What information and assessments are required prior to administering cancer therapy?

From Cancer Guidelines Wiki

Introduction

Ensuring that the appropriate information, medication and equipment is available and the relevant patient assessments and/or checks have been completed is an essential part of the safety process of administration of cancer therapy.[1]


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Evidence Summary

The appropriate assessment of the patient and a review of healthcare records minimises the risk of incorrect administration of cancer therapy. Ensuring that all cancer therapy medication to be administered (including pre-medication, equipment and consumables) is available prior to administration commencing reduces delay and potential distractions during the administration process.

Policies, procedures and equipment for safe administration and handling of cancer therapy must be available.[2][3] eviQ Cancer Education Online provides supporting information on the process for the safe administration of cancer therapy.[4]

Note: Further information on the medication order can be found in the prescribing section of these guidelines and the steps that should be taken when verifying an order are covered in detail in the nursing section on pre-administration verification.


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Recommendations

Consensus-based recommendationQuestion mark transparent.png

The following information should be made available prior to commencing the administration of cancer therapy (Polovich et al, 2014; Neuss et al, 2017; Belderson and Billett, 2017; Carrington et al, 2010):

  • Current diagnosis.
  • Medical history.
  • Medication and cancer treatment history.
  • The signed patient (or caregiver) consent, and where appropriate documented patient assent, according to local policy.
  • Allergies and history of any hypersensitivity reactions. If no allergies are known this must be documented on the medication chart and in the patient healthcare record.
  • A treatment plan.
  • An original and legible medication order.
  • Patient parameters (height, weight, BSA, age) and relevant laboratory values including full blood count, creatinine, urea and electrolytes and liver function tests. Depending on the treatment plan other tests may be necessary. Nursing staff should confirm the performance of required tests and results and contact the medical officer where results fall outside acceptable parameters.
  • Product information related to the cancer therapy and supportive therapy to be administered. The nursing staff administering the cancer therapy and related therapy must ensure they are familiar with the medications to be administered and any immediate expected side effects.
  • Policies, procedures and equipment required for the safe administration and handling of cytotoxic chemotherapy, non-cytotoxic cancer therapy and related waste. This includes policies and procedures for safe medication administration, management of extravasation and emergency procedure protocols (Carrington et al, 2010; Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013; Goldspiel et al, 2015; Neuss et al, 2017).

The following assessments must be completed prior to commencing the administration of cancer therapy (Neuss et al, 2017; Polovich et al, 2014; Carrington et al, 2010):

  • An assessment of the patient should be carried out according to Table 13 including a performance status assessment (Oken et al, 1982).
  • Questions regarding compliance, treatment tolerance, psychosocial concerns and adverse events must be addressed with the patient prior to administration.
  • The order should be verified and any discrepancies identified discussed with the prescribing medical doctor and/or pharmacist prior to administration of the medication(s). Documentation of any discrepancy and the resolution must be completed. Physical and staffing resources should enable the nurse to check an order away from distractions and interruptions to maximise safety.
  • Sufficient time is available to safely administer all components of the therapy according to the protocol including observation time and that staff will be able to support their responsibilities (nursing, pharmacy and medical) during and after administration.

The following medication and equipment must be available prior to commencing the administration of cancer therapy:

  • All cancer therapy and medication to be administered, including pre-medications and intravenous fluids.
  • Personal protective equipment (PPE), consumables, infusion pumps and other related equipment needed to safely administer and monitor cancer therapy (e.g. extravasation management kit).

An appropriately qualified and trained registered nurse or nurse practitioner must be available during and after administration of cancer therapy. A medical officer with suitable experience must also be available in close proximity to respond to emergencies related to the administration of the therapy. The proximity and response time of the medical officer should be defined by local policy but should not compromise patient safety.


Pre-treatment medications


Administration of pre-medications must allow an appropriate time span to elapse before chemotherapy, targeted therapy and biological therapy is administered.

  • For most antiemetics 30 minutes is the minimum time period required before chemotherapy is administered following administration of the pre-medication, however this time may vary according to route of administration and time of onset of action of the medication.
  • Pre-medications should not be given too early (usually > 60 minutes prior to the dose) unless specified, as this may lead to insufficient therapeutic levels of the medication when therapy is given. Where information is not contained in a protocol, advice should be sought from a pharmacist.

Pre-medication steroids such as dexamethasone may be self-administered by the patient at home prior to therapy. A check should always be performed with the patient to ascertain if the patient has self-administered prescribed pre-treatment medications.

(Polovich et al, 2014)[3] ;(Neuss et al, 2017)[2] ;(Belderson and Billett, 2017)[5] ;(Carrington et al, 2010)[1] ;(COSA & CPG, 2013)[6] ;(Goldspiel et al, 2015)[7] ;(Oken et al, 1982)[8]


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Tables

Table 13: Information to be assessed and checked by the nurse prior to administration

Patient’s medical and treatment history

A current diagnosis, treatment plan, documented protocol and medication history must be available and reviewed for current information.

Patient's height, weight, body surface area and where appropriate, age

Changes in weight (and height for paediatrics) should be assessed and the subsequent impact on BSA and dose assessed.[2][5]

Pathology and laboratory results

Pathology and laboratory results should be documented and confirmation given by the prescriber that they are appropriate for treatment to proceed.

Adherence to treatment

For oral chemotherapy an assessment for adherence should be performed.

Response to previous treatment and previous toxicities that may impact on treatment

Ensure that existing conditions or toxicities do not prevent treatment from proceeding (e.g. nausea and vomiting, mucositis, neuropathy, diarrhoea, hypertension).

Additional medications that the patient may have commenced since the last treatment should be discussed with the pharmacists and medical officer.

Psychosocial assessment

This should include the patient’s coping mechanisms, anxiety level and any cultural issues that may have an impact on the administration process. Where concerns are identified, referral to another healthcare professional should be considered according to local procedure. Ensure that identified issues do not preclude treatment from proceeding.

Patient and carers (where appropriate) comprehension of the treatment plan, including chemotherapy and associated medications

This should be confirmed at each appointment and further education provided if assessment identifies inadequate understanding.

Patient’s physical and performance status and vital signs

A physical assessment and subjective performance status assessment should be used: e.g. Eastern Cooperative Oncology Group (ECOG).[8]

Scans or investigations specific to the protocol

e.g. lung function tests, gated heart pool scan, echocardiogram.

Pre-medication required at home has been taken by the patient as instructed

e.g. steroids, antiemetics.

Access devices required for administration are in place and patent


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References

  1. 1.0 1.1 Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.
  2. 2.0 2.1 2.2 Neuss MN, Gilmore TR, Belderson KM, Billett AL, Conti-Kalchik T, Harvet BE, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology. Oncol Nurs Forum 2017 Jan 6;44(1):31-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28067033.
  3. 3.0 3.1 Polovich M, Olsen M and LeFevre KB. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Fourth Edition). Pittsburg: Oncology Nursing Society; 2014.
  4. Cancer Institute NSW. eviQ Cancer Education Online. [homepage on the internet]; 2017 Nov 24 Available from: https://education.eviq.org.au/.
  5. 5.0 5.1 Belderson KM, Billett AL. Chemotherapy safety standards: A pediatric perspective. Pediatr Blood Cancer 2017 Jun;64(6) Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28306217.
  6. Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia. Position Statement: Safe handling of monoclonal antibodies in healthcare settings.; 2013 [cited 2016 Sep] Available from: https://www.cosa.org.au/media/173517/cosa-cpg-handling-mabs-position-statement_-november-2013_final.pdf.
  7. Goldspiel BR, DeChristoforo R, Hoffman JM. Preventing chemotherapy errors: updating guidelines to meet new challenges. Am J Health Syst Pharm 2015 Apr 15;72(8):668-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825190.
  8. 8.0 8.1 Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982 Dec;5(6):649-55 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7165009.

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