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Intrathecal Chemotherapy Ordering, Administering (6.1.3)

Intrathecal Chemotherapy Ordering, Administering (6.1.3) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.3


UW HEALTH CLINICAL POLICY 1
Policy Title: Intrathecal Chemotherapy Ordering, Administration and Documentation
Policy Number: 6.1.3
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: June 8, 2016


I. PURPOSE

To assure safe ordering administration and documentation of intrathecal chemotherapy agents.

II. DEFINITIONS

High-alert Medication: Medications as listed in this policy that pose a heightened risk of causing signif icant
patient harm or injury w hen they are administered in error. Although mistakes may or may not be more
common w ith these medications, the consequences of an error assoc iated w ith their use are more
devastating to patients. Refer to UWHC Policy #8.33, High Alert Medication Administration.

Independent Double-check : An independent second verif ication by another licensed professional of the
medication label, dose (including calculations), route, frequency, patient, equipment, lines and/or
programmed rate of infusion versus the original order or pharmacy-approved medication administration
record.

Chemotherapy Roadmap: A schedule listing all the days of the pediatric patient’s chemotherapy treatment
w hich may include lab w ork, diagnostic imaging, lumbar punctures and bone marrow aspirations, as w ell as
chemotherapy.

Time Out: Refers to the active process of verifying the correct patient, correct procedure, correct patient
position, correct site and availability of correct medication(s) and equipment by those in attendance during
the procedure, including the patient as appropriate.

III. POLICY ELEMENTS

A. Intrathecal chemotherapy may only be prescribed by the follow ing individuals:
i. Oncology/Hematology/BMT Attending Physicians
ii. Oncology/Hematology Fellow s
B. Intrathecal chemotherapy may only be administered by the follow ing individuals:
i. Oncology/Hematology/BMT Attending Physicians
ii. Oncology/Hematology/BMT Fellow s
iii. Oncology/Hematology Nurse Practitioners w ho are privileged and trained in this technique
C. THE ONLY CHEMOTHERA PY DRUGS THAT CAN BE GIVEN INTRATHECALLY ARE:
i. Methotrexate
ii. Cytarabine
iii. Cytarabine Liposomal
iv. In addition, the follow ing solutions may be ordered as f lushes (or w ith the above drugs):
a. Hydrocortisone (preservative free)
b. Sodium Chloride 0.9% (preservative free)
c. Lactated Ringers solution (preservative free)
D. All intrathecal orders must be ordered in compliance w ith Administrative Policy #8.59
“Chemotherapy Processes: Informed Consent, Ordering, Verif ication, Administration,
Documentation and Patient/Family Education".
E. Intrathecal chemotherapy may be ordered w ithin a patients Beacon treatment plan. Paper orders
must be on the “Intrathecal Chemotherapy Order Form, Pre-Printed Chemotherapy Order” or on
research paper orders.
F. All intrathecal chemotherapy and f lushes must remain w ithin the pharmacy area (AFCH Clinic
pharmacy, Oncology Clinic pharmacy or inpatient unit medication room) until the clinician is ready
to administer these high alert medications. No other injectable medications are to be taken from the
pharmacy at the same time as the intrathecal medication.
G. Removal of intrathecal chemotherapy and f lush syringes from the pharmacy area requires an
independent double-check of the prepared product by either one pharmacist and one



UW HEALTH CLINICAL POLICY 2
Policy Title: Intrathecal Chemotherapy Ordering, Administration and Documentation
Policy Number: 6.1.3

chemotherapy certif ied RN, one chemotherapy certif ied RN and one chemotherapy certif ied
provider, or tw o chemotherapy certif ied RNs.
i. If the order is w ritten on approved paper order forms, these tw o individuals must also
document as directed on the original order that an independent double-check has
occurred.
ii. If the intrathecal chemotherapy is ordered using an electronic chemotherapy treatment
plan, a product verif ication note w ill be placed w ithin the electronic chart documenting the
double check has occurred.
iii. If the intrathecal procedure is performed outside the clinic or inpatient area, AND the
intrathecal chemotherapy order is w ritten on paper orders, the patient chart w ith the
ORIGINAL ORDER must accompany the patient to the procedure area.
iv. If the intrathecal procedure is performed outside the clinic or inpatient area for a pediatric
patient, the roadmap must accompany the patient. The Road Map and date of birth also
require a double check by the tw o chemotherapy certif ied RN’s.
v. The RN removing the intrathecal chemotherapy from the pharmacy must take the
medications directly to the procedure area OR hand directly to the administering provider.
vi. If the administering provider picks up the intrathecal chemotherapy from the pharmacy,
then the pharmacist w ill document a product verif ication note and send to the provider to
co-signature.
H. The provider performing the procedure w ill follow the universal protocol procedure and complete
the appropriate documentation as identif ied in Hospital Administrative policy #8.48 "Operative,
Invasive & Other Procedures" and Nursing Patient Care Departmental policy #10.14 "Access to
Intrathecal Reservoirs & Administration of Medications Including Chemotherapeutic Agents."
i. A time out must occur prior to administration of all intrathecal medications. This time out
may be in addition to the procedure time out that has already occurred. The provider
performing the procedure w ill confirm the right patient, the right medication, the right dose,
the right route and the right time prior to administration of intrathecal chemotherapy.
ii. The w itnessing RN/provider w ill document the medication administration on the MAR.
iii. The administering provider w ill provide a dual sign off on the administration of intrathecal
chemotherapy medications on the patient electronic MAR in accordance w ith UWHC
Administrative policy 8.33: “High Alert Medication Administration”. Documentation should
occur on the MAR at the bedside prior to administration of intrathecal chemotherapy and
should be edited after the procedure if the procedure is not completed.
iv. The administering provider w ill administer the medications as described in Nursing Patient
Care Departmental policy 10.14 (Access to Intrathecal Reservoirs & Administration of
Medications Including Chemotherapeutic Agents)
v. A procedure note w ill be w ritten by the administering provider performing the procedure to
include the procedure performed, drug administered, dose and route.
I. All used chemotherapy syringes must be disposed of properly as chemotherapy w aste (see
Hospital Administrative policy #5.27, Waste Management). Unused doses, due to procedural
failure, should be returned to the pharmacy for credit and subsequent disposal.

IV. COORDINATION

Author: Director, Oncology Nursing
Senior Management Sponsor: SVP, Patient Care Services and CNO
Approval committees: Oncology Practice Committee; Medication Safety Committee; Chemotherapy Review
Council; UWCCC Operations Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: May 16, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL




UW HEALTH CLINICAL POLICY 3
Policy Title: Intrathecal Chemotherapy Ordering, Administration and Documentation
Policy Number: 6.1.3

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

Johnson PE, Chambers CR, Vaida AJ. Oncology medication safety: a 3D status report 2008. J Oncol Pharm
Pract. 2008 Dec;14(4): 169-80.

Hennipman B deVries E, Bokkerink JP, et al. Intrathecal Vincristine: 3 fatal cases and a review of the
literature. J Pediatr Hematol Oncol. 2009 Nov; 31(11)816-9.

Potter SL, Berg S, Ingle AM, Krailo M, Adamson PC, Blaney SM. Phase 2 clinical trial of intrathecal
topotecan in children w ith refractory leptomeningeal leukemia: A Children's Oncology Group trial (P9962).
Pediatric Blood Cancer. 2012 Mar;58(3):362-5.

Leal T, Chang JE, Mehta M, Robins HI. Leptomeningeal Metastasis: Challenges in Diagnosis and
Treatment. Current Cancer Therapy Review s, 2011, 7, 319-27.

UWHC policy #8.48, Operative, Invasive and Other Procedures
UW Health clinical policy #6.1.1, Chemotherapy Processes: Informed Consent, Ordering, Verif ication,
Administration, Documentation and Patient/Family Education.
Nursing Patient Care Departmental Policy #10.14, Access to intrathecal reservoirs and administration of
medications including chemotherapeutic agents.
UWHC policy #8.33, High alert medication administration

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: June 2019
Formerly Know n as: Hospital Administrative policy #8.58