1. DETERMINE if you have the competencies to administer cytotoxic chemotherapy or biotherapy agents. LastReviewDate. Create Date

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1 PRACTICE LEVEL/COMPETENCIES To complete the non-oncology chemotherapy checklist and administer cytotoxic and biotherapy agents to non-oncology patients, the nurse must: Possess knowledge of safe handling guidelines for cytotoxic agents and waste products Familiarize self with actions, administration guidelines, and side effects of cytotoxic medications and biotherapy agents as outlined in pharmacy manual and other resources Be able to provide patient/family teaching in relation to side effects and management of side effects To complete the oncology chemotherapy checklist and to administer cytotoxic and biotherapy agents to oncology patients, the nurse must: Be knowledgeable about pediatric cancer diagnosis and treatment, hematopoeisis and immune response, treatment modalities, and psychosocial issues in pediatric oncology as attained through education and experience. Be able to teach patients/families about their diagnosis, treatment and the cancer experience. List and describe chemotherapy and biotherapy agents and classifications and their mode of action, administration considerations, toxicity and symptom management, and late effects Describe clinical trials and the role of the Children s Oncology Group These competencies to be achieved through: Attending the APHON Chemotherapy and Biotherapy Course Completing the Chemotherapy Level I PEAK Stream and all Records of Practice Requirements OR In process of completing Chemotherapy Level I PEAK stream (2nd RN verifying checklist must have completed the PEAK Stream Records of Practice Requirements) NOTE: Oral chemotherapy may be administered by a Registered Nurse to an oncology patient if the nurse has attained the competencies as outlined above for administration of cytotoxic drugs to nononcology patients, provided a chemotherapy checklist has been completed and verified by 2 chemotherapy competent nurses. Oral chemotherapy must be double checked by 2 RNs prior to administration. Peripheral Chemotherapy Competencies: Non-vesicant: same as above Vesicant: Able to identify vesicant agents and describe actions for prevention and management of extravasation as attained through: Completing the Level II Self Learning Guide and Practicum Requirements DEFINITIONS Extravasation: The unintentional leakage of vesicant intravenous fluids or medication into the perivascular, subcutaneous tissue or interstitial space which is capable of causing pain, necrosis and/or sloughing of tissue. Immediate emergency management of suspected vesicant extravasation must be performed to minimize tissue damage. Personal protective equipment Gloves: Nitrile or Latex gloves with long cuffs that can extend over cuff of gown sleeves Gown: Disposable low-permeable gown with solid front and long sleeves with cuffs Eye and face protection: Fluid resistant mask with eye shield or goggles Vesicant: An agent that can cause redness, pain, blistering and serious progressive tissue damage if it leaks into tissue outside the vein (extravasates). Can cause blistering and local or extensive tissue necrosis with or without ulceration and may become evident only days or weeks after exposure. PROCEDURE 1. DETERMINE if you have the competencies to administer cytotoxic chemotherapy or biotherapy agents. Sep 26, 2011 CM BC Children s Hospital Child & Youth Health Feb 18, 2008 Policy and Procedure Manual Page 1 of 5

2 2. ENSURE a chemotherapy checklist has been completed and verified by two RN s. 3. REVIEW checklist for any special instructions for patient care needs and monitoring requirements. 4. DETERMINE appropriate method of administration and prepare appropriate equipment. 5. GATHER equipment: o Personal protective equipment o Cytotoxic label to attach to infusion tubing as needed o Chemotherapy in sealed Ziploc bag o Patient s chart with physician s order for chemotherapy 6. CHECK chemotherapy dispensed with physician s written order and VERIFY with second RN: o patient name and unit number o drug name o dose o route o timing o rate and method of administration REVIEW side effects and management strategies with patient/family as required. 7. ENSURE emergency equipment is functioning and emergency drugs are readily available. 8. PERFORM hand hygiene. 9. DON personal protective equipment (PPE). 10. READ ALOUD information on chemotherapy label to second RN or parent/guardian (if present) and check against patient identification band: o patient name and unit number or birth date o drug name, dose, route, timing 11. ADMINISTER chemotherapy agent as appropriate using safe handling precautions: NOTE: a 2nd RN is required to do an independent double check of pump programming when administering chemotherapy via infusion pump. The 2 nd RN must independently calculate infusion rate and verify pump programming is correct. For continuous infusion or for infusions 6 hours or longer or in volumes of 500 ml or greater, administer as primary infusion. NOTE: When administering vinca alkaloids via peripheral infusion, great care must be taken to ensure that these agents are given into an intact vein with a good free flow of blood in order to avoid potential extravasation. Drug may leak from sites of recent punctures or from veins which are occluded from any cause, (tight clothing, obstructing masses, clots). Therefore, the injection site should not be distal to a recent venipuncture or in a limb with compromised circulation. It is preferable to select, if possible, a large vein which is not adjacent to a joint or tendon. The antecubital fossa and other joints are to be avoided because of the risk of undetected extravasation and permanent damage. Sites of choice in children include, in order of preference: dorsal hand, forearm, dorsal foot. During the infusion MONITOR venipuncture site and needle tip continuously and assess for signs and symptoms of infiltration (pain, swelling, redness, occlusion alarms or change in quality of infusion). 12. To flush chemotherapy given via the intermittent piggyback method, ADD 20 mls of NS or D5W to chemotherapy piggyback bag via the needle-free valve bag access port above the drip chamber as shown in FIGURE 1 and PROGRAM pump to deliver 25 ml flush. Sep 26, 2011 CM BC Children s Hospital Child & Youth Health Feb 18, 2008 Policy and Procedure Manual Page 2 of 5

3 13. To flush chemotherapy given via the continuous method, ADD 30 mls of NS or D5W to chemotherapy bag via the needle-free valve bag access port above the drip chamber as shown in FIGURE 1 and PROGRAM pump to deliver 25 ml flush. FIGURE PROGRAM pump to deliver flush at same rate as chemotherapy. 15. DISPOSE of tubing in appropriate cytotoxic waste container. PERFORM hand hygiene. 16. DOCUMENT on appropriate record(s): o Date, time o Drug, dose, route, infusion duration o Pre-, concurrent, and/or post-hydration intravenous fluids o Pre-medications o Patient s tolerance to treatment (side effects, interventions to minimize or alleviate side effects) o Patient/family education 18. COMPLETE the Potential Cytotoxic Agent Exposure Screening Record. REFERENCES Altman, A. J. (editor). (2004). Supportive Care of Children with Cancer, Johns Hopkins University Press, Maryland. BC Cancer Agency. (2006). Extravasation of Chemotherapy, Prevention and Management of. British Columbia: Author. Retrieved from: BC Cancer Agency. (2006). Cytotoxic Agents, Safe Handling Standards. British Columbia: Author. Retrieved from: BC Cancer Report to Provincial Systemic Therapy Program Committee September 26, 2007 Camp-Sorrell, D. (1998). Developing Extravasation Protocols and Monitoring Outcomes. Journal of Intravenous Nursing. 21(4) Capital Health. (2006). Cytotoxic manual: Administration and handling guidelines (version 2). Edmonton: Author. Sep 26, 2011 CM BC Children s Hospital Child & Youth Health Feb 18, 2008 Policy and Procedure Manual Page 3 of 5

4 Cardinal Health closed system solution for the safe handling of hazardous drugs. Quick Reference Guide, Conner, T.H. (2006). Hazardous anticancer drugs in health care. Annuls of the New York Academy of Science, 1076, Conner, T.H., Anderson, R.W., Sessink, P.J., Broadfield, L. & Power, L.A. (1999). Surface contamination with antineoplastic agents in six cancer treatment centers in Canada and the United States. American Journal of Health-System Pharmacy, 56, Conner, T.H., & McDiarmid, M.A. (2006). Preventing occupational exposures to antineoplastic drugs in health care settings. CA: A Cancer Journal for Clinicians, 56, Del Gauido, D. & Menonna-Quinn, D. (1998) Chemotherapy: Potential Occupational Hazards. American Journal of Nursing. 98(11): Ettinger, A.G., Bond, D.M. and Sievers T.D. in Baggott et al (eds): Nursing Care of the Child with Cancer, Third Edition, Chapter 6: Chemotherapy, WB Saunders Company, 2002 Fuchs, J., Hengstler, J.G., Jung, D., Hiltl, G., Konietzko, J., & Oesch, F. (1995). DNA damage in nurses handling antineoplastic agents. Mutation Research, 342, Gilbar, P.J. and Carrington, C.V. (2006). The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags. Journal of Oncology Pharmacy Practice. 12(2): Howard-Ruben, J. (2004). Are we handling chemotherapy safely? ONS News, 19(4):1-6. ISMP Canada Safety Bulletin, October 3, Published Data Supports Dispensing Vincristine in Minibags as a System Safeguard. Keene, N. (1999). Childhood Leukemia: A Guide for Families, Friends and Caregivers, Second Edition O Reilly & Associates, California Kline, N. (ed). (2004). The Pediatric Chemotherapy and Biotherapy Curriculum. Association of Pediatric Oncology Nurses. USA. Kline NE (ed), Essentials of Pediatric Oncology Nursing: A Core Curriculum, Second Edition, APON, 2004 Martin, S. (2005). The adverse health effects of occupational exposure to hazardous drugs. Community Oncology, 2, Max, A. and Groeben, V. (2004). Nursing Implications for Chemotherapy Administration at Moran, P. (2000). Cellular Effects of Cancer Chemotherapy Administration. Journal of Intravenous Nursing. 23 (1), National Institute for Occupational Safety & Health (NIOSH), (2004). NIOSH Publication No : Preventing occupational exposure to antineoplastic and other hazardous drugs in health care settings. Retrieved February 15, 2007 from: Oncology Nursing Society. (2001). Chemotherapy and Biotherapy: Guidelines and Recommendations for Practice 3rd Edition. ONS Publishing Division, USA. Schulmeister, L. (1997). Preventing Chemotherapy Dose and Schedule Errors. Clinical Journal of Oncology Nursing. 1(3), Schulmeister, L. & Camp-Sorrell, D. (2000). Chemotherapy Extravasation From Implanted Ports. Oncology Nursing Forum. 27(3), Secola, Rita et al. (2005). Nursing Guidelines for the Administration of Monoclonal Antibody Therapy. COG Nursing Discipline, COG Nursing Clinical Practice Committee, Pharmacology Section Sep 26, 2011 CM BC Children s Hospital Child & Youth Health Feb 18, 2008 Policy and Procedure Manual Page 4 of 5

5 Skov, T., Maarup, B., Olsen, J., Rorth, M., Winterereik, H. & Lynge, E. (1992). Leukemia and reproductive outcome among nurses handling antineoplastic drugs. British Journal of Industrial Medicine, 49, U.S. Department of Labor, Occupational Safety and Health Administration. (1995). OSHA Technical Manual, Section VI: Chapter 2. Washington DC: Author. Retrieved February 6, 2007 from: Woolery-Antill, M. in Baggott et al (eds): Nursing Care of the Child with Cancer, Third Edition, Chapter 7: Biotherapy, WB Saunders Company, 2002 WorkSafe BC. (2007). Regulation and guidelines for health care. Vancouver, Author. Retrieved February 18, 2007 from: on-guidelines-for-health-ca...&_title=patient-care World Health Organization, Alert No. 115, 18 July 2007 retrieved February 15 from Sep 26, 2011 CM BC Children s Hospital Child & Youth Health Feb 18, 2008 Policy and Procedure Manual Page 5 of 5