Author(s)
/ Dympna McParlan, Infusional Services Co-ordinatorInfusional Services Team
Ownership:
/Jennifer Welsh , Surgery and Specialist Services
Approval by:
/Insert name of Trust committee / group responsible for approval
/Approval date:
Operational Date:
/Next Review:
Version No. / V 0.2 / SupercedesLinks to other policies
/ NICaN Central Venous Access Device Guidelines for Adults (excluding non-tunnelled catheters)NICaN Guidelines for the safe prescribing, handling and administration of SACT
BHSCT Policy to be followed when obtaining consent for examination, treatment or care in adults and children
BHSCT Aseptic Non Touch Technique
BHSCT Hand hygiene
BHSCT Intravenous flushing of lines
BHSCT Peripheral cannulae- insertion and management
NICaN Management of chemotherapy extravasation
BHSCT Medicines Code/ Community Medicines Code
BHSCT Recognition and management of anaphylactic reactions
Version control for drafts:
Date / Version / Author / Comments
15/10/15 / 0.1 / Dympna McParlan Infusional Services / Initial Draft circulated to NICaN SACT Nurses group
03/02/16 / 0.2 / Dympna McParlan Infusional Services / Amendments made following comments from the NICaN SACT Nurses group
1.0INTRODUCTION / PURPOSE OF POLICY
1.1Background
The handling and administration of Systemic Anti-Cancer Therapy (SACT) is a recognised potential occupational hazard. Cytotoxic drugs have been shown to be mutagenic, teratogenic and carcinogenic and can be absorbed through the skin, inhaled or ingested. These agents must only be administered by specifically trained, skilled and experienced health care professionals. Knowledge of personal protective measures and side effects associated with specific drugs will enable the practitioner to handle and administer SACT agents safely and provide the necessary patient support and education.
1.2Purpose
To ensure all Cancer Treatment Services staff involved in the administration of SACT are skilled, safe and competent practitioners.
1.3Objectives
This policy aims to:
- Set out recommended practice for all staff administering SACT within
Cancer Treatment Services
- Ensure all nursing staff involved in the administration of SACT are skilled, safe and competent practitioners
- Standardise practice in relation to SACT administration
- Recognise the hazards associated with SACT
- Reduce or prevent exposure to these substances to a minimum.
2.0SCOPE OF THE POLICY
Applicable to all staff within Cancer Treatment Services who administer
SACT. This policy does not apply to paediatrics.
3.0 ROLES/RESPONSIBILITIES
It is the responsibility of all staff who administer SACT to adhere to this policy and their local Standard Operating Procedure for the Administration of SACT.
4.0 KEY POLICY PRINCIPLES
Only the following staff are permitted to administer SACT within Cancer
Treatment Services;
- Registered Medical Practitioners provided they have received relevant education and training
- A Registered Nurse provided that he/she is on Part 1 of the NMC Register and has undertaken the minimum competency as outlined in Appendix 1.
This policy must be used in conjunction with the NICaN Guidelines for safe
prescribing, handling and administration of SACT.
All staff administering SACT via a central venous access device (CVAD) must
be deemed competent in care and maintenance of these devices in
accordance with the CVAD Guidelines.
All staff administering intravenous SACT must be aware of and adhere to the
NICaN Management of Chemotherapy Extravasation Policy.
5.0IMPLEMENTATION OF POLICY
5.1Dissemination
Cancer Treatment Services staff who administer SACT will be made aware of
this policy. The policy will be available on the Trustintranet within the
policy section.
.
6.0MONITORING
This policy will be monitored by Cancer Treatment Services Managers to
ensure staff adhere to the policy.
7.0EVIDENCE BASE / REFERENCES
NICaN (2016) Guidelines for the safe prescribing, handling and administration
ofSystemic Anti-Cancer Therapy .
Nursing Midwifery Council (2015) The Code. Professional standards of
practice and behaviour for nurses and midwives, London, NMC.
Royal College of Nursing Intravenous Therapy Forum (2010) RCN Standards for Infusion Therapy. Royal College of Nursing, London.
8.0CONSULTATION PROCESS
NICaN SACT nurses group
Cancer Treatment Services SACT Operational group.
9.0 APPENDICES / ATTACHMENTS
Appendix 1:IV SACT Administration Minimum Competency Process Flow
Chart
EQUALITY STATEMENT
In line with duties under the equality legislation (Section 75 of the Northern Ireland Act 1998), Targeting Social Need Initiative, Disability discrimination and the Human Rights Act 1998, an initial screening exercise to ascertain if this policy should be subject to a full impact assessment has been carried out.
The outcome of the Equality screening for this policy is:
Major impact
Minor impact
No impact. x
SIGNATORIES
(Policy – Guidance should be signed off by the author of the policy and the identified responsible director).
______Date: ______
Name
Title
______Date: ______
Name
Title
______Date: ______
Name
Title
______Date: ______
Name
Title
Appendix 1. IV SACT Administration Minimum Competency Process Flowchart
12 months
3-6 months
NICaN – Policy for the administration of SACT –V0.2 2016Page 1 of 5