Verify accuracy and completeness of chemotherapy orders with a second RN and pharmacist preparing medication. Hydration, premeds, name of drug, drug dose, route, rate,, frequency of administration. 7. Provide patient education to include: Drug purpose The potential for immediate and delayed adverse drug reactions Symptoms to report 8. Obtain IV access. If a peripheral vein is to be used, select forearm venipuncture site (the forearm is the site of choice). KEY POINTS chemotherapy is essential to ensure safe contact by all associates with the patient’s excreta and IV fluids, which may contain chemotherapeutic agents up to 48 hours. 6. This verification process will also include chemo-specific verification of drug sequence, dosage and route of administration. Determine if medication is a vesicant or irritant. Reference High Alert IV Medication Administration Policy (PPINCH), H-1. 7. Patient education is documented on the Patient Education Assessment portion of the Patient Care Plan. 8. Proper administration site is essential to avoid extravasation of toxic drug into tissue. NOTE: If a vesicant drug is to be administered, and it will run longer than 60 minutes, a central venous access site is recommended. Small catheter size ensures good blood flow and maintains vein patency. Avoid IV sites subject to a lot of movement of flexion, such as the wrist or anticubital space. (Use of a central venous access does not preclude extravasation injuries. Extravasation in the upper torso or neck may result in serious injuries, requiring extensive reconstruction. It is imperative that administration of vesicant therapy into a central line be very carefully monitored.) The pharmacist will prepare all chemotherapeutic agents to include priming tubing with neutral IV fluid, which will then be transported to the nursing unit in a Note: Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the online version of the manual for the most current policy. C- 7.1 Administration of Intravenous Chemotherapy STEPS KEY POINTS chemotherapy zip-lock, safety bag, labeled with the patient’s name and attached to a chemotherapy tracking sheet. 9. Start normal saline or ordered IV fluids. 10. Observe and assess the patient at least 10. This step will assure no untoward every 60 minutes and/or between every drug effects go unnoticed. given for signs and symptoms of untoward effects. ADMINISTRATION OF CHEMOTHERAPEUTIC AGENTS 1. Perform 15 second hand-washing. 2. Don 2 pairs of chemo gloves and disposable, 2. Gloves and gown prevent direct skin non-absorbent, lint-free gown before contact with chemotherapeutic agents. administering chemotherapeutic drugs. 3. Assess IV administration site for patency by 3. Never use a chemo drug to check for checking for blood return and absence of vein patency; use normal saline. redness or swelling. Infuse 10 to 20 ml IV fluid to assure patency. 4. Place a plastic-backed liner underneath the 4. Protects the patient from exposure to IV connection site/port. chemotherapy drugs. 5. Use a sterile gauze pad(s) to connect and 5. Protects from splashing of disconnect the IV tubing or syringe chemotherapy drugs when attaching or containing chemotherapeutic agents. removing syringe or tubing.. DURING CHEMOTHERAPY ADMINISTRATION 1. Check IV for positive blood return after: 1. An infusion pump is to be used for intermittent or continuous IV drip. Each 2- 5 ml of medication is injected by IV push or; NOTE: If vesicant drug, the proficient RN At least every 60 minutes by IV drip must remain with the patient throughout the infusion. Do not place on pump but use gravity drip for those infusions lasting 60 minutes or less. 2. Assess IV site & patient response to 2. It is necessary to notify the physician of treatment every 20 minutes when any change that might alter the administering vesicants for signs of administration of drug. hypersensitivity reaction or extravasation (swelling, redness, pain, urticaria) and document in the flow record/medical record. 3. The nurse will contact the physician 3. It may be necessary to aspirate chemo immediately to reassess the patient for any of medication from the patient’s tissue (via the following conditions: the IV catheter) or to administer an antidote, per the physician’s order Significant change in the patient’s (reference C-7.3, Extravasation of a Note: Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the online version of the manual for the most current policy. C- 7.1 Administration of Intravenous Chemotherapy 4. 5. 6. 7. 8. 9. STEPS KEY POINTS medical status Chemotherapeutic Vesicant). a significant response (desired or undesired) to a procedure or intervention Extravasation suspected ~ If extravasation is suspected: Stop the infusion immediately Leave the IV catheter in place Do not attempt to flush IV line. Infuse 20 ml of normal saline in between all chemo medications, at the conclusion of the infusion and before discontinuing the IV line. Dispose of IV bags, tubing, syringes and needles in the chemotherapy zip lock safety bag and place in rigid biohazard waste container. Return the chemotherapy tracking sheet to pharmacy. Dispose of gloves, gown and plastic-backed liners in the rigid chemotherapy container and close lid tightly. Perform a 15 second hand washing. Assess IV site. Document patient’s tolerance of treatment 9. Reference documentation section below. and any adverse reactions and interventions in the patient’s flow record/medical record. AGE SPECIFIC TECHNICAL CONSIDERATIONS: Reference Micromedex, age specific drug reference manuals and pharmacist for age specific dosing information/considerations. DOCUMENTATION: See chart below for documenting patient/family response to therapy and site assessment. Initial RN physical assessment Site assessment and reassessments Drug administration Patient education Response to therapy RN initial assessment form Patient’s flow record/medical record MAK, I&O section of flow record/medical record Patient Education Assessment portion of Patient Care Plan Progress note section of flow record/medical record Note: Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the online version of the manual for the most current policy. C- 7.1 Administration of Intravenous Chemotherapy REFERENCES: Chemotherapy and Biotherapy Guidelines, Oncology Nursing Society, third edition, Oncology Nursing Society,(2009) Fundamentals of Administration, ( p.84 – 103), Safe handling of Hazardous Drugs, second edition, Oncology Nurses Society, 2011. (p. 34 – 47). Safe Handling of Hazardous Medications; (November 2010) In Mosby’s Nursing Skills. Maryland Heights, MO: Elsevier, Inc. Retrieved on August 2, 2011, from http://www.mosbysnursingskills.com KHS Policies or procedures: C7.2 Chemotherapeutic Spills; C 7.3 Extravasation: I 6 IV Push/Infusion Drug Administration ORIGINAL APPROVAL: Date: December 1994 Department/Committee: Patient Care Committee LIST OF REVIEW DATES: Date: October 1995 Date: November 2002 Date: March 2006 Date: March 2007 Departments/Committees: Departments/Committees: Departments/Committees: Departments/Committees: Pharmacy Date: March 2007 Departments/Committees: Oncology; Dr. Tom Summers LIST OF REVISION DATES AND APPROVAL: Date: March 2007 Departments/Committee: Patient Care Practice Committee Date: April 18, 2007 Departments/Committee: NEC Policy Subgroup Date: April 27, 2007 Departments/Committee: NEC Date: January 30, 2008 Departments/Committee: NEC Date: February 7, 2008 Departments/Committee: Patient Care Practice Committee Date: November 5, 2008 Department/Committee/Administration: Dr. Herriman, Cheryl Rosselli, Frank Hendrick, Linda Carrick, Ken Bevenour, Jackie Maddison, David Gibbons Date: September 8, 2011 Department/Committee: Patient Care Practice Committee Date: October 2011 Department/Committee: Nurse Executive Committee Note: Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the online version of the manual for the most current policy.