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Chemotherapy Vesicant Extravasation – Adult/Pediatric – Inpatient/Ambulatory [23]

Chemotherapy Vesicant Extravasation – Adult/Pediatric – Inpatient/Ambulatory [23] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 23

Delegation Protocol Title:
Chemotherapy Vesicant Extravasation – Adult/Pediatric – Inpatient/Ambulatory
Delegation Protocol Applies To:
UWHealth Oncology Clinics
University Hospital Inpatients

Target Patient Population:
Pediatric and adult patients experiencing extravasation of chemotherapy agents

Delegation Protocol Champion:
Dan Mulkerin, MD; Department of Medicine - Oncology
Ken DeSantes, MD, Department of Pediatrics - Oncology

Delegation Protocol Reviewers:
Mary Mably,RPh, BCOP – Pharmacy Oncology Coordinator
Wendy Curran, RN, MSN, CNS – Hematology, Oncology & Bone Marrow Transplant
Sharon Frierdich, RN, MS, CPNP, CPON – Pediatric Specialties

Responsible Department:
Pharmacy Department
Department of Nursing

Purpose Statement:
To delegate the authority from the chemotherapy-ordering provider to Registered Nurses and pharmacists to
place orders for the management of extravasation in a consistent and safe manner based on guidelines
approved by the UWHC Pharmacy & Therapeutics Committee

Who May Carry Out This Delegation Protocol:
Chemotherapy-certified registered Nurses (RNs) and pharmacists (RPhs) in the inpatient and outpatient setting

Guidelines for Implementation:
1. An RN assesses the vascular access site and determines that a vesicant chemotherapy extravasation has
occurred, and notifies the provider.
2. A chemotherapy-certified nurse or pharmacist will enter orders for the appropriate medications following
“UWHC Guidelines for the Management of Extravasation of Antineoplastic Agents”. The orders are entered
using the order set IP – Oncology Chemotherapy Vesicant Extravasation” and signed with an ordering mode
of “Protocol/Policy Without Cosignature”.

References:
1. University of Wisconsin Hospital and Clinics. Guidelines for the Management of Extravasation of
Antineoplastic Agents.
2009. https://uconnect.wisc.edu/servlet/Satellite?cid=1126666299748&pagename=B_EXTRANET_UWH_HO
ME%2FFlexMemberFile%2FLoad_File&c=FlexMemberFile. Accessed October 22, 2012



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Collateral Documents/Tools:
1. UWHC Guidelines for the Management of Extravasation of Antineoplastic Agents
2. Order Set: IP – Oncology Chemotherapy Vesicant Extravasation

Approved By:
UW Health Ambulatory Protocol Committee – November 2012
UWHC Nursing Practice Council – November 2012
UWHC Pharmacy and Therapeutics Committee - August 2013
UWHC Medical Board - September 2013
UW Health Chief Medical Officer:
Effective Date: September 2013

Scheduled for Review: September 2015

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org