What has long been a role solely of oncology nurses is now being performed by nurses around the hospital: chemotherapy drugs are increasingly being administered for non-oncology purposes and in non-oncology areas. This practice shift raises valid concerns about nursing training, safe handling practices, side effect and oncologic emergency management, and, ultimately, patient and nurse safety.

When and Where Chemotherapy May Be Administered

Drugs originally used for cancer histologies are now being given for non-oncology conditions. This includes diseases such as lupus, rheumatoid arthritis, vasculitis, Evan syndrome, and Wagner syndrome, says ONS member Chris Rimkus, RN, MSN, AOCN®, clinical nurse specialist in the Siteman Cancer Center at Washington University/Barnes-Jewish Hospital in St. Louis, MO.

Another example is when patients with cancer need to receive chemotherapy in non-oncology units. ONS member MiKaela Olsen, RN, MS, AOCNS®, oncology and hematology clinical nurse specialist for the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital in Baltimore, MD, explains that patients with cancer may be admitted to a non-oncology unit, either because the cancer center lacks enough beds or the patient needs special care (e.g., intensive care, neurologic care, cardiac care).

Olsen, who is a member of the Greater Baltimore ONS Chapter, says that in either of these instances, “safe administration of chemotherapy outside of the cancer center is the number-one goal. Knowledge of the non-oncology physician and RN team caring for the patient may be limited regarding safe handling and administration, side effects, and side-effect management. Personal protective equipment should be readily available on non-oncology floors, and staff should receive training in proper handling and disposal of any hazardous drug administered in this setting.

“Another situation that is occurring more frequently are patients with cancer who are on oral cancer therapy and need to continue that therapy while hospitalized for another issue,” Olsen continues. “For example, a patient with chronic myleogenous leukemia takes Gleevec and is admitted for a hip fracture. In these situations, the non-oncology RN receives training on the oral therapy administration, side-effect management, and special handling; after the teaching is complete, the unit will assume responsibility for administration of that oral drug.”

Chris Rimkus, RN, MSN, AOCN®; Note. Photo by Robert Boston, pho­tog­ra­pher at Wash­ing­ton University.

The Oncology Nurse’s Role

Rimkus, who is a member of the St. Louis ONS Chapter, feels that “oncology nurses should not be the ones to give chemotherapy/biotherapy for non-oncologic purposes. Oncology nurses are not knowledgeable about the non-oncology use of chemotherapy/biotherapy. The doses may be different [than those used for a cancer indication],” which often makes the side effects very different.

“An oncology nurse may tell patients with lupus receiving cyclophosphamide that they will lose their hair, which is actually unlikely,” Rimkus explains. “And for rheumatoid arthritis, rituximab can be given as high as 1,000 mg.”

She also cites concern about safe handling. “There are downstream effects when hazardous drugs such as chemotherapy/biotherapy are given in the operating room (OR). The OR technician staff or the nurses on the units the patients transfer to after chemotherapy are not informed that chemotherapy was given and thus do not use protective apparel.”

Olsen says that although the oncology clinical nurse specialists at her institution administer the chemotherapy on non-oncology units and do the patient and staff teaching, “resources can be an issue because two chemotherapy-trained RNs are needed to check the chemotherapy. This ties up two RNs for an extended time period. It could take two to four hours to administer the drugs and complete everything.”

Training Non-Oncology Nurses in Chemotherapy Administration

Both Olsen and Rimkus stress the need for specialized training for non-oncology nurses who will administer chemotherapy. Rimkus says that the biggest issues her practice faces are “getting and keeping the non-oncology staff proficient and the need for very specialized training that is different from oncology chemotherapy training. Finding another chemotherapy-trained RN to double check the chemotherapy is a logistical issue that we often have during off hours.”

To address these concerns, Rimkus developed a four-hour training class on chemotherapy administration for non-oncology nurses. “This course reviews what chemo/biotherapy is, why it is used for non-oncology diseases, the top drugs used outside oncology, safe medication administration, and safe handling.”

At last count, the program has trained 150 RNs. “The biggest challenge has been getting them their skills check-off training,” Rimkus says, “so I established a skills session with real-world scenarios outlining the issues that come up, such as who can order the drug, how to look for side effects, what teaching material to use that doesn’t say ‘this drug is for cancer.’ We amended our policies and procedures for chemotherapy and divided it into two tiers: tier I for non-oncology and tier II for oncology nurses. Tier I drugs include cyclophosphamide in doses less than 1 gm/m2, rituximab, methotrexate in doses less than 100 mg/m2, alemtuzumab, and ontak.”

The staff who attend Rimkus’s class are also provided with a binder that includes quick-reference materials about the non-oncology purposes of each drug, as well as general chemotherapy resources. “I also developed a website that offers articles and teaching sheets geared for the non-oncology use of chemotherapy/biotherapy; a listing of all the nurses who have been trained; and a checklist of what to do prior to giving chemotherapy/biotherapy,” Rimkus says.

Although Olsen’s workplace brings in the ONS Chemotherapy/Biotherapy course twice a year for its oncology nurses, it does not require nurses outside of oncology areas to attend the course. Instead, it offers “online self-learning modules and post-tests. The RNs in areas that give a set number of specific drugs for non-oncologic purposes receive training on those limited drugs.”

Developing Appropriate Patient Education

Included in training is the need for proper patient education. Rimkus has created patient education materials for the five tier 1 IV drugs that non-oncology nurses who are trained in chemotherapy/biotherapy administration can give to patients.

Although the RN administering chemotherapy is responsible for completing the teaching at Olsen’s institution, “we have a hospital-wide patient education committee and another committee for education of patients with cancer. We also have a chemotherapy teaching video that patients receive.”

In summary, Olsen says, regardless of who is administering chemotherapy, “it is important in any hospital to have a process in place for tracking the ordering and dispensing of all chemotherapy/biotherapy drugs so that safety measures can be put into place for all healthcare providers.”

“Addressing chemotherapy administration by non-oncology nurses has been a labor of love and much work, but it is going better,” Rimkus says. “There are still many challenges, but it is working.”

Earlier in 2012, ONS and the American Society of Clinical Oncology published a revision to their 2009 ASCO/ONS Standards for Safe Chemotherapy Administration. The standards are open for public comment until April 9, 2012.

Comments

Posted by Desiree Wyatt … (not verified) 5 years 1 month ago

Call it territorialism, but farming-out the chemotherapy patients from the oncology-educated RN is giving away our work. On a much smaller scale I have had that happen to me, and I will never be party to it again.

Posted by Aran Levine (n… (not verified) 5 years 1 month ago

Paula,
Thank you so much for writing this article! It is so timely because we are developing a process right now to ensure safety in these situations. You hit all the points we have talked about in meetings along with sharing other ideas that we had not thought about. Thank you and MiKaela and Chris!

Posted by Avigail (not verified) 2 months 3 weeks ago

Hi Paula,
Thank you for sharing this article. At our institution, we are developing policies to better equip our nurses and our pharmacists alike with regards to handling and compounding chemotherapeutic agents. Our main challenge is how to classify which chemo drugs should be compounded in the flow hood and which ones can be safely manipulated in the nursing units. What references would you recommend for us to read on about this? Thank you very much.

Posted by Katie Wiley (not verified) 1 month 3 weeks ago

Hello and thank you for your comments. I am one of the Oncology Clinical Specialists on staff with ONS, and saw your request for resources on what references to recommend for determining which drugs should be compounded in the flow hood. The best resource I can suggest would be the NIOSH List of Hazardous Agents, which can be found here: https://www.cdc.gov/niosh/topics/antineoplastic/pdf/hazardous-drugs-lis…

However, the pace at which new antineoplastics, including targeted and immunotherapy agents makes this quite complicated. Not a lot is known about the long term affects of these agents. NIOSH recommends a practice sites make a drug-specific determination of some of the newer released agents based on biohazard potential and mechanism of action.

Posted by Kathleen Wiley (not verified) 1 month 3 weeks ago

Thank you all for your comments. I am one of the Oncology Clinical Specialists with ONS. I noticed your request for references regarding which agents need to be compounded using a hood. The best reference to which I can direct you is the NIOSH list of hazardous agents. It is a list of all known hazardous drugs, which should be treated as such. However, with the rapid emergence of new targeted and immunotherapy agents, not a lot is known about the long-term effects of these agents. NIOSH is recommended that all practice sites develop a drug-specific determination of the need for hazardous drug precautions based on mechanism of action and biohazard characteristics.

You can access the NIOSH list here: https://www.cdc.gov/niosh/topics/antineoplastic/pdf/hazardous-drugs-lis…

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