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1 SH CP 192 SOP Disconnection of continuous infusional chemotherapy from CVADs in the Community Version 2 March 2018

SH CP 192

Standard Operating Procedure Disconnection of continuous infusional chemotherapy from

Central Venous Access Devices (CVADs) in the Community

Version: 2

Summary:

This Standard Operating Procedure states Southern Health Foundation Trust’s position and expectation for all clinical teams with regards to the procedure for disconnection of continuous infusional chemotherapy for patients with CVADs

Keywords (minimum of 5): (To assist policy search engine)

chemotherapy, intravenous, cytotoxic drugs, disconnection, chemo, cyto

Target Audience:

All clinical teams who support patients

Next Review Date: March 2021

Approved and ratified by:

Patient Safety Group Date of meeting: 15th February 2018

Date issued:

March 2018

Author:

Steve Coopey Head of Clinical Development Juliet Wells Principal Pharmacist (North) Steve Mennear Medication Safety Officer Dr Abigail Barkham Integrated Services Matron

Sponsor:

Medical Director


Version Control

Change Record

Date Author Version Page Reason for Change

April 16 J Wells 1 4 Summary flow chart added

Aug 16 J Wells 1 To cover all kits as may vary with time

16/01/18 Reviewed no change

Reviewers/contributors

Name Position Version Reviewed & Date

Dr Abigail Barkham Integrated Service Matron April 2015

Steve Coopey Head of Clinical Development June 2015, Aug 2016

Sue Hobbs Community Matron (Yew) April 2015

Juliet Wells Principal Pharmacist (North) June 2015, Aug 2016

Steve Mennear Medication Safety Officer June 2015, Aug 2016

Marie Corner Medical Device Adviser June 2015

Jacky Hunt Infection Control Nurse June 2015

Paula Deery Lead Chemotherapy Nurse (RSCH) June 2015

Jenny Nops Area Matron Winchester District and Enhanced Recovery +Support@Home

January 2018


Contents Section Title Page

Quick reference guide 4 1 Purpose of this Standard Operating Procedure (SOP) 5 2 Glossary of Terms 5 3 Background 6 4 Expectations 6 5 Who can disconnect Infusors? 6 6 Training requirements 6 7 Supporting References

6

SOP Guidance and Rationale

8

A1 Risk Assessment

10

A2 Clinical Competencies for Chemotherapy Disconnection 12 Levels of competency Rating Scale for the disconnection of

chemotherapy (PICC or CVC) 14

A3 Healthcare Waste Collection Referral Form Councils’ Contacts Table

15 17


Patient’s

Home

Wash hands

Document

Standard Operating Procedure Disconnection of continuous infusional chemotherapy from Central Venous Access Devices (CVADs) in the

Community

Secondary

Care

ICS Registered Nurse competent in Chemotherapy CVAD disconnection

IV therapy trained + assessed in practice, using the ‘Clinical Competencies for the disconnection of continuous infusional chemotherapy’ assessed by another competent nurse or if already competent by self-assessment

Not IV trained; attend SHFT IV Therapy training day & assessment in practice

Equipment PPE & Nitrile Gloves

Purple lidded (cytotoxic) waste bin with absorbent layer

Chemo spill kit

0.9% sodium chloride flush & administration equipment + a prescription or PGD 109

Risk Assessment (Appendix 1)

Disconnection Check that all the drug is delivered

Check that there is no leakage

Clamp

Remove Infusor & attach red bung

Flush (PGD 109)

Purple Cytotoxic Waste bin Put Infusor in purple bin

Inform patient

Arrange collection by secondary care or local council collection (Appendix 3)

Dispose of PPE Double bag

label

Preparation Discuss process with patient

Obtain patient’s consent

Wash Hands (SH CP 12)

Put on PPE & gloves

Aseptic Preparation

Complete full risk assessment for disconnection of

chemotherapy (appendix 1)


Disconnection of continuous infusional chemotherapy from Central Venous Access Devices (CVADs) in the Community

1. Purpose of the Standard Operating Procedure (SOP)

This SOP sets out a Trust wide statement and vision on how Southern Health NHS Foundation Trust (SHFT) plans to support the process for disconnection of continuous infusional chemotherapy for patients referred to SHFT community care. This document provides guidance to managers and teams on how SHFT expects staff to carry out this procedure safely. Clinical evidence demonstrates that a robust assessment is imperative in order to plan and execute an excellent standard and quality of care. Sufficient evidence exists indicating that staff that come into contact with cytotoxic drugs are at potential risk of harm. Therefore a robust SOP will assist the mitigation of risk and harm to both patients and SHFT staff.

2. Glossary of Terms

Central Venous Catheter (CVC) An intravenous device that allows access to a vein for the purposes of administering medications, where the distal tip of the device/catheter sits in the lower third of the superior vena cava. PICC A Peripherally Inserted Central Catheter (PICC) is a form of intravenous (IV) access device that can be used for a designated prolonged period of time e.g. 46 hours, 4 days, or 7 days. Skin tunnelled catheter (STC) This central venous catheter is inserted in secondary care and is used for long term access for IV therapy. These can have an external clamp (Hickman catheter) or internal valve (Groshong PICCs). Each type has its own management guidelines for flushing solutions and frequency for flushing. Implanted Ports An implanted vascular access device placed under the skin, made of two components: a reservoir with a self-sealing septum which is attached to a silicone catheter. It is a central venous catheter licensed for long term use and becoming more commonly used in cancer chemotherapy settings Chemotherapy Infusor A closed system elastomeric device that administers cytotoxic medication over a set time to the patient via a PICC or other type of CVC. Referred to as infusors. PPE Kit. Personal Protective Equipment which is intended to be worn or held by healthcare workers to promote personal and patient safety (nitrile gloves, aprons and eye protection). Nurse Throughout this document the term nurse refers to practitioners who are currently registered with the Nursing and Midwifery Council (NMC).


3. Background Chemotherapy treatments and administration has significantly changed within the community resulting in increased need for staff working in this environment to understand the implications of these changes for their practice. Chemotherapy infusors are lightweight, portable, disposable elastomeric infusion devices that allow administration of chemotherapy as a continuous infusion over several days thus enabling patients to be treated at home rather than in hospital. The chemotherapy is contained in a balloon reservoir inside a casing. As batteries are not used in the device, it does not make any noise. Patients will have their infusors initiated in secondary care by oncology specialist services. Disconnection of these devices pumps often falls upon the services of SHFT staff and requires the procedure to be undertaken in patient’s homes or community clinics.

4. Expectations

SHFT expects all nurses to complete a comprehensive holistic assessment within 24 hours of patient admission to the Integrated Community Team. This will:

Help patients to realise their concerns are worthy of consideration and not unusual.

Open the door to discussion and bring attention to sources of help that may not be required immediately but maybe needed at some point later.

Allow patients and carers to discuss their concerns or issues at an early stage

Enable realistic goals to be set.

Enable safe and effective discharge planning through effective well-being planning

Ensure that a robust risk assessment is in place for patient and staff safety.

Ensure that correct equipment is in place for the management of this procedure.

Ensure that cytotoxic waste is disposed of safely.

It is expected that all Nurses must be competent to complete the disconnection of chemotherapy from a CVAD.

5. Who can disconnect Infusors?

Only Nurses in Integrated Community Services that have been trained in IV therapy and have successfully completed assessment of competence in practice.

6. Training requirements

All Nurses must complete the single IV therapy training day and be assessed in practice as competent to undertake the disconnection of continuous infusional chemotherapy from a CVAD. If already competent in IV therapy, the Nurse must complete the self-assessment of ‘Competency to disconnect a continuous infusional chemotherapy infusor or be assessed by another competent Nurse. The training records are to be kept on the staff member’s LEAD training record.

7. Supporting references

CQC (2009) Essential Standards of Quality and Safety, London, CQC HPC (2008)Standards of Conduct, Performance and Ethics


NMC (2015) The Code: Professional standards of practice ad behaviour for nurses and midwives London NMC

NMC (2008) Standards for Medicines Management

NPSA (2007) Promoting Safer Use of Injectable Medicines

SHFT SH CP137 Intravenous Therapy and Cannulation Policy

SHFT SH CP1 Medicines Control, Administration and Prescribing Policy

SHFT SH NCP Handling and Disposal of Healthcare Waste Policy

SHFT SH CP14 Sharps and inoculation Management

SHFT SH CP 12 Hand Hygiene Procedure

SHFT PGD 109 Sodium Chloride 0.9% Injection

http://www.hse.gov.uk/healthservices/safe-use-cytotoxic-drugs.htm

http://www.christie.nhs.uk/booklets/13.pdf

Herman GD, Kenyon RJ (1987) Competency-Based Vocational Education. A Case Study, Shaftsbury, FEU, Blackmore Press, cited in Fearon, M. (1998) Assessment and measurement of competence in practice, Nursing Standard 12(22), pp43-47.

http://www.hse.gov.uk/healthservices/safe-use-cytotoxic-drugs.htm

http://www.christie.nhs.uk/booklets/13.pdf


STANDARD OPERATING PROCEDURE

Title Disconnection of Continuous Infusional

Chemotherapy from a Central Venous Access device in the Community

There is sufficient evidence that staff who come into contact with cytotoxic medication are potentially at

risk of harm. Expert review suggests that efforts should focus on ensuring correct procedure in

handling such medication. Risks fall into the following categories;

1. Local effect caused by direct contact with skin, eyes, mucous membrane e.g. dermatitis.

2. The systematic effects of inhaling or ingesting cytotoxic drug during contact.

3. Effects on the unborn child if pregnant

The safe procedures regarding intravenous access to the patients should also be adhered to.

Action Rationale

1. Read care plan / support plan and check prescription details ensuring the right patient / patient is identified. Check the name, NHS number or date of birth, prescriber’s signature, approved medicine name, dose and frequency of administration, rate, diluent, date and route of administration.

1. Plan will explicitly identify care required. Chemotherapy disconnection should only be undertaken with the written directions of the secondary care provider through referral process.

2. Ensure that a full risk assessment of environment & patient/family, and staff safety is completed, before carrying out the procedure (Appendix 1)

2. This will ensure that the home environment is clean and calm for the task being undertaken. If not a more suitable community environment may be required to be sourced such as a clinic or community hospital.

3. Ensure that the following equipment is available;

PPE

Nitrile Gloves

Purple lidded sharps bin (cytotoxic sharps) with absorbent layer

Chemotherapy Spillage Kit

0.9% sodium chloride (saline) Flush and equipment to administer

Prescription/PGD109 to administer 0.9% sodium chloride injection.

3. To ensure that time is not wasted and procedure goes smoothly. To prevent infection.

4. Explain procedure to the patient and ask for and record verbal consent

4. To inform the patient and obtain evidence of informed consent.

5. Wash own hands with soap and water or clean with alcohol sanitising foam if hands socially clean as per Hand Hygiene Procedure SHCP12 Thendon PPE equipment: Plastic Apron, Nitrile Gloves, Eye Protection

5. To prevent cross infection and contamination from chemotherapy by following the Trust Infection Prevention and Control Policy and Hand Hygiene Procedure (SH CP 12)

6. Prepare the equipment for aseptic procedure 6. To minimise risk of infection


7. Before starting the disconnection procedure, ensure the complete delivery of the drug has occurred and there are no signs of leakage. If this is not the case contact initiating hospital centre for advice

7. To minimise risk of exposure to staff and patient. To ensure the patient has received their treatment.

8. Clamp off the infusor prior to disconnection 8. To prevent the spillage of cytotoxic medication on removal.

9. Remove the infusor from the CVAD. Attach the red bung to end of infusor line clamp and dispose of it in the designated purple lidded sharps bin provided from secondary care for collection by local council

9. Ensuring safe storage and disposal in that area

10. Flush the CVAD with 0.9% sodium chloride injection

10. Ensuring correct care of the Intravenous Access Device according to Therapy and Peripheral Cannulation Policy SHCP 137.

11. Ensure all PPE equipment is disposed of by placing in in a clinical waste bag. Only double bag if it has been contaminated by cytotoxic drugs and label clearly ‘Cytotoxic Waste’. Contact local council for collection (see Appendix 3. Clean hands.

11. Ensuring the safe disposal of waste potentially contaminated by cytotoxic drugs

12. Inform the patient to (a) return the waste bin back to secondary care, or (b) store safely until local Council collection. The bin will need to be sealed and labelled whilst awaiting disposal.

12. This will enable the waste to be disposed of and stored safely and that it is returned to the administering location or collected by the local Council

13. Record the details of the administration in the appropriate documentation

13. To prevent duplication of treatment and adherence to policy guidelines


APPENDIX 1 – Risk Assessment for Disconnection of Chemotherapy from a CVAD

A risk assessment must be fully completed by the Registered Nurse before the procedure of chemotherapy disconnection and line flushing is undertaken.

If the answer is ‘no’ to any of these questions an alternative strategy is required.

Patient Name _________________________

NHS Number___________________ D.O.B:_______________

1 Patient Yes / No

1.1 An assessment and individualised care record has been completed by a registered practitioner.

1.2 The patient has no family or informal carers able to complete this

procedure, who have had the appropriate training

1.3 The patient’s physical condition requires the procedure to take place in the community

2 Registered Practitioner

2.1 The Registered Nurse (s) has completed training to undertake this role and has been assessed as competent.

2.2 Following training, the Registered Nurse accepts responsibility to perform the procedure of disconnecting continuous infusional chemotherapy from a CVAD management of a chemotherapy

disconnection to the standard required by SHFT

2.3 Pregnant staff or those planning their pregnancy should be advised of the potential risk associated with handling

chemotherapeutic/cytotoxic agents and given the opportunity to refrain from completing this task

3 Task Yes / No

3.1 Environmental risks have been identified, assessed, minimised and documented

3.2 The patient has been referred with required equipment and there is access to Personal Protective Equipment

3.3 There is an appropriate chemotherapy spill kit available


3.4 There are suitable storage facilities in the patient’s home for

securing waste including a purple-lidded sharps bin containing and

absorbant to contain any cytotoxic liquid, which might leak from the

device.

3.5 There are suitable disposal & collection facilities for medication

waste

(return to secondary care or Council collection)

All aspects of the risk assessment have been completed and control measures achieved

To be completed by Registered Nurse:

Name

Designation

Signature

Date


APPENDIX 2 - Clinical competencies for the Disconnection of Continuous Infusional

Chemotherapy from a CVAD

Name: Role:

Base: Date initial intravenous therapy training completed:

Date aseptic e-assessment completed:

Competency Statement:

The participant demonstrates clinical knowledge and skill in chemotherapy disconnection. Assessment in

practice must be by a Registered Nurse who can demonstrate competence at level 4 or above.

Performance criteria Assessment method

Level achieved

Date Assessor

1. Demonstrates safe knowledge in disconnecting IV chemotherapy. a) Identify the correct venous access device appropriate for cytotoxic therapy.

Questioning / Observation

b) List three complications of cytotoxic therapy


c) Describe and demonstrate the precautions taken when handling cytotoxic medicines


d) Demonstrate knowledge / practice on how to manage a cytotoxic spillage


e) Describe and demonstrate precautions which should be taken by a pregnant or breast feeding woman in relation to cytotoxic therapy


f) Demonstrate correct documentation following procedure/removal.

Questioning/ Observation

2. Demonstrates safe practice in disconnecting chemotherapy a) Demonstrate safe knowledge and practice of the equipment and preparation required for disconnection of chemotherapy including; patient preparation and comfort, and selection of correct equipment.


b) Demonstrates knowledge and practice of safe removal of a chemotherapy infusor

Assessment of patient and

medical condition.

Awareness of risks associated



with removal.

Appropriate use of PPE.

Correct disposal of equipment.

Ensuring patient comfort and

safety.

c) Demonstrate correct use of aseptic technique during the procedure, identifying key parts and key sites

Observation

d) Demonstrate appropriate equipment preparation.

Observation

e) Demonstrate correct removal technique

Observation

f) Demonstrate correct disposal of waste and sharps.

Observation

g) Demonstrate correct documentation following removal.

Observation

Date all elements of Competency Tool completed _________________

Name _____________________ Signature ____________________________________

Status______________________________ Date _________________

For Assessor

I confirm that I have assessed the above named Registered Nurse and that he/she has

demonstrated an overall competence in chemotherapy disconnection at level _________

Assessor ___________________________ Signature ____________________________

Status_________________ Date ___________

Review

Dates:

Competent

Yes / No

Registered

Nurse Signature

Assessor

signature

Comments


Levels of competency Rating Scale for the disconnection of chemotherapy (PICC or CVC)

Level of achievement Level

Novice Cannot perform this activity satisfactorily to the level required in order

to participate in the clinical environment

0

Can perform this activity but not without constant supervision and

assistance

1

Can perform this activity with a basic understanding of theory and

practice principles, but requires some supervision and assistance

2

Competent

Practitioner

Can perform this activity with understanding of theory and practice

principles without assistance and/or direct supervision

3


principles without assistance and/or direct supervision, at an

appropriate pace and adhering to evidence based practice

At this level competence will have been maintained for at least 6

months and/or is used frequently (2-3 times /week) The practitioner

will demonstrate confidence and proficiency and show fluency and

dexterity in practice

This is the minimum level required to be able to assess practitioners

as competent

4



appropriate pace and adhering to evidence based practice.

At this level the practitioner will be able to adapt knowledge and skill

to special/ novel situations where there may be increased levels of

complexity and/or risk

5

Expert Can perform this activity with understanding of theory and practice


appropriate pace and adhering to evidence based practice.

Demonstrate initiative and adaptability to special problem situations,

and can lead others in performing this activity

At this level the practitioner is able to co-ordinate, lead and assess

others who are assessing competence. Ideally they will have a

teaching and /or mentor qualification

6

Adapted from: Herman GD, Kenyon RJ (1987) Competency-Based Vocational Education. A Case Study, Shaftsbury,

FEU, Blackmore Press, cited in Fearon, M. (1998) Assessment and measurement of competence in practice, Nursing

Standard 12(22), pp43-47.

HEALTHCARE WASTE COLLECTION REFERRAL FORM


APPENDIX 3 - Waste Management

Sections to be completed by a Healthcare Professional – Strictly Confidential

PATIENT’S DETAILS

Patient’s Name

Patient’s Address

(Including Postcode)

Patient’s Telephone Number

HEALTHCARE ASSESSMENT OF INTENDED WASTE RESULTING FROM TREATMENT Tick

category

YELLOW SHARPS BOX Infectious sharps contaminated with medicines

YELLOW SHARPS BOX

PURPLE LID

Infectious sharps contaminated with cytotoxic / cytostatic products

ORANGE SACK Infectious waste that can be treated

OFFENSIVE Waste that is not infectious and does not require specialist treatment or disposal

HEALTHCARE PROFESSIONAL DETAILS

(To include Healthcare Professional; Name, contact number, address, fax or email - stamp may be used)

Declaration to be completed by PATIENT if PATIENT is submitting referral form to Local Authority

Only waste as described above should be presented by the Patient under this referral

Print Name Signature Date

Once complete Healthcare Professional or Patient to send form to

Local Authority collection service (details on reverse of form)



Additional information for Hampshire Local Authority use only

Local Authority Reference Number

Property type and Pick up location

Likely frequency and duration of requirement (e.g. weekly, on request)

Sharps Box collection service (tick requirement) Sack collection service (tick requirement)

Deliver sharps box Deliver sacks

Collect and replace box Collect and replace sacks

Collect only no replacement Collect only no replacement



Fax Number Email address

Southampton City

CouncilBusiness Support

Regulatory Services, Civic Centre, Southampton. SO14 7LY

02380-833005 02380-833079 [email protected]

Eastleigh Borough

CouncilDirect Services

Hedge End Depot, Botley Road, Hedge End , Southampton,

SO30 2RA 02380-688440 02380-688382 [email protected]

New Forest District

CouncilWaste Management

Marsh Lane Depot, Marsh Lane, Lymington, Hampshire,

SO41 9BX 02380-285000 02380-285052 [email protected]

[email protected]

[email protected]

Winchester City

[email protected]

East Hampshire

District [email protected]

Portsmouth City

CouncilWaste Collection team

Street Environment, Portsmouth City Council, Civic Offices,

Guildhall Square, Portsmouth, PO1 2NE 02392-834092 02392-841561 [email protected]

Havant Borough

CouncilCustomer Services

Havant Borough Council, Southmoor Offices and Depot, 2

Penner Road, Havant, Hampshire, PO9 1QH 02392-446010 02392-498031 [email protected]

Gosport Borough

CouncilAdministration team

Streetscene, Community Customer service unit, Gosport

Borough Council, Town Hall, High Street, Gosport, PO12

1EB

0800-0198598 n/a [email protected]

Fareham Borough

CouncilAdministration team

Civic Offices, Civic Way, Fareham, PO16 1AZ

01329-236100 01329-550468 [email protected]

Basingstoke &

Deane Borough

Council

Hart District Council

Rushmoor Borough

CouncilContracts Team

RBC Healthcare Waste, Council Offices, Farnborough

Road, Farnborough, Hampshire, GU14 7JU 01252-398399 01252-398694 [email protected]

[email protected] waste client team

Telephone

Number

Healthcare Professional use only

Joint waste client team

East Hampshire District Council, Penns Place, Petersfield,

GU31 4EX

01730-234307

01264-368393 01264-353603

Local Authority Department Contact Postal Address

Hart District Council, Civic Offices, Harlington Way, Fleet ,

Hampshire, GU51 4AE

01256-622122 01252-774408

01730-234291

Please phone

before use

Test Valley Borough

CouncilClinical Waste Services

Unit 37 Macadam Way, West Portway, Andover,

Hampshire, SP10 3XW

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