chemotherapy administration clinical practice standard · • pharmacy: check all chemotherapy...

Title: Chemotherapy Administration Clinical Practice Standard

Effective: 18 March 2015

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Contact: Program Officer Clinical Practice Standards (M.Weston) Directorate: Medical Services TRIM Record # ED-CO-15-93655

WACHS Version: 1.00 Date next review: 18/03/2018 Date Published: 2016

Purpose To establish minimum practice standards for chemotherapy administration throughout South Metropolitan Health Service (SMHS). This Clinical Practice Standard (CPS) may be used in conjunction with specific site departmental requirements. Information excluded from this CPS relate to: · Specific chemotherapy protocols, administration regimens and dose modification

guidance · Febrile neutropenia and thrombocytopenia management · Chemotherapy induced nausea and vomiting management Further information relating to specialty areas including Child and Adolescent Health Service (CAHS), Women and Newborn Health Services (WNHS) and Mental Health Services can be found via healthpoint.hdwa.health.wa.gov.au.

Scope All medical, nursing and allied health staff employed within WACHS. All health care professionals are to work within their scope of practice appropriate to their level of training and responsibility. Further information can be found via healthpoint.hdwa.health.wa.gov.au.

The relevant eviQ Cancer Treatments Online resources may be read in conjunction with the information found in this clinical practice standard. The relevant WA Cancer and Palliative Care Network resources may be read in conjunction with the information found in the clinical practice standard.

Specific information topics and procedures found within this CPS are included as appendices: Appendix 1: Patient Education Appendix 2: Transporting Cytotoxic Chemotherapy Appendix 3: Cytotoxic Waste Management Appendix 4: Handling Cytotoxic Spill Appendix 5: Extravasation Prevention and Management Appendix 6: Intravenous and Intra-arterial Chemotherapy Administration Appendix 7: Oral and Enteral Chemotherapy Administration Appendix 8: Intramuscular and Subcutaneous Chemotherapy Administration Appendix 9: Intrathecal and Intraventricular Chemotherapy Administration Appendix 10: Topical Cytotoxic Administration Appendix 11: Intraperitoneal Chemotherapy Administration Appendix 12: Intravesical Chemotherapy and Immunotherapy Administration Appendix 13: Intrapleural Chemotherapy Administration

This CPS has been endorsed for use by WACHS and is to be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.

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Procedural Information Where care requires specific procedures that may vary in practice across SMHS sites, staff should seek senior clinician advice.

Considerations For further information refer to: Operational Directive (OD)/ Information Circular (IC) Search: www.health.wa.gov.au Staff are required to consider the following requirements and comply with the relevant Operational Directives and SMHS Policies for: · Appropriate training and supervision for staff handling and using cytotoxic drugs, as per

OD 1961/05 Safe handling of cytotoxic drugs. · OD 0020/06 Policy for the safe administration of intrathecal chemotherapy. · OD 0021/06 Policy for the safe administration of vinca alkaloids. · OD 0647/16 National recommendations for user-applied labelling of injectable

medicines, fluids and lines. · Australian Commission on Safety and Quality in Health Care Recommendations for

Terminology, Abbreviations and Symbols used in Medicines Documentation

General Information Cytotoxic drugs or neoplastic agents are used as either a single agent or within a chemotherapy regime primarily for the treatment of cancer1. These medications by their nature interfere with cell growth, and many have proven or potential mutagenic, teratogenic and/or carcinogenic effects2,3. Skin and eye irritation, dermatitis, liver damage, and risk of miscarriage or teratogenesis are also related to occupational exposure to cytotoxic drugs1,4,5. Cytotoxic drugs are administered within a variety of routes, either systemically or at isolated targets depending on the aim of the chemotherapy1. These include: Administration Route Therapeutic Aim Intra-arterial Infusion or bolus Isolated target Intramuscular Injection deep into muscle Systemic treatment Intra-ocular Injection into the eye Systemic treatment Intraperitoneal Infusion within peritoneal cavity Isolated target Intrapleural Infusion into the pleural cavity Isolated target Intrathecal Injection via lumbar puncture Isolated target Intraventricular Instillation via implanted intraventricular device Isolated target Intravenous Infusion or bolus Systemic treatment Intravesical Instillation into the bladder Isolated target Oral/enteral Ingested orally or via enteral feeding device Systemic treatment Subcutaneous Injection into subcutaneous tissue Systemic treatment Topical Application of ointments, lotions or eye drops Isolated target Patients receiving chemotherapy often do so for extended periods and can experience a wide range of side effects requiring specialised clinical and supportive interventions1. Clinical staff with the appropriate specialised knowledge and skills, play a major role in providing safe chemotherapy treatments.

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https://www.safetyandquality.gov.au/publications/recommendations-for-terminology-abbreviations-and-symbols-used-in-medicines-documentation/

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Patient Monitoring Individualised management plan to be documented in the patients’ health records as soon as is practicable. At a minimum the plan must consider: · Patient history and diagnosis for clinical conditions, medications, psychosocial and

cultural factors that could influence observations · Presence of comorbidities and treatment · Frequency and specific observations · Site requirements, patient education and consent · Any restriction to intervention associated with advance health directives (AHD) or

similar. · Refer to Standard 9: Criterion: Recognising clinical deterioration and escalating care.

National Safety and Quality Health Service Standards

Documentation Failure to accurately and legibly record, and understand what is recorded, in patient health records contribute to a decrease in the quality and safety of patient care. Refer to WACHS Documentation Clinical Practice Standard

Prescription Documentation Requirements for Parenteral Cytotoxic Agents Prescriptions may only be written by Consultants and In-training Senior Registrars. The following details are required: · Patient name and URMN (use addressograph label) · Date · Dose: including number of doses and frequency of dosing · Rate of infusion and diluent · Patient’s height, weight and body surface area · Ward or clinic where administration is planned

Clinical Handover Information exchange should adhere to the WA Health Clinical Handover Policy (iSoBAR).

Compliance Monitoring Evaluation, audit and feedback processes should be in place to monitor compliance.

Procedural Guideline Key points prior to commencing any chemotherapy administration procedure

Clinical Safety Considerations A cytotoxic spill kit and staff trained in Handling Cytotoxic Spill must be available where ever chemotherapy agents, in all forms, are prepared, transported, administered or disposed2,4,6. A cytotoxic spill may also occur in relation to contaminated waste or body fluids4. Extravasation kits and staff trained in Extravasation Management are to be readily available wherever intravenous or intra-arterial chemotherapy are administered3.

http://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/

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Clinical Safety Considerations - Continued When prescribing, dispensing or administering chemotherapy treatments, ensure drug and dose checking is undertaken at each stage, as appropriate to professional role7: · Medical: Check all prescriptions with consultant. Obtain countersignature as required. · Pharmacy: Check all chemotherapy orders and products before issue. · Nursing: Check all chemotherapy prior to administration with another nurse. Ensure the

competency skill mix for this process is relevant to the intended treatment. Clinical area, staffing level and skill mix are appropriate to the planned procedure7; e.g. · Commence and infuse chemotherapy treatments during normal working hours when there is

a larger compliment of medical and nursing staff available. · All cytotoxic agents are prepared by appropriately trained pharmacy staff, in purposely

designed cleanroom areas, wearing appropriate PPE4. Chemotherapy administration and storage areas are to be separate from those designated for staff eating, drinking and storing food4. All cytotoxic preparations are to be placed in containers dedicated to purpose that are2,7: · Labelled, sealed and impervious with hard walls. · Capable of protecting the contents from spillage, leakage and breakage during transport. · Provided with safe storage areas designed to minimize risk breakage risk and contain spills. Unused chemotherapy medications are to be returned to pharmacy promptly, and are not to be stored in clinical areas.

Patient Support Considerations Assess patient suitability prior to commencing treatment8, ensure to review patient’s: · Full blood results: i.e. review white cell count (and differential) and platelets · Relevant organ function: i.e. renal and liver functions · Most recent imaging or blood result evaluating measurable disease Ascertain if the patient is participating in a clinical trial. Ensure the patient has received the appropriate education and information, and has given appropriate consent to treatment. Ensure to undertake patient identification and procedure matching processes.

Hand Hygiene Considerations6 Hand hygiene must be carried out9: · Before and after: touching the patient or undertaking a procedure · After: touching a patient’s surroundings, a body substance exposure risk or removing gloves Use soap and water for hand hygiene following cytotoxic spill management6, and handling or administering chemotherapy treatments. Also consider that: · Alcohol based hand products bind to cytotoxic drugs and can spread chemical

contamination. · Hand creams and skin emollients may aid the absorption of cytotoxic drugs.



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Equipment Required · Equipment must be appropriate for the age, size and clinical requirements of the

patient · Equipment must be serviced and calibrated in accordance with manufacturer’s

recommendations to ensure reliability and accuracy · Specific sites may have pre prepared equipment packs and contents may vary

Personal Protective Equipment (PPE) Considerations2,4 Select PPE appropriate to the chemotherapy procedure being undertaken. Where PPE available is reusable ensure it is: · Decontaminated after use · Stored away from potential contamination sources · Regularly maintained The following PPE may be included: · Long sleeve impervious material gowns with wrist cuffs · Two pairs of mid arm length non-sterile gloves · Goggles · Fluid resistant and fog free procedure mask with splash guard visor · Respiratory protective mask · Shoe protection · Hairnets

Vascular Access Device Infection Prevention Equipment Considerations Select from the following antiseptic solutions in following order of preference for patient skin or VAD catheter access hub where relevant to patient sensitivity:10 · Minimum 0.5% chlorhexidine in 70% alcohol · 5%-10% alcohol based povidone-iodine · 70% alcohol When applying VAD catheter access hub antiseptic solution ensure to:10 · Determine compatibility with the indwelling VAD, e.g. aqueous or alcohol based solution · Utilise a residual antiseptic where indicated for specific VAD, e.g. CVC insertion Select equipment, including PPE that is appropriate to the device and procedure in relation to: · Aseptic non-touch technique and/or maximum barrier precautions. · Situational requirements for utilising personal protective equipement (PPE).

Chemotherapy Equipment Administration Considerations Select equipment that provide closed systems for administering liquid chemotherapy agents: · Include: Luer lock and needless fittings · Except: devices used to administer intrathecal chemotherapy agents



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Staffing Requirements Staff involved in the administration of chemotherapy treatments, are required to maintain the level of competency and continuing professional education that is required for undertaking their role7. Staffing levels and skill mix for the procedures described within this clinical practice standard are to be selected to ensure safe administration of chemotherapy treatments appropriate to the clinical condition of the patient7. Staff who are pregnant, breastfeeding or planning pregnancy (male or female) are advised to2,4: · Ensure vigilant use of PPE · Avoid exposure prone procedures, and/ or transfer to another working environment

Acknowledgement of previous site endorsed work used to compile this standard We would like to thank the following people for their contribution to the project: AHS, Same Day Policy Manual: Cytotoxic Spill: Management of 2011 AHS, Policy Manual: Adriamycin – Intravesicular (Bladder Instillation) – Pre and Post Procedure Management, 2010 AHS, Policy Manual: BCG – Intravesicular (Bladder Instillation) – Pre and Post Procedure Management, 2010 FHHS, Pharmacy Department Stores; Handling of Cytotoxic Drugs (year unknown) FHHS Pharmacy Department Dispensary; Handling and Dispensing of Oral Cytotoxic (year unknown) FHHS, Pharmacy Department; PowerPoint Presentation; Cytotoxic Handling and Spills (year unknown)

Fyfe, T. Senior Pharmacist RPH, Department of Medical Oncology: Procedure and Protocol Manual 2012 AHS, Same Day Policy Manual: Cytotoxic Spill: Management of 2011

Morley, B, A/Director of Nursing FHHS, Pharmacy Department: Medical Officers Manual: Chemotherapy, Cytotoxic Medication, Parenteral Cytotoxic Prescribing Guidelines 2011

Copeland, T, Senior Pharmacist FHHS, Nursing Practice Manual 121 B9N/B91, Cancer Diagnosis: Education for New Patients, Policy and Procedure 2012 FHHS, Nursing Practice Manual 41: Chemotherapy, Cytotoxic Drugs Policy 2011 FHHS, Nursing Practice Manual 42: Chemotherapy, Cytotoxic drugs: Management of a Cytotoxic Spill, Procedure 2011 FHHS, Nursing Practice Manual 43: Chemotherapy, Cytotoxic Drugs: Extravasation Procedure 2010 FHHS, Nursing Practice Manual 44: Chemotherapy, Cytotoxic Drugs: Oral, Subcutaneous, Intramuscular, Intrathecal, Intravenous (IV) Infusions and Bolus, Intraperitoneal Administration, Procedure 2011

O’Callaghan, B, CNC Cancer Services



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RPG, Clinical Practice Manual AC:08: Chemotherapy Drugs: Oral, Subcutaneous, Intramuscular, Intrathecal, Intravenous (IV) Infusions and Bolus, Intraperitoneal Administration (Acute): Procedure 2010 RPG, Clinical Practice Manual AC:09: Chemotherapy, Cytotoxic Drugs: Management of Cytotoxic Spill (Acute): Procedure 2010 RPG, Clinical Practice Manual AC:58: Chemotherapy, Cytotoxic Drugs: Extravasation (Acute) Procedure 2011 RPG, Clinical Practice Manual AC:60: Chemotherapy, Cytotoxic Drugs (Acute) Policy 2010

CNS Chemotherapy RPG, Waste Management Procedure RKPG SPE:17 2013 RPG, Spill: Clinical, Cytotoxic and Chemical RKPG SPE:18 2013

Operations Manager FHHS, Haematology Department, Haematology Manual, Policy for Credentialing of Registrars for: Lumbar Puncture/Intrathecal Therapy 2013

Copeland, T, Senior Pharmacist Leahy, M, HOD: Clinical Professor O’Callaghan, B, CNC Haematology/Oncology

FHHS, Pharmacy Department: Practical Management of Cytotoxic Extravasation Classification of Antineoplastic Agents as Neutral, Irritant or Vesicant 2012

Copeland, T. Senior Pharmacist Fyfe, T. Senior Pharmacist

RPH, Nursing Practice Standard for Chemotherapy Administration 2012 Barratt, C. CNS Cancer and Neurosciences Kovac, R. ND Cancer and Neurosciences Simpson, S. SDE Evidence Based Practice

RPH, Nursing Practice Standard for Collection of Cerebral Spinal Fluid (CSF): Lumbar Puncture and Ommaya® Reservoir 2013

Kilcullen, A. CNC Haematology Cancer and Neurosciences Bedford, M. SDN Critical Care Division Gillman, L. SDE The Education Centre

Site Representatives Anderson, M. OSH Program Manager, SMHS Bamblett, M. CNC Haematology, FHHS Brozicevich, M. Senior Project Officer, SMHS Davidson, A. HOD Medical Oncology, RPH MacLean, A. DCS, AHS Reynolds, M. CNS Chemotherapy, RPG Legislation Acts Amendment (Consent to Medical Treatment) Act 2008 Carers Recognition Act 2004 Civil Liability Act 2002 Disability Services Act 1993 Equal Opportunity Act 1984, Equal Opportunity Regulations 1986 Guardianship and Administration Act 1990 Health Practitioner Regulation National Law (WA) Act 2010 Mental Health Act 1996



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Occupational Health Safety and Welfare Act 1984 Occupational Health and Safety Regulations 1996 Poisons Act 1964, Poisons Regulations 1965, Poisons Amendment Regulations 2010 Public Sector Management Act 1994 State Administrative Tribunal Act 2004, State Administrative Tribunal Regulations 2004 State Records Act 2000 - The children and community Services Amendment (Reporting Sexual Abuse of Children) Act 2008 The Children and Community Services Amendment Bill 2010

Standards EQuIPNational www.achs.org.au/ National Standards for Mental Health Services (NSHMS)

WA Department of Health Policies (Operational Directives) healthpoint.hdwa.health.wa.gov.au www.health.wa.gov.au Consent to Treatment Policy for the Western Australian health system, 2011 (OD 0324/11) Clinical and Related Waste Management – Clinical Wastes (OD 0259/09) Clinical Handover Policy, 2012 (OD 0403/12) Clinical Incident Management Policy, 2012 (OD 0421/13) Correct Patient, Correct Site and Correct Procedure Policy and Guideline for WA Health Services 2nd Edition (OD 0004/06) Hand Hygiene in Western Australian Hospitals (OD 0263/10) Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia (OD 0410/12) Medical Emergency Response (OD 0040/07) Post-Fall Management Guidelines in Western Australian Healthcare Settings (OD 0442/13) The Policy for Credentialling and Scope of Clinical Practice for Medical Practitioners 2nd Edition 2009 (OD 0177/09) Western Australian Patient Identification Policy 2010 (OD 0312/10) SMHS Policies healthpoint.hdwa.health.wa.gov.au Aboriginal and Multicultural Groups (SMAHS CF: 02) Bariatric Management: (SMAHS COC: 06) Consumer and Carer Participation: (SMAHS CF: 03) Consumer and Carer Participation in Mental Health: (SMHS CF: 07) Health Record Documentation Policy and Standards (SMAHS COC: 03) Infection Prevention and Management Policy (SMHS PS:06) Mandatory Training Governance Policy (SMHS HR: 04) OSH: Manual Handling (SMAHS SPE: 04) Single Use/Single Patient Use Medical Devices: (SMAHS SPE: 40)

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Standardised Logos EQuIPNational www.achs.org.au/

Governance for Safety and Quality in Health Service Organisations

Partnering with Consumers

Preventing and Controlling Healthcare Associated Infections

Medication Safety

Patient Identification and Procedure Matching

Clinical Handover

WA Department of Health iSoBAR - Guide to Handover Content and Structure

i IDENTIFY Introduce yourself and your patient

S SITUATION Describe the reason for handing over

o OBSERVATIONS Include vital signs and assessments

B BACKGROUND Pertinent patient information

A AGREE A PLAN Given the situation, what needs to happen

R READ BACK Clarify shared understanding

Blood and Blood Products

Preventing and Managing Pressure Injuries

Recognising and Responding to Clinical Deterioration in Health Care

Preventing Falls and Harm from Falls

Service Delivery

Provision of Care

Workforce Planning and Management

Information Management

Corporate Systems and Safety

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18. Cancer Institute NSW. Patient information: Care at home following an extravasation injury [part of the eviQ Cancer Treatment Information and Resources]. Eveleigh, NSW: Cancer Institute NSW; 2012: https://www.eviq.org.au/Protocol/tabid/66/id/497/view/Fullview/Patient+Information+-+Care+at+Home+Following+an+Extravasation+Injury.aspx. Accessed 11 July 2013.

19. Cancer Institute NSW. Clilnical procedure: Extravasation management of vesicants using dimethyl sulfoxide solution [part of the eviQ Cancer Treatment Information and Resources]. Eveleigh, NSW: Cancer Institute NSW; 2012: https://www.eviq.org.au/Protocol/tabid/66/id/1072/view/Fullview/Clinical+Procedure+-+Extravasation+Management+of+Vesicants+Using+Dimethyl+Sulfoxide+Solution.aspx. Accessed 11 July 2013.

20. Cancer Institute NSW. Clilnical procedure: Extravasation management of vesicants using hyaluronidase [part of the eviQ Cancer Treatment Information and Resources]. Eveleigh, NSW: Cancer Institute NSW; 2012: https://www.eviq.org.au/Protocol/tabid/66/id/1192/view/Fullview/Clinical+Procedure+-+Extravasation+Management+of+Vesicants+Using+Hyaluronidase.aspx. Accessed 11 July 2013.

21. Cancer Institute NSW. Clilnical procedure: Extravasation management of irritants with vesicant properties general care [part of the eviQ Cancer Treatment Information and Resources]. Eveleigh, NSW: Cancer Institute NSW; 2012: https://www.eviq.org.au/Protocol/tabid/66/id/1193/view/Fullview/Clinical+Procedure+-+Extravasation+Management+of+Irritants+with+Vesicant+Properties+General+Care.aspx. Accessed 11 July 2013.

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http://www.eviq.org.au/Protocol/tabid/66/id/1002/view/Fullview/Quicklinks+Table+-+Extravasation+Management.aspx

http://www.eviq.org.au/Protocol/tabid/66/id/1002/view/Fullview/Quicklinks+Table+-+Extravasation+Management.aspx

http://www.eviq.org.au/Protocol/tabid/66/id/497/view/Fullview/Patient+Information+-+Care+at+Home+Following+an+Extravasation+Injury.aspx

http://www.eviq.org.au/Protocol/tabid/66/id/497/view/Fullview/Patient+Information+-+Care+at+Home+Following+an+Extravasation+Injury.aspx

http://www.eviq.org.au/Protocol/tabid/66/id/1072/view/Fullview/Clinical+Procedure+-+Extravasation+Management+of+Vesicants+Using+Dimethyl+Sulfoxide+Solution.aspx




http://www.eviq.org.au/Protocol/tabid/66/id/1192/view/Fullview/Clinical+Procedure+-+Extravasation+Management+of+Vesicants+Using+Hyaluronidase.aspx

http://www.eviq.org.au/Protocol/tabid/66/id/1192/view/Fullview/Clinical+Procedure+-+Extravasation+Management+of+Vesicants+Using+Hyaluronidase.aspx

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24. Cancer institute NSW. Clinical procedure - Oral antineoplastic drug administration. Eveleigh, NSW: Cancer Institute NSW; 2012: https://www.eviq.org.au/Protocol/tabid/66/id/919/Default.aspx. Accessed 31 July 2013.

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27. Cancer institute NSW. Clinical procedure - Intrathecal administration of antineoplastic drugs. Eveleigh, NSW: Cancer Institute NSW; 2013: https://www.eviq.org.au/Protocol/tabid/66/id/919/Default.aspx. Accessed 31 July 2013.

28. Cancer institute NSW. Resource document - Administration of methotrexate cytarabine and thiotepa via an intraventricular reservoir. Eveleigh, NSW: Cancer Institute NSW; 2012: https://www.eviq.org.au/Protocol/tabid/66/id/919/Default.aspx. Accessed 31 July 2013.

29. Markman M, Walker JL. Intraperitoneal chemotherapy of ovarian cancer: a review, with a focus on practical aspects of treatment. J Clin Oncol. Feb 20 2006;24(6):988-994.

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UpToDate; 2013.

This document can be made available in alternative formats on request for a person with a disability Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.


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Appendix 1: Patient Education Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Staffing Requirements · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill · Extravasation Management Refer to the WA Cancer and Palliative Care Network resources in conjunction with this appendix: · Brochure Series: Support for People with Cancer

Ensure patient education is given prior to, and separately from chemotherapy administration. Deliver education that address the patient’s potential2: · Cultural needs · Language requirements · Literacy ability · Communication impairment · Learning style · Previous chemotherapy experience Provide opportunity for the patient, and ensure consent is obtained prior to having significant others present during education.

Patient Education Preparation Determine the provision of patient education appropriate to the clinical discipline and scope of practice7. Liaise with other clinical disciplines to coordinate and ensure the information discussed with the patient is delivered appropriately for their treatment7. Consider the goals of the particular patient education session1,2,7 e.g: · Explaining treatments · Identifying potential side-effects · Decreasing anxiety · Managing cytotoxic substances · Undertaking self-care · Accessing community support resources · Post-treatment instructions · On-site contacts for advice regarding treatment and its effects Assess the patient to identify and determine specific education needs1. Ensure to arrange for resources in adequate time prior to undertaking patient education2 e.g: · Interpreter services · Appropriate written materials · Community support details · Appropriate DVD or CD material · Details for on-site contacts · Site specific education resources and/or checklist Understand the chemotherapy treatment process prior to undertaking patient education8 and provide information for2,7: Treatment details including7: · Aim of treatment regimen · All drugs used: cytotoxic agents, and non-chemotherapy drugs · Length and frequency of treatment · Mode of administration for treatment Specific pre and post drug administration precautions.

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Identifying, preventing and managing common side effects7, including: · Potential complications related to mode of chemotherapy administration · Specific drug or systemic side effects Where ever patients are anticipated to continue with chemotherapy treatments at home, provide information as to: · Store as directed, separate from other medications and away from children. · Take the medication only as prescribed. · Wash hands with soap and water, before and after handling medications. Undertaking Patient Education · Introduce self to patient and others present8. · Describe purpose of education session7. · Use an open communication style to maximise understanding and enable the patient to

ask questions. · Determine the level and type of any previous education the patient may have been

given on previous occasions or by other clinical disciplines1. · Answer any questions raised. · Discuss the treatment regimen7:

· Drugs and agents to be used · Aim, length and frequency of treatment · Mode of administration

· Describe potential side effects7: · Giving advice for prevention and management for side effects relevant to that

regimen. · Provide written material and discuss its importance7. · If self-care activities are discussed, where possible observe to ascertain correct technique. · Provide information for whom to contact if any there are any concerns2,7. · Ask the patient and others present if they have any questions. · Conclude the patient education session. Patient Education Follow-up Treatment and Discharge · When the patient presents for further treatment: discuss any concerns or issues and

reinforce the education previously given7. · Prior to discharge assess the patient for their understanding of the education previously

given, including: · Chemotherapy regime · Prevention and management of potential side effects · Follow-up appointments · Whom to contact for any concerns or problems

Documenting Patient Education · Document all patient education provided in the health record2. · Provide referral to allied health services for additional advice and support as

appropriate.



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Appendix 2: Transporting Cytotoxic Chemotherapy Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Cytotoxic Waste Management · Handling Cytotoxic Spill

Intrathecal chemotherapy during transport from pharmacy to designated area shall be under the direct control of an intrathecal-qualified nurse or pharmacist. Intrathecal medications must be transported and stored separately from other cytotoxic agents7. All personnel involved in receiving and distributing cytotoxic agents are required to ensure competency in Handling Cytotoxic Spill.

Container Considerations

All cytotoxic preparations are to be placed in containers dedicated to purpose that are2,7: · Specifically designed with hard-walls to protect contents from spillage,

leakage and breakage during transport · Securely closed and clearly labelled with a purple cytotoxic waste label · Provided with safe storage areas designed to minimize breakage risk

and contain spills. Transport Considerations When transporting cytotoxic preparations to clinical destination: · Keep cytotoxic agents separate from other preparations. · Utilise goods and services lifts only. · Do not use pneumatic tube systems. Management of Infusion During Transport Patients being transported with a chemotherapy infusion insitu, must be escorted by a nurse with chemotherapy competency. Prior to commencing patient transport: · Ensure vascular access device is patent and all connections are secure. · Obtain a portable spill kit, and an extravasation kit. Only disconnect chemotherapy infusion for those patients undergoing radiotherapy treatments. · Disconnection and reconnection to be undertaken by chemotherapy competent nurse.



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Appendix 3: Cytotoxic Waste Management Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Handling Cytotoxic Spill

Cytotoxic wastes are items contaminated with a cytotoxic drug. This may include: · Empty ampoules, vials, needles, and syringes · Used swabs, intravenous administration lines, and bags · Patient excreted waste, and used contaminated continence, ostomy or sanitary products · Wet dressings, tracheal secretions, breast milk, sexual fluids, vomit, and blood

Waste Handling Before handling any cytotoxic waste utilise the correct type of personal protective equipment to maximise protection and minimise cytotoxic waste permeability. All persons handling wastes must use gloves as minimum and combine with impervious gown and goggles or face shield where splash risk is likely2,11. Container Considerations

All items used for administering cytotoxic agents are to be disposed of in containers that are:

· Specifically designed to protect contents from spillage, leakage and breakage during transport

· Clearly labelled with a purple cytotoxic waste label · Cytotoxic contaminated sharps must be disposed into hard walled purple cytotoxic

sharps containers. · Containers must be kept capped at all times when not being accessed. · Do not squeeze air out cytotoxic waste bags when sealing closed. This may create aerosols. · Never over fill containers. Contaminated Linen or Clothing Items Hospital linen items contaminated with cytotoxic chemotherapy, or contaminated patient body fluids or wastes, is placed in a purple cytotoxic bag and disposed as cytotoxic waste. For non-disposable (washable) contaminated linen and clothing items2-4: · Handle items with gloves · Store items in a plastic bag if not able to be washed

immediately · Use regular detergent · Wash separately from other laundry · Line dry · Items may be handled normally once clean For machine washable items: · Select a hot and maximum wash cycle · Rewash if heavily contaminated For hand wash items (in patient’s own home): · Clean gently with detergent and water

Title: Chemotherapy Administration Clinical Practice Standard Effective: 18 March 2015

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Contaminated Patient Body Fluids and Excreted Waste · Body wastes excreted from patients receiving cytotoxic chemotherapy may contain small amounts of cytotoxic chemotherapy, their

active metabolites. Most are excreted in urine and/or faeces. · Consider all body wastes excreted from the patient contaminated from 48-72 hours up to 7 days after the completion of treatment. As

this will depend on the type of chemotherapy treatment, and body waste excreted, refer to Table 1: Timeframes and excretion rates for body waste contaminated by cytotoxic drugs.

· Wear appropriate clothing PPE and double glove, when handling or cleaning contaminated body wastes and fluids. · When disposing of body waste into, or after patients’ use of the toilet (sewerage or septic connected), close the lid and double flush

using the using full flush option2,4. · Advise male patients to sit rather than stand when urinating. · Use indwelling catheters for urinary incontinent patients. · In patient’s own home: contaminated items such as gloves, continence or sanitary products are to be immediately placed in a

sealable plastic bag and disposed in household rubbish4. Table 1: Timeframes and excretion rates for body waste contaminated by cytotoxic drugs4,12 Drug Urine: Timeframe & Excretion Rate Faeces: Timeframe & Excretion Rate Other Abiraterone 5% excreted in the urine Approx. 2.5

days 88% excreted

Amsacrine 3 days 20% in 1st 8hrs 2 days Asparaginase Trace amounts Bleomycin 3 days Up to 68% in 1st 24hrs Busulphan 12-24hrs 30-60% excreted within 48hrs

<2% of the dose excreted unchanged within 24hrs

Trace amounts

Cabazitaxel <4% of drug and metabolites 76% excreted Approx. 80% of dose excreted within 2 weeks

Capecitabine 1 day Carboplatin 1-2 days 60-80% in 1st 24hrs Carmustine 4 days 60-70% as metabolites 1% of dose 10% as CO2


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Drug Urine: Timeframe & Excretion Rate Faeces: Timeframe & Excretion Rate Other Chlorambucil 2 days Cusplatin 7 days Cyclophosphamide 3 days (IV) 25% unchanged drug in 1st 48hrs;

total of 62% over 48hrs 5 days (PO) 4% after IV 72hrs: sweat and saliva

Cytarabine 1 day Dacarbazine 6hrs Dactinomycin 5 days 20% in 1st 24hrs 7 days Daunorubicin 2 days 20% in 1st 24hrs 7 days 20% in 1st 24hrs:

gallbladder Docetaxel 7 days 7 days 80% in 1st 48hrs Doxorubicin 6 days 7 days 5 days: bile Doxorubicin Liposomal

unknown Unknown: extended elimination Plasma clearance slower than for Doxorubicin

Epirubicin 7 days 5 days Etopophos 5 days Etoposide 4 days 40-60% mainly unchanged 7 days 15% excreted Fludarabine 2 days Bolus: 60% in 1st 24hrs

Infusion: 40% metabolised in 24hrs & 60% in 72hrs

Fluorouracil 2 days Bolus: 15% unchanged in 1st 24hrs Infusion: 4% unchanged over 24hrs

5 days

Fotemustine 4 days 30-40% in 1st 24hrs 50% excreted Ganciclovir No data available Gemcitabine 7 days Almost complete elimination in form

of metabolites in 24hrs 1% excreted

Hydroxyurea 1 day 50-80% in 24hrs Idrarubicin 4 days 7 days Ifosfamide 2 days 63% unchanged with another 20%

as metabolites


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Drug Urine: Timeframe & Excretion Rate Faeces: Timeframe & Excretion Rate Other Imatinab mesylate 7 days 7 days Irinotecan 2 days Lomustine 1 day 66% in 1st 24hrs Melphalan 2 days 28% in 1st 24hrs after PO

56% in 1st 24hrs after IV 7 days 20-50% after PO

Mercaptopurine 2-3 days 50% in 1st 24hrs 5 days Methotrexate 3 days Majority in 1st 8hrs

Low dose: 40-50% in 48hrs High dose: up to 90% in 48hrs

7 days 9% after IV

Mitomycin 1 day 10% as active drug Small amount in bile Mitoxantrone 6 days 6.5% unchanged drug

3.6% metabolised drug 7 days 18% over 5 days

Oxaliplatin 3 days 40-50% of the dose in 1st 24hrs Paclitaxel 1 day 13% unchanged drug 5 days Pemetrexed 3 days 70-90% of dose unchanged in 1st

24hrs

Procarbazine 2 days 5% as unchanged drug and 70% as metabolites in 1st 24hrs

Good adsorption from GIT 12% of dose eliminated from GIT in 4 days

Raltitrexed 8 days Temozolomide Unknown 10% of dose in 1st 24hrs Teniposide 5 days 10% of dose in 1st 24hrs 2 days Thioguanine 1 day 85% unchanged and metabolites Thiotepa 3 days 60% as metabolites in 1st 24hrs Topotecan 2 days Vinblastine 4 days 7 days Vincristine 4 days 7 days Vindesine 4 days 7 days Vinorelbine 4 days 7 days



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Appendix 4: Handling Cytotoxic Spill Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Cytotoxic Waste Management · Extravasation Management

A cytotoxic spill kit and staff trained in Handling Cytotoxic Spill must be available where ever chemotherapy agents, in all forms, are prepared, transported, administered or disposed2,4,6. · A cytotoxic spill may also occur in relation to contaminated waste or body fluids4. People within the vicinity of a cytotoxic spill must be immediately alerted to stand clear.

Spill Kit Considerations4,6 · A risk assessment should be used to determine if the contents are appropriate to the

situation in which the cytotoxic spill kit will be used. · Spill kits must contain clear instructions in the safe work procedures for the

management of cytotoxic spill. · Locations for storing spill kits must be selected and sign-posted. · Contents of spill kit must be routinely reviewed and replaced when items are deteriorated. · Replacement spill kits are available from pharmacy. Hand Hygiene Considerations6 Use soap and water for hand hygiene only. Also consider that: · Alcohol based hand products bind to cytotoxic drugs and can spread chemical

contamination. · Hand creams and skin emollients may aid the absorption of cytotoxic drugs. Reporting and Documenting Cytotoxic Spill Notify the head of department or relevant senior staff delegate; e.g. Chemotherapy Clinical Nurse Specialist. Complete the following incident notification forms, as relevant to tier of governance: · Clinical Incident Form: as per DoH OD 0569/15 Clinical Incident Management Policy · Hazard Report Form (or similar at each site): as per WACHS OSH: Staff Accident,

Incident and Hazard Reporting · Cytotoxic Incident Form (or similar at each site): As supplied in cytotoxic spill kit and

forwarded to pharmacy.

http://www.health.wa.gov.au/CircularsNew/attachments/1056.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/WACHS/WACHS%20Safety%20Risk%20Report%20Form.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/WACHS/WACHS%20Safety%20Risk%20Report%20Form.pdf



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Equipment Required · Contents and quantities of equipment contained within a cytotoxic spill kit may vary,

and contents should be listed within the kit instructions. · The spill kit may include following contents4,6 Instructions Hazard signs Incident report forms Cytotoxic waste bags and ties Cytotoxic waste containers Plastic scoop and scraper Cleaning agents: e.g. detergent Water for irrigation Cleaning cloths: e.g. Chux®

type · PPE P2 or N92 mask Protective eyewear/ face shield Impermeable gown Gloves: multiple pairs and types

Overshoes Hairnet

· Chemical absorbent materials Chemical spill pillow Chemical absorbent pads or

mats Waterproof sheets: e.g. blueys

Gauze swabs Absorbent towels Procedure: Patient or Staff Contamination 1. Assess patient or self for contamination. Don PPE. Evident skin contamination: remove contaminated clothing, place in cytotoxic waste

bag. Wash skin with large amounts of water and mild soap, or shower self or patient in nearest bathroom.

Eye splash: flush affected eye with large amounts water or 0.9% sodium chloride for irrigation for 15 – 20 mins.

Broken skin contamination: Where accidental cut, scratch or needle stick to staff member. Immediately encourage bleeding. Rinse thoroughly, wash with mild soap and water.

2. Perform hand hygiene with soap and water. 3. Arrange for medical review. Report cytotoxic spill. 4. If patient contaminated, document exposure in health record. Procedure: Furniture or Floor 1. Inform colleagues and request cytotoxic spill kit. Do not allow other personnel to enter the

area. 2. Seek assistance from staff trained in handling cytotoxic spill to contain and remove spill. Cytotoxic Spill Trained Staff Member Only: 3. Open spill kit. Read instructions. Don PPE. Erect hazard signs. 4. Contain and remove the spill as per cytotoxic spill kit instructions.

· Begin cleaning from the outside of the spill and gradually work towards the centre. 5. Dispose of contaminated and clean up items within appropriate cytotoxic specific

wastes bags and containers. 6. Once spill completely removed, wash or mop the area thoroughly. 7. Remove PPE. Discard disposable PPE. Decontaminate reusable PPE and ensure to

wear appropriate PPE to undertake this. 8. Perform hand hygiene with soap and water. 9. Return the used spill kit to pharmacy, and obtain a replacement spill kit. 10. Report cytotoxic spill.



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Appendix 5: Extravasation Management Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Handling Cytotoxic Spill

Extravasation kits and suitably educated staff in extravasation management are to be readily available wherever intravenous or intra-arterial chemotherapy are administered3.

Extravasation Considerations2,3,8,13 · Extravasation is where an administered vesicant drug accidentally leaks or infiltrates

into surrounding tissue, leading to tissue damage with potential for further harm: i.e. blistering, subsequent cell death and tissue necrosis

Morbidity from extravasation depends on the: · Drug vesicant characteristics and concentration · Amount of drug extravasated · Timely response for recognition and treatment

Several chemotherapy agents may cause toxicity to surrounding tissues ranging from; local pain and inflammation to full thickness ulcers. Cytotoxic drugs may be classified according to their effect on tissues when extravasated:

· Vesicant: a drug that causes local tissue necrosis · Irritant: a drug which produces burning or inflammation without necrosis · Neutrals (non-irritants): a drug which rarely produces an acute reaction or necrosis

Patients at risk of extravasation include those who are: · Elderly · Communication impaired · Unconscious, sedated, confused · Thrombocytopaenic · Currently taking: Anticoagulants or steroid medications Or who have: · Lymphodaema · Vascular disease · Superior Vena Cava syndrome · Undergone previous: Repeated venepuncture or sclerosing/ irritating drug treatments

Preventing Extravasation13 Only suitably educated and competent staff are able to administer and manage chemotherapy. Select appropriate vascular access device (VAD) and optimum insertion site. Ensure patency of VAD prior to administering chemotherapy. Administer vesicant drugs first14,15 and:

· Infuse slowly · As soon as possible after VAD insertion · Through the side arm or Y-connection of the intravenous administration line14,15



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During administration of chemotherapy drugs ensure: · VAD insertion site is constantly observed for signs of: infiltration, extravasation and

leakage · To check continually for patency by: allowing free fluid flow or withdrawing blood · Not to pinch the intravenous tubing, and increase venous pressure

Provide patient education regarding13: · Risk of extravasation · Immediate reporting of any pain and swelling relating to the VAD · Keeping the limb still when a vesicant drug (or with vesicant properties) is

administered via peripheral vascular access cannula (PIVC). Recognising Extravasation13,16 · Patient may complain immediately of a sharp stinging and burning in relation to VAD · Swelling or leakage is observed in relation to the VAD · Absence of free intravenous fluid flow during infusion · Resistance is felt on the plunger during bolus administration · In the presence of other symptoms:

· Blood flashback on syringe pull back is absent · Redness or blanching at the VAD insertion site or surrounding tissues

Table : Antineoplastic Agents Classification and Specific Extravasation Antidote13,17 Agent Classification Antidote Compress

Arsenic Neutral Not indicated Not indicated Bevacizumab Neutral Not indicated Not indicated Bleomycin Neutral Not indicated Not indicated Bortezomib Irritant Not indicated Cold compress: Comfort measure only Carboplatin Irritant Not indicated Cold compress: Comfort measure only Carmustine Irritant Not indicated Cold compress: Comfort measure only Cetuximab Neutral Not indicated Not indicated Cisplatin (>0.5mg/mL)

Vesicant treated as irritant with vesicant properties

No recommended antidote

Cold compress: Applied 15-20 mins 4 times a day for 48hrs

Cladribine Neutral Not indicated Not indicated Colaspase Neutral Not indicated Not indicated Cyclophosphamide Neutral Not indicated Not indicated Cytarabine Neutral Not indicated Not indicated Dacarbazine Irritant Not indicated Cold compress: Comfort measure only

Dactinomycin Vesicant Topical DMSO Cold compress Applied intermittently

Daunorubicin Vesicant Topical DMSO Cold compress: Applied 15-20 mins 4 times a day for 48hrs

Docetaxel Irritant with vesicant properties



Doxorubicin HCl Vesicant Topical DMSO Cold compress: Applied 15-20 mins 4 times a day for 48hrs



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Agent Classification Antidote Compress

Doxorubicin Lip. Irritant with vesicant properties

No recommended antidote Do Not use DSMO


Epirubicin Vesicant Topical DMSO Cold compress: Applied 15-20 mins 4 times a day for 48hrs

Etoposide Irritant Not indicated Cold compress: Comfort measure only Etoposide Phosphate Irritant Not indicated Cold compress: Comfort measure only

Fludarabine Neutral Not indicated Not indicated Fluorouracil Irritant Not indicated Cold compress: Comfort measure only Fotemustine Irritant Not indicated Cold compress: Comfort measure only Gemcitabine Irritant Not indicated Cold compress: Comfort measure only

Idarubicin Vesicant Topical DMSO Cold compress: Applied 15-20 mins 4 times a day for 48hrs

Ifosfamide Neutral Not indicated Not indicated

Irinotecan Irritant Not indicated Cold compress Comfort measure only

Melphalan Irritant with vesicant properties



Methotrexate Neutral Not indicated Not indicated

Mitomycin-C Vesicant Topical DMSO Cold compress: Applied 15-20 mins 4 times a day for 48hrs

Mitozantrone Irritant with vesicant properties



Oxaliplatin Irritant with vesicant properties

No specific antidote No compress

Paclitaxel Irritant with vesicant properties



Paclitaxel NAB Irritant with vesicant properties



Pemetrexed Irritant Not indicated Cold compress: Comfort measure only Ralitrexed Neutral Not indicated Not indicated Rituximab Neutral Not indicated Not indicated Tenoposide Irritant Not indicated Cold compress: Comfort measure only Thiotepa Neutral Not indicated Not indicated Topotecan Neutral Not indicated Not indicated Trastuzumab Neutral Not indicated Not indicated

Vinblastine Vesicant Subcutaneous hyaluronidase

Warm compress: Applied 15-20 mins 4 times a day for 48hrs

Vincristine Vesicant Subcutaneous hyaluronidase


Vinorelbine Vesicant Subcutaneous hyaluronidase



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Equipment Required · Consider the requirements for Handling Cytotoxic Spill. · Consider the requirements for flushing, disconnecting and/or removing VAD. Refer to Vascular Access Devices Management Clinical

Practice Standard · Some extravasation antidotes and treatment measures may not be readily available within the extravasation kit, due short expiry date

or refrigeration requirements; e.g. Hyaluronidase for injection or cold gel pack. · Contents and quantities of equipment contained within an extravasation kit may vary. The following contents may be included3:

Extravasation management procedure 10mL water for injection 20mL 0.9% sodium chloride for injection Hyaluronidase injection 1500 international units 21g needles 5mL syringes Alcohol swabs Dimethyl sulphoxide solution (DMSO) 20mL Chemotherapy gloves Impermeable gown Protective eyewear Gel pack for hot or cold compress and waterproof covering Sterile gauze squares Waterproof skin marker Procedure: Extravasation Management 2,3,13,18

1. Once extravasation suspected: Cease infusion immediately. Do not remove VAD. 2. Notify medical officer, senior nurse and pharmacist. 3. Don PPE: gloves, gown and eyewear. Attempt to aspirate extravasated drug and assess relevant VAD.

Assess VAD Patency: or Assess Implanted Port: or Assess CVC/PICC: a. Attempt to withdraw 3 to 5mL of blood

from the VAD. b. If good blood return: flush with 10mL

0.9% sodium chloride. If patent proceed cautiously and monitor patient closely.

c. If no blood return: extravasation suspected.

a. Determine if port or needle placement problematic.

b. If correct needle position: Attempt to flush with 5mL 0.9% sodium chloride.

c. If unsure of correct needle position: Remove needle from port.

d. If port problematic: liaise with medical officer to assess port via venogram.

a. Flush with 5mL 0.9% sodium chloride. b. If flush unsuccessful: Liaise with medical

officer to assess CVC/PICC via venogram.

4. Once extravasation aspiration attempted: Obtain extravasation kit. 5. If PIVC insitu, remove and do not apply pressure. 6. Initiate appropriate extravasation management and/or antidote in steps outlined below.




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DMSO for Extravasation Management of Vesicants:19

or

Hyaluronidase for Extravasation Management of Vesicants:20

or

Extravasation Management of Irritants with Vesicant Properties:21

· Dactinomycin · Daunorubicin · Vinblastine · Cisplatin >0.5mg/mL · Doxorubicin · Epirubicin · Vincristine · Liposomal Doxorubicin · Idarubicin · Mitomycin · Vinorelbine · Paclitaxel NAB d. Ensure skin is dry. DMSO applied to

wet skin my result in burns. e. Using a glass dropper, apply a thin

layer of DMSO solution: 4 drops DSMO per 10cm2 affected area.

f. Allow to air dry and do not apply a dressing. · Repeat DMSO application 4 times a

day for minimum 7 days, and maximum 14 days.

g. Apply COLD compress to affected area for 15 – 20 minutes. · Repeat compress 4 times a day for

48 hours. · Do not apply pressure. · Do not use for Liposomal

Doxorubicin or Liposomal Daunorubicin extravasation.

a. Reconstitute Hyaluronidase 1500 International Units in 2 to 5mL water for injection: depending on size of extravasation

b. Administer Hyaluronidase 1500 International Units subcutaneously in 0.2 to 0.4mL volumes around the area of extravsation using the ‘pin cushion’ technique: · Mark the circumference of the area with

an imaginary ‘clock face’ · Start at 12 o’clock and inject the antidote

at ‘2 hourly intervals’ c. Gently massage the area to facilitate drug

dispersal d. Apply WARM compress to affected area for

15 – 20 minutes. · Repeat compress four times a day for 48

hours.

· Paclitaxel · Docetaxel · Melphalan · Mitozantrone a. Apply COLD compress to affected area

for 15 – 20 minutes. · Repeat compress 4 times a day for 48

hours.

· For Oxaliplatin, do not apply a cold or warm compress.

7. Once appropriate extravasation management and/or antidote undertaken: Remove PPE and perform hand hygiene with soap and water. 8. Elevate affected limb overnight. Encourage movement. Administer analgesia as prescribed and required. 9. Mark area of induration with waterproof skin marker.

· Arrange photograph of affected area via Medical Illustration Dept. if extravasation severe. 10. Plan ongoing observation and deliver appropriate patient education:

· Inpatients: observe area daily, and as required for increasing erythema, induration, blistering and necrosis. · Outpatients: arrange review appointment(s) within 72 hours of extravasation incident. Follow-up patient closely for minimum 2 weeks.

11. Arrange early consultation with plastic surgeons if necessary.


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Documenting Extravasation Management 1. If a vesicant involved: complete Vesicant Extravasation Assessment Form 2. Document incident in patient health record, including the following details: · Date and time · Signs and symptoms · VAD type and anatomical insertion site · Drug sequence, concentration, and approximate amount of drug extravsated · Intravenous administration technique: i.e. bolus/ infusion · Appearance, length and width (or diameter) of area · Details of intervention and required ongoing treatments: i.e. further treatment plans · Follow-up arrangements: i.e. photography, outpatient appointments, plastic surgeon referral 3. Complete Clinical Incident Form (CIF)



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Appendix 6: Intravenous and Intra-arterial Chemotherapy Administration Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill · Extravasation Management Refer to the following SMHS Clinical Practice Standards in conjunction with this appendix: · Vascular Access Devices Management Clinical Practice Standard · Ports - Implanted Venous and Arterial Clinical Practice Standard

Extravasation kits and staff trained in Extravasation Management are to be readily available wherever intravenous or intra-arterial chemotherapy are administered3. During administration of chemotherapy drugs ensure vascular access device insertion site is able to be observed for signs of: infiltration, extravasation and leakage1,2. When undertaking chemotherapy intravenous and intra-arterial administrations, consider the requirements for Management of Infusion During Transport. Refer to the DoH OD 0647/16 National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines for full instructions relevant to intravenous labelling. Prepare and administer relevant chemotherapy preparations as per the DoH OD 0021/06 Policy for the safe administration of vinca alkaloids.

Chemotherapy Infusion Considerations Intravenous (IV) administration of cytotoxic agents is the most common delivery chemotherapy treatment and provides for3,8: · Rapid and reliable method of delivery of the cytotoxic agent to the tumour site · Rapid dilution of the drug, reducing local irritation and tissue damage · Consistent absorption of the drug Cytotoxic agents may be administered intravenously via: · Peripheral Intravenous Cannula (PIVAS) · Central Venous Catheter (CVC), including:

· Implanted Venous Port · Peripherally Inserted Central Catheter (PICC) · Tunnelled Central Venous Catheter

Intra-arterial (IA) administration of cytotoxic agents are utilised to deliver chemotherapy treatment directly to the tumour site3,8. Intra-arterial administration of cytotoxic agents may be via: · Intra-arterial Catheter or Sheath · Implanted Arterial Port · Implanted Arterial Pump



http://www.health.wa.gov.au/CircularsNew/circular.cfm?Circ_ID=13282





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Where chemotherapy is administered as a continuous infusion over a number of days, ensure the administration line is changed, every: · Infusion bag change · 48 hours when connecting with CVC or when resiting PIVC · 48 hours when a PIVC is resited Vesicant Chemotherapy Considerations When deciding on utilising gravity fed, volumetric or ambulatory pump for administration of vesicant chemotherapy, consider2,3,8: · Infusion length time · Venous pressure of infused solution · Vascular Access Device (VAD) type selection · Clinical or domiciliary environment for infusion That is: · Longer infusions (>30-60 minutes) via CVC and volumetric pump. · Shorter infusions via PIVC and gravity infusion. · Continuous or intermittent infusions via ambulatory pump for the domiciliary setting. Refer to the following specific sections within this CPS for Extravasation Management: · Extravasation Considerations · Preventing Extravasation · Recognising Extravasation Equipment Required · Consider the requirements for Handling Cytotoxic Spill. · Consider the requirements for Extravasation Management. · Consider the requirements for administering medications via implanted ports. · Medications Chemotherapy prescription and prepared cytotoxic agent Patient prescribed: anti-emetic and/or additional premedication · PPE Chemotherapy gloves Impermeable gown Protective eyewear · Infusion Equipment Compatible diluent and appropriate volume: e.g. 50mL 0.9% sodium chloride or glucose 5% · Bolus Equipment Compatible diluent and appropriate volume: e.g. 250mL or 500mL 0.9% sodium chloride or glucose 5% 10mL Luer lock syringes 10mL ampoules 0.9% sodium chloride Sterile gauze Kidney dish · Additional Equipment VAD antiseptic solution swabs Appropriate administration line Waterproof sheet e.g. bluey Cytotoxic waste container Trolley/ firm surface User-applied labels Volumetric or ambulatory pump Primary and secondary closed system device attachments


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Procedure: Intravenous and Intra-arterial Chemotherapy Administration Assess and Prepare Patient

1. Confirm that patient treatment suitability has been assessed and reviewed by the medical team. Refer to Patient Support Considerations. 2. Confirm that patient has appropriate VAD insitu for planned chemotherapy infusion. Refer to Vascular Access Devices Management

Clinical Practice Standard · Assess all VAD for patency, and assess PIVC also for phlebitis. 3. Provide patient education suitable for situation: i.e. either initial or subsequent administration. Refer to Patient Education. 4. Explain procedure, and obtain appropriate consent. 5. Provide advice for recognising and reporting extravasation symptoms to insertion site and/or surrounding tissues.

Administer appropriate and prescribed anti-emetic medication.

Prepare Chemotherapy Administration 1. Perform hand hygiene at all appropriate moments throughout chemotherapy administration procedure. 2. Check chemotherapy treatment with two nurses, away from the patient bed-side. Undertake to: Check following items on written orders: · Medical officer’s specific dosage · Dosages are correct according to chemotherapy protocol and

patient parameters

Check following items on prepared cytotoxic agent: · Drug details: Dose; Route; Expiry; Duration · Patient: Name; URMN; Allergies · Drug condition: Cloudiness, particulate matter, leakage14,15

3. Check patient identification details at bedside with second nurse. 4. Don PPE: Gown; Gloves; Goggles 5. Commence a compatible diluent intravenous infusion to VAD. Flush 10mL of solution. · Ensure insertion site is visible. · Ensure all Luer lock connections are secure. · Undertake intravenous infusion as appropriate to gravity infusion or volumetric pump. · Swab all access hubs with a VAD antiseptic solution swab. · Attach primed primary and un-primed secondary closed system device attachments. Apply clamps. · Place waterproof sheet under patient’s infusion/connection port. · Intravenous infusion is not required for 5 Fluorouracil. 6. Open sealed bag containing prepared cytotoxic agent. Ensure to undertake: at waist height, on waterproof sheet, on firm surface. 7. Proceed to either: Infusion Administration or Bolus Administration or Ambulatory Pump.




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Infusion Administration or Bolus Administration or Ambulatory Pump

a. Cease primary attachment with compatible diluent intravenous infusion.

b. Pierce the spiking port of the prepared cytotoxic agent with secondary device attachment: at waist height, on waterproof sheet, on firm surface.

c. Infuse agent according to prescribed orders. Check with second nurse: · Rate and volume on volumetric

pump · Drip rate for gravity infusion

d. Monitor the patient, and VAD patency during infusion: · 1 hourly: PIVC or 2 hourly: CVC

e. On completion of infusion, clamp secondary attachment.

f. Recommence compatible diluent intravenous infusion.

a. Establish fast running compatible diluent gravity infusion. Maintain throughout procedure.

b. Clean injection port hub. Allow to air dry. c. Place sterile gauze under injection port. d. Remove cap, connect the syringe

containing the cytotoxic agent, and gently deliver a long thin stream of agent. · Do not expel any air from syringe

e. Monitor the patient and VAD patency during bolus administration: · Regularly draw back syringe for

blood and monitor for free-flow of fluid.

f. On completion remove syringe carefully from the injection port, occluding the end with the gauze swab. Directly dispose of syringe into cytotoxic waste.

g. Flush line with compatible diluent.

a. Clean injection port hub. Allow to air dry. b. Remove cap from administration line in

the cassette of the pump. c. Connect the administration line to the

injection port of the VAD. d. Program pump infusion with second

nurse. Refer to manufacturer guidelines. e. Commence infusion. f. Recheck programming, ensuring pump

is at correct rate, at 1 hour post commencement. · Outpatient: Check undertaken by

nurses. · Patient at home: Educate patient to

check pump. Provide contact details for incorrect infusion rate.

8. Dispose of all cytotoxic waste in cytotoxic waste container. Remove PPE, and perform hand hygiene. 9. If patient requires multiple chemotherapy infusions, repeat steps 5 – 8. Post Chemotherapy Administration

1. Monitor the VAD site and surrounding tissue for 24 hours following chemotherapy administration. Educate patient to observe and report. · Observe for: Pain; Swelling; Leaking; Redness

2. Document the relevant details into the patient health record following chemotherapy administration: · Total volume of chemotherapy infusion every 4 hours on fluid balance chart if present. · On Inpatient or Outpatient chemotherapy medication chart.



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Appendix 7: Oral and Enteral Chemotherapy Administration Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill In clinical areas22 or in home environment never23: · Halve, crush and/or dissolve tablets · Empty and/or dissolve capsules

Oral Cytotoxic Handling and Dispensing Considerations Pharmacy is responsible for ensuring chemotherapy agents are appropriately prepared for the intended oral or enteral administration7. All cytotoxic tablets and capsules required a designated counting tray and spatula. Refer to Material Safety Data Sheets (MSDS) for specific information. Oral Considerations The oral route of administration, when compared with other treatment routes is; convenient, economical and non-invasive4. It provides increased patient sense of control2. Oral Contraindications Oral route chemotherapy administration may unsuitable in the following situations2,3,24: · Dysphagia · Nausea and vomiting · Patient non-compliance · Alimentary malabsorption · Extensive gastric surgery · Potential drug interactions Consider alternative administration route where required. Enteral Considerations Administration via an enteral feeding tube is necessary for patients who are unable to swallow, and has an enteral feeding tube insitu7. Equipment Required · Consider the requirements for Handling Cytotoxic Spill. · Cool boiled or sterile water for flushing enteral feeding tube if patient is immunocompromised. · Medications Chemotherapy prescription and prepared cytotoxic agent Patient prescribed: anti-emetic · PPE Chemotherapy gloves Impermeable gown Protective eyewear · Oral Equipment Disposable medicine cup Water to drink · Enteral Equipment Water for flush Luer lock syringes Waterproof sheet e.g. bluey If required: pH strips or feeding tube connector · Additional Equipment Cytotoxic waste container Kidney dish



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Procedure: Intravenous and Intra-arterial Chemotherapy Administration Assess and Prepare Patient

1. Confirm that patient suitability has been assessed and reviewed by the medical team. Refer to Patient Support Considerations. 2. Provide patient education suitable for situation: i.e. either initial or subsequent administration. Refer to Patient Education. 3. Explain procedure, and obtain appropriate consent. 4. Provide advice for managing and reporting vomiting within 6 hours of chemotherapy treatment. 5. Administer appropriate and prescribed anti-emetic medication; at least 30 minutes before chemotherapy treatment. Undertake Chemotherapy Administration

1. Perform hand hygiene at all appropriate moments throughout chemotherapy administration procedure. 2. Don PPE: Gloves only for tablet oral. Gloves; Gown; Goggles for administering liquid preparations. 3. Check chemotherapy treatment with two nurses, away from the patient bed-side. Undertake to: Check following items on written orders: · Medical officer’s specific dosage · Dosages are correct according to chemotherapy protocol and

patient parameters

Check following items on prepared cytotoxic agent: · Drug details: Dose; Route; Expiry; Duration · Patient: Name; URMN; Allergies

4. Check patient identification details at bedside with second nurse. 5. Proceed to either: Oral Administration or Enteral Administration

Oral Administration or Enteral Administration a. Dispense medication into cup, using non-touch technique. b. Instruct patient to swallow medication whole:

· Directly from cup. · Without chewing.

c. Ensure medication is swallowed, and follow with water.

a. Place waterproof sheet under enteral tube connector. · NGT Only: Aspirate and test contents with pH strip.

b. Assess tube patency, and flush with minimum 30mL sterile water. c. Connect medication securely. Gently push medication. d. Disconnect medication. Flush with 30mL sterile water.

· Straight drainage: Leave tube spiggotted. · Feeds: Recommence as required.

6. Dispose of all cytotoxic waste in cytotoxic waste container. Remove PPE, and perform hand hygiene. 7. Document the relevant details into the patient health record: On Inpatient or Outpatient chemotherapy medication chart. 8. Provide patient education as relevant to situation. Consider instructions for safe storage at home and self-administration.



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Appendix 8: Intramuscular and Subcutaneous Chemotherapy Administration Key points prior to commencing this procedure Refer to the following general sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill

Refer to WACHS Medication Administration Policy Intramuscular and Subcutaneous Considerations Injectable cytotoxic drugs are a risk hazard for 3: · Aerosol · Spill · Needle stick contamination · Never expel air or excess cytotoxic agent from the syringe under any circumstances

(eviQ). Establish the location of the previous injection site and rotate to a different site. During assessment of potential injection site, avoid areas within 2cm of old, tender, red, hard or bruised sites25. Other sites and areas to consider avoiding: · Lymphoedema · Broken or irritated skin · Abdomen in patients with acites · Navel and belt line · Cutaneous tumour sites · Sites irradiated within previous

8 weeks · Scars · Bony prominences or joints Intramuscular injections are to be undertaken as a Z-track technique, to prevent leaking through the subcutaneous tissue3. A limited number of drugs can be given by injection due to: · Incomplete absorption · Irritant or vesicant drug properties · Bleeding at site · Discomfort of regular injections Equipment Required · Select Luer lock syringes only. · Equipment required Chemotherapy prescription and prepared cytotoxic agent Patient prescribed: anti-emetic Chemotherapy gloves Impermeable gown Protective eyewear Skin antiseptic solution swab Sterile gauze squares Needles: 21g or 25g Waterproof sheet e.g. bluey Cytotoxic waste containers Kidney dish Bandaid

https://healthpoint.hdwa.health.wa.gov.au/_layouts/Health.Intranet/ViewPolicyItem.aspx?ItemId=1&ItemUrl=https%3a%2f%2fhealthpoint.hdwa.health.wa.gov.au%2fpolicies%2fPolicies%2fWACHS%2fMedication+Administration+Policy.pdf&Source=https%3A%2F%2Fhealthpoint%252



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Procedure: Intramuscular and Subcutaneous Chemotherapy Administration Assess and Prepare Patient 1. Confirm that patient treatment suitability has been assessed and reviewed by the

medical team. · Refer to Patient Support Considerations.

2. Provide patient education suitable for situation: i.e. either initial or subsequent administration.

· Refer to Patient Education. 3. Explain procedure, and obtain appropriate consent. 4. Administer appropriate and prescribed anti-emetic medication. Undertake Chemotherapy Administration 1. Perform hand hygiene at all appropriate moments throughout procedure. 2. Don PPE: Gloves; Gown; Goggles for administering liquid preparations. 3. Check chemotherapy treatment with two nurses, away from the patient bed-side.

Undertake to: Check following items on written orders: · Medical officer’s specific dosage · Dose is correct according to chemotherapy

protocol and patient parameters


4. Check patient identification details at bedside with second nurse. 5. Assess planned area for injection site. Swab with skin antiseptic. 6. Administer cytotoxic agent as prescribed:

· Intramuscular: Use Z-track technique, inserting needle at 90 degree angle. · Subcutaneous: Pinch up a fold of subcutaneous tissue, inserting needle at 90

degree angle. 7. Apply pressure to area with gauze as needle is removed.

· Patients with platelet count; less than 50 x 109/L apply pressure for 10 minutes. 8. Dispose of all cytotoxic waste in cytotoxic waste container. 9. Remove PPE, and perform hand hygiene. 10. Document the relevant details into the patient health record:

· On Inpatient or Outpatient chemotherapy medication chart. 11. Provide patient education as required.



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Appendix 9: Intrathecal and Intraventricular Chemotherapy Administration Key points prior to commencing this procedure Refer to the following general sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill

Refer to the following WACHS Clinical Practice Standards in conjunction with this appendix: · Lumbar Puncture Clinical Practice Standard · Full Neurological Observations Clinical Practice Standard

Alert: Intrathecal chemotherapy incorrectly administered can have fatal consequences26,27. Refer to the DoH OD 0020/06 Policy for the Safe Administration of Intrathecal Chemotherapy for full instructions relevant to intrathecal and intraventricular chemotherapy administration. Refer to the DoH OD 0647/16 Updated: National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines for full instructions relevant to intrathecal labelling. Intrathecal and intraventricular access enables direct administration of chemotherapy agents to the patient’s the cerebral spinal fluid (CSF)3,8,27,28. · Intrathecal administration refers to the injection of a chemotherapy agent via lumbar

puncture3. · Intraventricular administration refers to the instillation of chemotherapy agent into a

surgically implanted device e.g. Ommaya®, that enables access to the intraventricular space in the patient’s brain3,8,28.

Staffing Requirements All staff (all grades) involved in the prescribing, dispensing, checking or administration of intrathecal chemotherapy must be intrathecal-qualified appropriate to their professional role26. Prescription and Preparation Requirements Intrathecal chemotherapy prescriptions must be signed or countersigned by a haematology/ medical oncology consultant or senior registrar. · The full drug name and route intrathecal must be written on the prescription. Intrathecal chemotherapy must not be planned for the same day as intravenous chemotherapy, unless dictated by chemotherapy protocol. · If required to administer intrathecal and intravenous therapy on same day, then only

one item will be issued from the pharmacy at a time. · The second item will only be issued after the pharmacist in charge has positively

confirmed that the first therapy has been administered. i.e. sighting signed administration order.









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Intrathecal chemotherapy injection syringes must be: · Labelled with a For Intrathecal Use Only warning. · Placed inside a sealed yellow outer bag, and labelled with patient name, drug name

and clear warning For Intrathecal Use Only. Issuing and Administration Requirements Intrathecal chemotherapy during transport from pharmacy to designated area shall be under the direct control of an intrathecal-qualified nurse or pharmacist. Intrathecal medications must be transported and stored separately from other cytotoxic agents7. Intrathecal chemotherapy not administered must be returned to pharmacy intact and disposed of. · A new dose should be prepared if another attempt to administer the drug is required. Intrathecal and intraventricular chemotherapy are to be administered: · In designated cytotoxic suites, or wards managing cancer patients, theatre or radiology

areas. · During normal working hours, and when a full complement of intrathecal-qualified staff

are present. Unless dictated by chemotherapy protocol. · Only after an intrathecal-qualified nurse or pharmacist verifies the correct: patient,

route, drug and dose with the intrathecal-qualified person who will administer the drug to the patient.

· By a haematology/ medical oncology registrar, consultant or other intrathecal-qualified senior medical personnel, including radiologists.

Potential Problems During or Post Procedure Neurotoxicity signs and symptoms · Headache · Drowsiness · Nausea and vomiting · Ataxia · Blurred vision · Fever +/- neck stiffness Equipment Required · Consider the requirements for Handling Cytotoxic Spill. Refer to WACHS Lumbar Puncture Clinical Practice Standard for equipment requirements · Medications Chemotherapy prescription and prepared sterile cytotoxic agent (room temperature) · Sterile and/or non-sterile PPE Chemotherapy gloves Impermeable gown Protective eyewear Mask · Intraventricular equipment Dressing pack Small drape pack 3-way stop cock 25g butterfly needle Luer lock syringes · Additional equipment Skin antiseptic solution Waterproof sheet e.g. bluey Dressing trolley Gauze dressing Cytotoxic waste container Suitable lighting Procedure: Intrathecal and Intraventricular Chemotherapy Administration Undertake the functions of this procedure appropriate to individual professional role, credentialed scope of practice and/or level of competency. Perform hand hygiene at all appropriate moments throughout procedure. Don required non-sterile and/or sterile PPE at all appropriate situations throughout procedure.



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Assess and Prepare Patient · Confirm that patient treatment suitability has been assessed and reviewed by the medical team. Refer to Patient Support Considerations. · Provide patient education suitable for situation: i.e. either initial or subsequent administration. Refer to Patient Education. · Check patient identification details. Explain procedure. Obtain appropriate consent. · For Intraventricular device: Asses scalp cleanliness and access. Wash or clip hair as required. Observe for signs of infection. · Perform and document neurological assessment. · Place patient in appropriate position. · Administer any prescribed and required premedications: e.g. analgesia, antiemetic or anti-anxiolytics Undertake Chemotherapy Administration

1. Assemble required equipment. 2. Ensure the intrathecal-qualified nurse or pharmacist verifies the correct: patient, route, drug and dose with the intrathecal-qualified person

who will administer the drug to the patient. 3. Open the outer yellow bag, and remove inner bag. Open the inner bag, and without contamination place the sterile syringe onto the sterile

field. Check the syringe label against the label on the outer yellow bag for correct drug volume. 4. Proceed to either: Intrathecal Administration or Intraventricular Administration. Intrathecal Administration or Intraventricular Administration (Ommaya®) a. Support patient to remain in correct position. b. Undertake lumbar puncture. c. Inject chemotherapy treatment. d. Apply occlusive dressing. Refer to Lumbar Puncture Clinical Practice Standard for further details.

a. Palpate the intraventricular reservoir area, lightly depress (pump) reservoir to allow refill. If reservoir does not appear to refill, do not proceed.

b. Clean area with skin antiseptic solution, allow to air dry. c. Insert butterfly needle, with 3 way stop cock attached. d. Attach syringe, prime tubing with CSF, reserve 2-3mL to use as flush. e. Attach chemotherapy syringe and slowly instil treatment. f. Instil remaining CSF. g. Rate of infusion or withdrawal from reservoir should not exceed 2mL/min.

eviQ h. Remove butterfly needle from reservoir, apply light pressure. i. Gently “pump” the reservoir 3-5 times to assist distribute medication. j. Apply occlusive dressing.



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5. Dispose of all cytotoxic waste in cytotoxic waste container. Remove PPE, and perform hand hygiene. 6. Plan post-administration care as clinically indicated. 7. Observe site for signs of CSF leakage or haemoserous ooze.

· 15 minutely for 30 minutes · As clinically indicated

8. If complaining of headache encourage patient to remain supine or semi-recumbent for 30 minutes. 9. Encourage oral fluid intake 10. Provide patient education as relevant to situation. Provide advice for recognition of neurotoxicity. 11. Document details of procedure in patient health record. Record administration on chemotherapy prescription.



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Appendix 10: Topical Cytotoxic Administration Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill Topical Cytotoxic Considerations Topical cytotoxic preparations3,4,7: · Are utilised for the treatment of superficial malignant lesions. · May include ointments, lotions or eye drops. · Carry the risk of exposure by: ingestion, and mucosal or dermal absorption. During or following application of topical cytotoxic preparations, avoid3,4,7: · Directly handling the medications · Contamination of clothing · Rigorously washing the area during treatment · Unintended application to eyes, nose, mouth and unaffected skin Provide patient education regarding: · The expectation of local erythema, blistering/ulceration, before sloughing and

regranulation over a period of usually 4 weeks. · Lightly wash the affected area during treatment. · Report burning pain, puritis or hyperpigmentation3,7. · Place medication in a plastic bag and request re-prescription if outside container

becomes contaminated. Equipment Required · Exact equipment requirements may vary; refer to specific instructions provided with

topical cytotoxic preparation. · Medications Chemotherapy prescription and prepared cytotoxic agent · PPE Chemotherapy gloves Impermeable gown Protective eyewear · Additional equipment Cytotoxic waste container Disposable non-metal spatula Low linting swabs Waterproof protective sheet, bluey

Any required dressings, eye pads, tape, etc



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Procedure: Topical Cytotoxic Administration Assess and Prepare Patient 1. Provide patient education suitable for situation: i.e. either initial or subsequent

administration. Refer to Patient Education. 2. Explain procedure. Obtain appropriate consent. Undertake Topical Cytotoxic Application 1. Perform hand hygiene at all appropriate moments throughout procedure. 2. Don PPE: Gloves; Gown; Goggles. 3. Check chemotherapy treatment with two nurses, away from the patient bed-side. Check following items on written orders: · Medical officer’s specific dosage

Check following items on prepared cytotoxic agent: · Drug details: Dose; Route; Expiry · Patient: Name; URMN; Allergies

4. Check patient identification details at bedside with second nurse. 5. Protect area with waterproof protective sheet 6. Apply topical cytotoxic preparation, using a non-touch technique:

Skin Application or Eye Application

· Apply the prescribed dose as a thin film using the spatula (or low-linting swab).

· Replace dressing as necessary.

· Apply eye drops as prescribed. · Replace eye pads as necessary.

7. Leave waterproof sheet to protect clothing. 8. Dispose of all cytotoxic waste in cytotoxic waste container. 9. Remove PPE, and perform hand hygiene. 10. Document the relevant details into the patient health record: · On Inpatient or Outpatient chemotherapy medication chart. 11. Provide patient education as required.



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Appendix 11: Intraperitoneal Chemotherapy Administration Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill

Label all peritoneal administration lines as per the requirements of the DoH OD 0647/16 Updated: National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines Intraperitoneal Infusion Considerations Administering cytotoxic agents into the peritoneal cavity or space provides localised treatment at the specific tumour site3,8. High concentrations of chemotherapy treatments may be utilised, with lower amounts entering the systemic circulation, and thus minimising systemic side effects3,8. Intraperitoneal chemotherapy may be administered by2,8: · Placement of a temporary indwelling catheter; often utilised in palliative care. · Surgical placement of an external catheter through the anterior abdominal wall. · Surgical placement of an implanted peritoneal port. Patient Monitoring Observe for the following signs associated with intraperitoneal chemotherapy administration: Pyrexia · May indicate a developing infection or reaction to administered chemotherapy. · Report any febrile episode to medical officer. Respiratory Distress · May be related to increased abdominal pressure. · Report to medical officer if respiratory distress occurs. Diarrhoea · May be related to increased abdominal pressure. · Report any unresolved diarrhoea to medical officer.





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Abdominal pain or discomfort · Is common and associated with abdominal distention developing soon after

administration. · To alleviate symptoms related to increased abdominal pressure: elevate the head of

bed or change position throughout procedure. Report to medical officer whenever abdominal pain is associated with: · Guarding · Nausea · Vomiting · Diarrhoea · Pyrexia · Elevated white cell count Presentation of these signs and symptoms may relate to peritonitis or abdominal injury requiring further investigation29. Potential Problems Associated with Procedure Leakage may occur where the peritoneum is not intact, or the catheter is not entirely within the peritoneal cavity3,29. All leakage from infusion is to be treated as cytotoxic spill. Abdominal Surgical Site Leakage · Cover leaking abdominal sites with a stoma bag. Vaginal Leakage · Nurse patients with previous vaginal leakage on waterproof protective sheets, and with

appropriate absorbent incontinence pads. Anal Leakage · Cease intraperitoneal infusion and report to medical officer. Rectal leakage may require

surgical gastrointestinal diversion. · Nurse patients with anal leakage on waterproof protective sheets, and with appropriate

absorbent incontinence pads.

Equipment Required · Consider the requirements for Handling Cytotoxic Spill. · Consider the requirements for individual peritoneal access device management. · Consider the requirements for patient hydration and urine output monitoring. · Medications Chemotherapy prescription and prepared cytotoxic agent Prescribed premedication · PPE Chemotherapy gloves Impermeable gown Protective eyewear · Peritoneal Infusion Equipment Appropriate peritoneal administration line; closed system attachments; bungs; caps 50mL bag diluent compatible with prepared cytotoxic agent · Additional Equipment Cytotoxic waste container Volumetric pump Waterproof sheets e.g. bluey Blood/fluid warmer and associated administration devices Access device antiseptic wipe Firm stable surface Transfer set with twist clamp Intravenous stand



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Procedure: Intraperitoneal Administration Assess and Prepare Patient 1. Confirm that patient treatment suitability has been assessed and reviewed by the

medical team. · Refer to Patient Support Considerations.

2. Provide patient education suitable for situation: i.e. either initial or subsequent administration. · Refer to Patient Education.

3. Explain procedure, and obtain appropriate consent. 4. Administer prescribed premedication. Undertake Chemotherapy Administration 1. Perform hand hygiene at all appropriate moments throughout procedure. 2. Don PPE: Gloves; Gown; Goggles 3. Assemble intraperitoneal administration line and attachments, prime with compatible

diluent. · Prepare fluid warmer, and associated administration line as required. · Ensure all connections are secure.

4. On flat stable surface with waterproof sheet, open heat sealed cover containing chemotherapy.

5. Check chemotherapy treatment with two nurses, away from the patient bed-side. Undertake to:

Check following items on written orders: · Medical officer’s specific dosage · Dose is correct according to

chemotherapy protocol and patient parameters

Check following items on prepared cytotoxic agent: · Drug details: Dose; Route; Expiry; Infusion

timeframes · Patient: Name; URMN; Body surface area;

Allergies 6. Check patient identification details at bedside with second nurse. 7. Using clean technique connect peritoneal access device to prepared cytotoxic agent.

· Remove priming diluent bag from peritoneal administration line, then insert peritoneal administration line into spiking port of prepared cytotoxic agent.

· Remove appropriate cap, scrub hub of peritoneal access device with device antiseptic wipe.

8. Commence infusion. Check infusion rate with second nurse. 9. Dispose of all cytotoxic waste in cytotoxic waste container. 10. Remove PPE, and perform hand hygiene. 11. Document the relevant details into the patient health record:

· Chemotherapy medication chart and fluid balance chart. 12. Provide patient education as required, and assist with positioning. 13. On completion of infusion either: close peritoneal administration line roller clamp; or

turn of volumetric pump. · Ensure peritoneal access device remains connected with peritoneal administration

line and empty cytotoxic agent bag.



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Drain Chemotherapy Infusion 1. Perform hand hygiene at all appropriate moments throughout procedure. 2. Don PPE: Gloves; Gown; Goggles 3. Observe and wait prescribed timeframe. 4. Place empty cytotoxic agent bag on waterproof sheet on floor. 5. Open peritoneal administration line roller clamp and allow cytotoxic agent to drain into

empty cytotoxic agent bag. · If drainage does not occur or there is a significant reduction on volume drained to

volume infused report to medical officer. 6. Once drainage is complete ensure all clamps are closed and use clean technique to

disconnect peritoneal administration line from peritoneal access device. · Bung end of peritoneal administration line and cap end of peritoneal access device. · Clean any peritoneal access device attachments with access device antiseptic wipe.

7. Dispose of all cytotoxic waste in cytotoxic waste container. 8. Remove PPE, and perform hand hygiene. 9. Document the relevant details into the patient health record:

· Fluid balance chart and patient integrated notes. 10. Provide patient education as required.



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Appendix 12: Intravesical Chemotherapy and Immunotherapy Administration Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill

Refer to the WA Cancer and Palliative Care Network in conjunction with this appendix: · Guidelines for the administration of intravesical cytotoxic and immunotherapeutic drugs

within the hospital setting, 2010. · Administration of Intravesical Therapies: Self Directed Learning Package, 2010 · Intravesical Mitomycin treatment – Patient information · Intravesical BCG treatment – Patient information Refer to following site specific guidelines in conjunction with this appendix in relation to: · Patient bookings and pre-admission assessment processes · Submission of prescriptions to pharmacy · Insertion and management of urinary catheter · Intravesical bladder cancer clinical pathway

http://www.healthnetworks.health.wa.gov.au/cancer/providers/hp_cancer.cfm#resources







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Appendix 13: Intrapleural Chemotherapy Administration Key points prior to commencing this procedure Refer to the following sections of this CPS: · Considerations · Patient Monitoring · Procedural Guideline · Equipment Required · Staffing Requirements · Patient Education · Transporting Cytotoxic Chemotherapy · Cytotoxic Waste Management · Handling Cytotoxic Spill Refer to following site specific guidelines in conjunction with this appendix in relation to: · Insertion and management of pleural drainage systems Intrapleural Infusion Considerations3 Malignant effusions are a complication of malignant disease, causing patient distress from increasing distress from dysponea and discomfort3. Malignant effusions are commonly associated with cancers of the: · Breast · Prostate · Ovary · Lung · Gastrointestinal tract

Normally there is approximately 5mL of fluid present between the visceral and parietal pleurae, creating lubrication and hydraulic seal3. Infection and malignancy interrupt this mechanism. Malignant effusions may be managed by aspiration alone provided it is not required less than weekly. Where required cytotoxic agents are given post aspiration of pleural effusion, and are designed to create an inflammatory response to obliterate the space causing pleurodesis3,30,31. This inflammatory response causes pain for 24-48 hours. Pleural effusions may be managed by: · Aspiration · Pleuralcath · Intercostal catheter Following administration of cytotoxic agent ensure patient rotates positions to distribute medication throughout pleural space3. Equipment Considerations · Consider the requirements for Handling Cytotoxic Spill. · Consider the requirements for type of pleural drainage system chosen. · Medications Chemotherapy prescription and prepared sterile cytotoxic agent Prescribed analgesia and anti-emetic as required · Sterile and/or non-sterile PPE Chemotherapy gloves Impermeable gown Protective eyewear Face shield mask



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Procedure: Intrapleural Chemotherapy Administration

Undertake the functions of this procedure appropriate to individual professional role, credentialed scope of practice and/or level of competency. Perform hand hygiene at all appropriate moments throughout procedure. Don required non-sterile and/or sterile PPE at all appropriate situations throughout procedure.

Assess and Prepare Patient · Confirm that patient treatment suitability has been assessed and reviewed by the

medical team. Refer to Patient Support Considerations. · Provide patient education suitable for situation: i.e. either initial or subsequent

administration. Refer to Patient Education. · Check patient identification details. Explain procedure. Obtain appropriate consent. · Administer any prescribed and required premedications: e.g. analgesia, and antiemetic. · Position the patient either: on their side with affected side up, or over the edge of the

bed in a hunched position. Keep the patient warm. Undertake Intrapleural Chemotherapy Administration · Assemble required equipment. · Open sealed bag containing prepared cytotoxic agent. Ensure to undertake: at waist

height, on waterproof sheet, on firm surface. · Ensure the correct: patient, route, drug and dose are verified between the assisting

nurse and the medical officer who will administer the drug to the patient. Check following items on written orders: · Medical officer’s specific dosage · Dose is correct according to chemotherapy

protocol and patient parameters


· Check patient identification details at bedside with both staff members. · Support patient to remain in correct position. · Insert pleural drainage system. Dress and secure site as per relevant site specific

guidelines. · Ensure all fluid is drained. · Instil cytotoxic agent and clamp tubing. · Maintain instillation for minimum of 4 hours. During instillation ensure to:

· Provide adequate analgesia. · Re-position patient if required. · Maintain clamp on tubing if left insitu. · Request patient to not pull or displace catheter.

· Unclamp tubing and remove at 12 hours following further drainage. · Apply occlusive dressing. · Dispose of all cytotoxic waste in cytotoxic waste container. · Provide patient education as relevant to situation. Provide advice for pain relief. · Document details of procedure in patient health record. Record administration on

chemotherapy prescription.