Guideline for the Safe Handling and Administration of Subcutaneous Cyotoxic Chemotherapy for Adults in the Community Setting

Transcription

1 Guideline for the Safe Handling and Administration of Subcutaneous Cyotoxic Chemotherapy for Adults in the Community Setting

2 Guideline for the Safe Handling and Administration of Subcutaneous Cyotoxic Chemotherapy for Adults in the Community Setting Document Type Clinical Guideline Unique Identifier CL-104 Document Purpose To safeguard patients, relatives/visitors and staff by setting out general guidance for the safe handling and administration of subcutaneous cytotoxic chemotherapy for adults in the community setting Document Author Carole Roberson, Specialist Practice Facilitator Target Audience All Community staff within the Trust Responsible Group Clinical Policies Group Date Ratified 26 June 2013 Expiry Date 26 June 2016 The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or 1 of 15

3 Version History Version Circulation Job Title of Person/Name of Brief Summary of Date Group circulated to Change Nurse Consultant in Infection Prevention and Control Integrated Safeguarding Team Drafting comments and suggestions; References updated. Manager Audit, Research and clinical Effectiveness Manager IV Therapy Team Leader Clinical Services Manager, South Worcestershire Drafting comments and suggestions; Section on health and Clinical Services Manager, safety clarified; Redditch and Bromsgrove Clinical Services Manager, Wyre Administration procedure clarified; Forest Risk Assessment Chief Pharmacist, WHCT statements Quality Lead, Community Care strengthened. SDU Locality Operational Quality Lead, Wyre Forest Locality Operational Quality Lead, Redditch and Bromsgrove Clinical Lead for Evesham Enhanced Care Team District Nurse Case Manager, Whiteacres Medical Centre District Nurse Team Leader, Riverside Surgery District Nurse Team Manager, Dow and Woodrow Team 7 Clinical Director, Haematology, WAHT General Manager, Haematology, WAHT Matron, Haematology, WAHT Specialist Nurse Practitioners, Haematology, WAHT Clinical Policies Group Document purpose clarified; Monitoring and review updated. 2 of 15

4 Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number ( ). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting. Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. 3 of 15

5 Contents Page 1.0 Introduction Purpose Scope Definitions Referral Health and Safety Procedure Monitoring and review References 9 Appendices Appendix 1 Referral Form 10 Appendix 2 Patient Information Leaflet 12 4 of 15

6 1.0 Introduction 2.0 Purpose 3.0 Scope a. With the introduction of new drugs and the overall increase in the use of chemotherapy, a growing number of non-complex chemotherapy treatments are now being delivered either close to, or in patients own homes (National Cancer Action Team, 2008). b. Because patients undergoing such treatments are extremely vulnerable to lifethreatening infections the opportunity to deliver care at home within an agreed guideline will not only increase capacity and flexibility in service provision but may also be more appropriate in terms of reducing the risk of health care associated infection. Additionally, treatment that is delivered in the patient s own home is convenient and timely thereby improving the patients overall experience of their healthcare journey. c. It must be acknowledged however, that the use of cytotoxic chemotherapy drugs in the management of malignancy, or long term conditions such as rheumatoid arthritis, can be potentially hazardous to both the health care personnel involved in their preparation and administration and to the patient receiving them. Therefore whatever the setting, chemotherapy needs to be administered by staff who are aware of the hazards and who are competent and confident to deliver the treatment. a. Under COSHH regulations 2002, all staff must be made and kept aware of the risks and circumstances under which they may be exposed to a carcinogenic agent. Therefore, the purpose of this document is to safeguard patients, relatives/visitors and staff by setting out general guidance for the safe handling and administration of subcutaneous cytotoxic chemotherapy in the community setting. a. This guideline is intended for all staff working with adult patients who have been assessed as suitable by a Consultant Physician to receive subcutaneous cytotoxic chemotherapy in the community setting, as part of a protocol in the treatment of malignant disease. Some of these patients may have also consented to be part of a clinical trial that has been approved by both the Acute Trust s Local Research Ethics Committee and the Worcestershire Health and Care NHS Trust risk management and governance manager. The guideline will also support staff in the treatment of patients with chronic, long term conditions such as rheumatoid arthritis where the patient cannot self inject or have no carer to inject. b. For short term intervention the patients will remain under the care of an Acute Trust Consultant Physician throughout their treatment and will be supported by a named Acute Trust Clinical Nurse Specialist who understands the nature of their disease and the dilemmas they face. In the case of patients with a long term condition they will be jointly managed by their Consultant Physician and General Practitioner. c. The Clinical Nurse Specialist acting within the guidance of the Area Prescribing Committee shared care guidelines will also provide information and support to community nurses involved in the administration of the treatment in advance of the patient s planned discharge. This will include any specific safe handling and administration issues and 24 hour contact telephone numbers for emergency advice. They will also ensure that the patient s blood results are within the agreed 5 of 15

7 parameters for treatment and will arrange and monitor all subsequent blood tests required during the course of the treatment. d. Information, advice and support can also be accessed via the countywide Intravenous Therapy team ( ) many of whom have additional skills and knowledge in the handling and administration of a wide range of cytotoxic chemotherapy interventions. 4.0 Definitions 5.0 Referral a. The definitions that apply to this policy are as follows: Clinical Nurse Specialist - A Registered Nurse usually employed by the Acute Trust, who has undergone specific training in their field of expertise and who has specific responsibility for the provision of patient-centred care and the involvement, as necessary, of other professionals. Community Nurse - A Registered Nurse with or without a Specialist Qualification working in or on behalf of Worcestershire Health and Care NHS Trust, who provides care to patients in the community setting. Non Touch Aseptic - Any healthcare procedure in which added precautions are Technique used to prevent contamination of a person, or area by microorganisms. a. Referral will be made by an Acute Trust referring back into County to the receiving community nursing team in advance of the patient s planned discharge. Initial referral will be by telephone and must be followed up in writing with a dedicated referral form (see Appendix 1). The receiving nurse must establish whether the drug has been approved for use in the community setting by the Trusts Medicines Management Committee before accepting the referral. This can be done by contacting the Pharmacy and Medicines Management Team on b. Details regarding any special requirements that would be needed by the patient in terms of race, gender, disability, sexual orientation, age, religion or belief should be established at the point of referral so that action can be taken to address any negative impact that could arise from any of these issues (see also 7.1). 6.0 Health and Safety a. Health and safety is not an individual issue but a team issue whereby each member ensures safety for themselves, their colleagues, their patients and the environment in which they are working. Effective communication of all written and verbal instructions relating to the patient s treatment must be conveyed to all those involved and recorded / filed in the patient held notes. b. Handling of cytotoxic drugs is an activity that should be undertaken with caution thereby ensuring that practice remains safe at all times. c. Staff should be made aware that there is a theoretical risk to a foetus in the early stages of pregnancy and careful consideration needs to be taken by individuals who are planning pregnancy, pregnant or breastfeeding as to whether or not they wish to be involved with cytotoxic drugs. Staff can seek advice from Occupational Health and should discuss any concerns with their line manager so as they can make an informed choice. 6 of 15

8 d. The use of personal protective clothing (PPE) including aprons and gloves must be worn at all times during the administration procedure. Eye Protection must also be worn if there is an actual or potential risk of splash or spray during the procedure. This will minimise the risk of exposure to cytotoxic drugs. All PPE worn during the procedure must be disposed of and sealed in a yellow hazardous waste bag supplied by the Acute Trust oncology unit or ward and returned by the patient or their representative once the cycle of treatment has finished. e. Needles and syringes that are actually or potentially contaminated with cytotoxic/cytostatic drugs or hazardous medication must be disposed of in a sharps bin that is designated for cytotoxic sharps. The sharps bin which is supplied by the Acute Trust, will contain an absorbent pad and must be sealed, labelled and returned to the oncology unit or ward by the patient or their representative once the cycle of treatment has finished. f. Accidental contamination with a cytotoxic drug whether it is the patient or the member of staff (or both) must be documented in the patient s notes and reported to Worcestershire Health and Care NHS Trust management using an incident reporting form. Occupational Health must also be informed. The immediate treatment for any contamination is to wash the affected area with copious amounts of soapy water or plain water if only the eyes are affected. Clothing that is contaminated must be removed and washed separately in a washing machine as soon as possible. g. Spillages must also be reported using an incident reporting form. The procedure for cleaning up a spillage is to immediately cover the area with the absorbent pad contained in the spillage kit then put on protective clothing (unless it is already being worn) and mop up the spill using the absorbent pad. The area should then be washed with copious amounts of soapy water using inward movements so as not to spread the contamination. All items used to deal with the spill should then be disposed of in the bag contained in the spill kit. h. All waste must be disposed of in accordance with Environment Agency legislation and guidance of the safe management of healthcare waste (DH 2011). i. In the event of a needle stick injury, encourage the area to bleed, wash the skin with copious amounts of soap and water and cover with an impervious dressing. Follow the standard procedure for a blood borne contamination incident detailed in the Infection Control Policies and Procedures Binder. Document in the patients notes, inform Occupational Health and complete a Trust incident reporting form. 7.0 Procedure for the administration of subcutaneous chemotherapy a. Prior to discharge from hospital the patient will be given a valid prescription that will authorise community nurses to administer the drug. The prescription will contain their name and NHS Number/hospital number, the name of the drug to be administered, the dosage and route of administration along with their own labelled pre-filled syringes of medication. In the case of a patient whose chronic condition is jointly managed by their consultant and General Practitioner, then a Worcestershire Health and Care NHS Trust medication administration form will be used as authorisation. b. The patient will also be issued with a cytotoxic spillage kit, yellow hazardous waste bags and a cytotoxic sharps bin and will be given written (Appendix 2) and verbal information on how to transport and store the medication and contact numbers for advice and support if needed. For patients who require the written information to be available in a different format or language other than that 7 of 15

9 available in this document every attempt should be made to facilitate this. Agencies that may need to be considered are: Applied Language Solutions Deaf Direct Speakeasy c. As part of the holistic assessment of the patient community nurses will undertake an environmental risk assessment. Community nurses administering the subcutaneous cytotoxic chemotherapy must ensure that the patient has received all the information required in terms of their treatment, the transportation and storage of their drugs and that they have consented to the treatment with their Acute Trust Consultant Physician. Verbal consent will also need to be gained prior to each injection procedure by the community nurse administering the treatment and this will be recorded in the patient s Clinical Record. d. The community nurse administering the medication will also need to have an understanding of the drug they are dealing with including the potential side effects and will have access to an anaphylaxis shock pack in case of emergency. e. All adverse incidents must be documented in the patient s notes and reported to the Medicines and Healthcare products Regulatory Agency (MHRA) using the yellow card system. An incident reporting form must also be completed and Worcestershire Health and Care NHS Trust management informed. f. The technique used for subcutaneous chemotherapy administration will be the same as for any other subcutaneous medication administration. 7.1 Procedure for the administration of subcutaneous cytotoxic chemotherapy PROCEDURE Explain procedure to the patient and gain their verbal consent. Check that the prescription is clear, unambiguous, signed and dated with the name of the patient and their NHS Number/hospital number, the name of the drug, the dose, the route and method of administration, date and the time it should be given. Check allergy status. Check against the prescription that the correct drug and dose has been supplied and its expiry date. Undertake hand hygiene, open out sterile dressing pack and place equipment required to administer the drug onto the sterile field using strict non touch aseptic technique. RATIONALE Reduces patient anxiety, gains concordance and fulfils legal requirements. To ensure the patient receives the correct drug in the prescribed dose and by the correct route (NMC 2008a, NPSA 2008). Patient safety. Reduces risk of infection. 8 of 15

10 Assist patient into the required position and remove appropriate clothing to expose injection site. Put on personal protective clothing - apron, sterile gloves (and eye protection where there an actual/potential risk of splash or spray). Assess the injection site for signs of inflammation oedema, infection and skin lesions. Cleanse skin at the site of the injection (usually the abdominal area) with a 70% alcohol swab and allow to air dry for 30 seconds. Attach the needle to the syringe and administer the injection subcutaneously using strict non touch aseptic technique. There is no requirement to expel air from pre-filled syringe prior to administration. Monitor patient throughout the procedure. Wipe away any visible traces of the drug on the skin surface with sterile gauze and cover injection site with a sterile impervious plaster. Dispose of all contaminated or potentially contaminated equipment in the cytotoxic sharps bin provided. Undertake hand hygiene. Rotate injection sites for each subsequent administration. Sign the administration of medication sheet and complete all relevant documentation in the nursing notes including batch number, expiry date, time, date, route and site given. To allow access to the injection site and aid relaxation of muscles. Reduces risk of exposure to cytotoxic drug. To promote effectiveness of the injection and reduce risk of infection or trauma. Reduces risk of infection, particularly in immuno-compromised patients. Reduces the risk of infection to the patient and contamination to both staff and patient in terms of accidental spillage, splash or spray. Reduces risk of accidental contamination with cytotoxic drug. Reduces risk of exposure to cytotoxic drug. Minimise cross contamination. Reduces pain and the risk of potential complications associated with overuse of the site. Legal requirement and good practice. 8.0 Associated Documentation a. This document should be used in conjunction with Worcestershire Health and Care NHS Trust Medicines Policy, Health and Safety Policies on Waste Management, Consent to Treatment Policy, Infection Control Policy and Procedures and Clinical Record Keeping Guidelines. 9.0 Monitoring and review a. It is intended that this guidance will be monitored annually against referral trends and actions taken to address any special needs or requirements in terms of the six equality strands. It will also be monitored against critical incidence reporting in 9 of 15

11 9.0 References terms of handling, administration, spillage and disposal of cytotoxic chemotherapy. This will be carried out jointly by an Acute Trust Clinical Nurse Specialist and the Specialist Practice Facilitator. The results will be used to inform the revision of this document and to identify any education and training needs. Department of Health. (2011). Safe Management of Healthcare Waste. Version: 2.0: England Elkin et al (2007) Nursing Interventions and Clinical skills.4 th edition, Mosby. Health and Safety Executive (2002) Control of Substances Hazardous to Health (COSHH). Health and Safety Executive.(2003) Safe handling of cytotoxic drugs, information sheet MISC615. MARCH (2007) Management and Awareness of the Risks of Cytotoxic Handling. NHS Greater Glasgow (2003) Guidelines for safe handling and administration of cytotoxic chemotherapy, 2 nd Edition. NHS National Cancer Action Team (2008) Chemotherapy Services in England: Ensuring Quality and Safety. NICE (2003) Improving outcomes in haematological cancers the manual: London. NMC (2008a) The code: Standards of conduct, performance and ethics for nurses and midwives. NMC (2008b) Standards for medicines management. NMC (2008c) Consent. NMC (2009) Record keeping: guidance for nurses and midwives. NPSA (2008) The National Patient Safety Agency s rapid response report. Oncology Nursing, 11(3), Workman (1999) Safe injection techniques. Nursing Standard,13(39), of 15

12 Appendix 1 SUB-CUTANEOUS CHEMOTHERAPY REFERRAL FORM Date: NHS No: Name of Patient: DOB: Address: Phone Number: GP Does the patient have a disability or any special requirements that need to be considered? Yes / No If yes please give details and action taken: Details of referral: Is patient part of a clinical trial? Yes / No if Yes please give details Has patient consented to treatment? Yes / No Written / Verbal Has patient been given instructions regarding: Transportation of drugs Yes / No Written / Verbal Storage of drugs Yes / No Written / Verbal Spillage of drugs Yes / No Written / Verbal Has patient been issued with: A valid prescription Yes / No Sufficient drugs Yes / No Cytotoxic waste sharps bin Yes / No Yellow hazardous waste bag Yes / No Spillage kit Yes / No Emergency contact numbers Yes / No Written / Verbal 11 of 15

13 Are patient s bloods within therapeutic limits for treatment to commence? Yes / No Has patient been given dates for recall for routine bloods & appropriate signed forms? Yes/No Is patient at risk of neutropenic sepsis? Name of referring nurse: Yes / No Name of receiving nurse: Contact number: Contact number: 12 of 15

14 Appendix 2 Patient information Subcutaneous Cytarabine Medication You will only be supplied with 5 days worth of treatment as the expiry date of the drug is short. You will be expected to collect the remainder of your treatment from the specialist ward or unit. A collection date will be given to you prior to your departure. Transportation You will be given the chemotherapy in an orange, padded zipped bag. This can be transported in the car safely. Please inform your car insurance company that you will be transporting chemotherapy. 13 of 15

15 Please return the orange bag back to the specialist unit once your treatment is complete Storage At home open the orange bag and transfer the contents into a clean Perspex box (e.g. sandwich box) and store in the refrigerator. Please ensure that there is no contact with food. Waste You will be provided with a sharps box and a yellow waste bag for the nurse to dispose of the needles and syringes and any protective clothing that is worn during the procedure. 14 of 15

16 When your treatment is complete the District Nurse will close the sharps box and the yellow bag and ask you to return it to the specialist ward or unit, where you can pass it on to a nurse to dispose of safely. Spillage You will be provided with a spill kit to take home. If there is a leak or spillage of chemotherapy drug please follow the spillage guidelines on how to mop up the spill. Do not touch the chemotherapy without wearing the gloves or apron contained in the spill kit. THANK YOU FOR YOUR CO-OPERATION 15 of 15