Chemotherapy Infusions

155Administration of chemotherapy in the home setting varies across different regions of the country. Because of the need for close monitoring and risk of drug reactions, complex multidrug regimens are infrequently administered in the home setting. However, for patients who require longer infusions of chemotherapy drugs, home care offers a cost-effective option and a variety of advantages often expressed by health care providers and patients including decreased risk of infection in the home, ability to continue many normal activities of daily living, and participation in own care. Although not widely practiced, home administration of chemotherapy for pediatric patients may also offer advantages such as improved appetite, well-being, and ability to keep up with school work and less disruption in the family routine.

Safety is paramount when administering home chemotherapy. Because the consequences of a chemotherapy error could result in significant patient harm, chemotherapy agents are on the list of “high-alert” medications for both acute and community-based care (Institute for Safe Medication Practices [ISMP], 2011, 2014). The Oncology Nursing Society (ONS, 2015), in a position paper, asserts that only qualified clinicians administer cancer chemotherapy and biotherapy based on completion of a specialized education and competency program, and furthermore recommends an annual assessment of competency. This paper and position are supported also by the Infusion Nurses Society (INS; Gorski et al., 2016, p. S127). Safe preparation and handling of chemotherapy agents in the home is essential. The nurse must understand dose-limiting toxicities of chemotherapy drugs, expected side effects, and strategies for management. The reality is that most chemotherapy drugs are administered in outpatient settings and the home care nurse may administer only a portion of the protocol. However, in managing this patient population, the home care nurse must be well-educated in overall monitoring, side effects, and patient education. The home care nurse plays an important role in managing the physical and psychological effects of chemotherapy (White, 2015). The ONS provides online courses in chemotherapy administration, which can be found on the website www.ons.org/education.

After reading this chapter, the reader will be able to:

■ 156Summarize patient selection criteria

■ Describe key aspects of chemotherapy administration including safe practices

■ Summarize components of comprehensive care, assessment, and monitoring

■ Prepare a plan for patient education

OVERVIEW OF CHEMOTHERAPY

Chemotherapy drugs administered in the home setting most often are those given as an intermittent or continuous infusion. Adjuvant drugs such as those that potentiate the action of the chemotherapy agent (e.g., leucovorin with 5 fluorouracil [5-FU]) or rescue agents may be part of the regimen (e.g., mesna to prevent hemorrhagic cystis). Other therapies may be administered in conjunction with the chemotherapy such as hydration fluids, antiemetic or anti-infective drugs, and/or hematopoietic growth factors (e.g., filgrastim).

The basic mechanism of chemotherapy is to interrupt the synthesis of DNA, disrupting cell division and causing cell death. Chemotherapy drugs may exert their action during a specific phase of the cell or may exert their effect in all phases of the cell cycle. Cell cycle–specific drugs include drugs classified as antimetabolites (e.g., 5-FU), vinca alkaloids, and a variety of miscellaneous agents. Cell cycle–nonspecific drugs include drugs classified as alkylating agents, antitumor antibiotics (e.g., doxorubicin), hormonal agents, and nitrosureas. These drugs act on cells that are not going through the cell division stage. Because chemotherapy agents do not distinguish cancer cells from normal cells, those cells that are frequently dividing are affected including those in the bone marrow, gastrointestinal tract, mucosa, gonads, and hair follicles. Side effects resulting from damage to these cells include 157myelosuppression, nausea, vomiting, diarrhea, mucositis, infertility, and hair loss (Czaplewski & Vizcarra, 2014).

The drug 5-FU is commonly administered as a home infusion for patients. Based on the protocol for the patient’s cancer diagnosis, infusions may be over 22 to 48 hours every 1 to 3 weeks or as a continuous infusion lasting 5 to 8 weeks (Chavis-Parker, 2015). There is scarce reporting of other home-administered chemotherapy drugs. Additional chemotherapy drugs that have been home administered, based on this author’s experience, are presented in Table 11.1. Consult a drug resource (e.g., Gahart, Nazareno, & Ortega, 2016) or other chemotherapy reference for information about other chemotherapy drugs and for specifics of drug actions, dosing, and additional information. Cancer care and treatment also include numerous biological agents that are administered as infusions such as monoclonal antibodies, fusion proteins, interleukins, and immunoglobulins. There is scarce data regarding the administration of biologicals for cancer treatment in the home setting. The risk of severe reactions is often a limiting factor. For this reason, this chapter is limited to only chemotherapy cancer treatment. Immunoglobulin therapy, which may be administered in the treatment of cancer, may be home-administered and is addressed in Chapter 14.

PATIENT SELECTION CONSIDERATIONS

■ The patient and family are motivated, willing, and capable of participating in self-infusion management.

Chemotherapy infusions may be continuous or long intermittent infusions (hours) and are delivered via a central vascular access device (CVAD) using an infusion pump. This requires at least some level of patient or caregiver participation in infusion administration, venous access device–related care, and monitoring.

■ The patient is clinically stable prior to initiating chemotherapy.

Nutritional status is adequate and the patient is able to tolerate adequate food and fluid intake.

Elimination status includes adequate bowel and urine elimination.

Recent hematologic and renal function laboratory results are checked. General guidelines for administering chemotherapy include:

Serum creatinine and blood urea nitrogen (BUN) are within normal limits.

158Table 11.1

Selected Chemotherapy Drugs

159

160

Platelets are more than 100,000.

Absolute neutrophil count (ANC)* is more than 1,500.

■ 161The patient has previously received the chemotherapy drug without reaction.

■ A CVAD is in place.

Patients may have an implanted port (very common), a tunneled catheter, or a peripherally inserted central catheter (PICC).

Peripheral intravenous (IV) or midline catheters are not used to administer continuous vesicant infusions (Gorski et al., 2016).

■ The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone.

■ Reimbursement is verified.

Private third-party payers vary in coverage.

Certain diagnoses and continuous chemotherapy infusions may be covered under the durable medical equipment benefit for external infusion pumps under Part B of the Medicare program.

COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING

Plan for Home Care and Visit Frequency

■ Schedule initial home visits to coincide with the initiation and the discontinuation of the (intermittent) infusion.

■ Follow up by telephone 2 to 3 days after infusion starts to identify if there are any problems or side effects (e.g., nausea, vomiting, and diarrhea).

■ 162Schedule a home visit or telephone call during nadir period to assess for any signs/symptoms of infection.

■ Coordinate overall plan for home care with physician office/outpatient chemotherapy clinic.

Safety and Home Chemotherapy

Drug Preparation and Storage

■ Chemotherapy drugs are prepared in the infusion pharmacy and delivered to the home ready for administration.

■ IV drug reservoirs/bags are delivered “preprimed” from the infusion pharmacy.

■ Store drug, supplies, and cytotoxic waste container in an area safe from children and pets.

Drug Administration

■ Wear personal protective equipment (PPE; e.g., chemotherapy gloves and impermeable gown).

■ Use a plastic-backed pad on a clean surface to set up supplies and drug reservoir/pump.

■ Use all luer-lock connections.

■ Discard all used supplies that have had contact with the chemotherapy (e.g., gloves and tubings) in the cytotoxic waste container.

Spills

■ A “spill kit” is provided by the infusion pharmacy.

■ The spill kit includes PPE, absorbent sheets/materials for containing the spill, and plastic bag for disposal with label for contaminated items.

■ Instruct the patient and caregiver in how to use the spill kit should any leaks occur.

■ A chemotherapy spill should be reported as an agency occurrence.

Chemotherapy Administration

■ Coordinate the time of the infusion with the referring physician, infusion pharmacy, and the patient. Certain chemotherapy protocols are very specific in terms of timing. The infusion chemotherapy administered by the home care nurse is often part of a protocol that is administered in the outpatient clinic.

■ A written order from a physician or licensed provider with appropriate credentialing is needed for the administration of all 163chemotherapeutic agents. Verbal and telephone orders are not acceptable except in the instance of discontinuing a chemotherapy medication.

The drug order includes patient’s name, drug name(s), dosage/m² or dose per unit body weight or dose for an area under the concentration–time curve (AUC), and/or total dose, frequency, and route.

Orders may also include premedications (e.g., antiemetic) and/or plan for hydration, if needed.

Dosage information should be verified by two professionals (e.g., registered nurse and infusion pharmacist).

Ensure that orders for extravasation and anaphylaxis treatment (if applicable) are included if vesicant drugs or first doses are administered.

■ Check that laboratory values are within acceptable parameters for the drug to be administered.

■ Recalculate body surface area (BSA) and drug dosage; websites are available for calculation (e.g., www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm).

■ Compare order on infusion container to physician’s order and verify infusion parameters on pump (e.g., rate and reservoir volume) prior to starting pump.

Consider a double-check system such as having the home care nurse call the pharmacist while in the home and read the infusion pump parameters. There are reported cases of patient death and hospitalization due to pump parameter errors resulting in overdoses of 5-FU (Ewen, Combs, Popelas, & Faraone, 2012; ISMP Canada, 2007). Based on such medication safety issues, the use of elastomeric devices (in contrast to a programmable infusion pump) for 5-FU was evaluated (N = 574 home care patients) and was found to be a safe administration method (Broadhurst, 2012).

■ Use appropriate PPE.

■ Verify patency of CVAD including presence of free-flowing blood return.

Assessment and Monitoring

Immediate Complications of Chemotherapy Administration

Extravasation

Extravasation is defined as the inadvertent administration of vesicant medication or solution into the surrounding tissue instead of into the intended vascular pathway (Gorski et al., 2016). Vesicant drugs are those capable of causing tissue injury and are highlighted in Table 11.1.

164■ Extravasation can occur when drugs are administered through a CVAD.

■ Causes of CVAD-related extravasation include incomplete port needle insertion, dislodged port needle, catheter separation from body of port, damaged catheter (e.g., hole in tunneled catheter under the skin), backtracking of medication along catheter into subcutaneous tissue.

■ Prevention of extravasation:

Use a noncoring needle to access port that is long enough to touch bottom of port and can be stabilized and secured to the skin.

Assess for signs of venous thrombosis prior to starting infusion. If present, notify physician and ensure that patient has radiographic flow study prior to CVAD use.

Ensure that there is a free-flowing blood return prior to administration of the vesicant. Never start a vesicant infusion in the home without obtaining a blood return.

Ask the patient if there is any pain, burning, or stinging as the CVAD is flushed with saline and assess for any swelling in the area. Other signs of concern include shoulder pain and ringing in ears during flushing. If present, do not initiate chemotherapy; contact physician to discuss need for radiographic study of catheter placement/flow.

Stabilize port needle and pump tubing to avoid tension or “pulling” at needle insertion site.

Teach patient about risks and preventive actions (Patient Education: Key Points).

Refer to Chapters 4 and 5 for management of extravasation.

Anaphylaxis

■ Avoid first doses of chemotherapy drugs in the home.

■ If first dose is given, ensure presence of and orders for emergency drugs (e.g., epinephrine and diphenhydramine) and remain in the home for 20 to 30 minutes after initiation of infusion to monitor for any reactions.

■ Instruct patient and family in actions to take should a severe reaction occur (call 911).

165Side Effect Management

Bone Marrow Suppression

The risk is greatest during the drug’s nadir period, the time when the blood count reaches its lowest point. For most chemotherapy agents, this occurs about 7 to 10 days after drug administration.

■ Monitor WBC (ANC), hemoglobin, and platelet count.

■ Monitor for signs/symptoms of infection, bleeding (including occult bleeding and headache), and anemia.

■ Monitor temperature. Be aware that if patient is neutropenic, fever (≥100.4) is the most reliable and often only indicator of infection (ONS, 2001). A fever needs to be reported to the physician immediately.

■ Instruct patients in good handwashing and hygiene including oral and perineal care, and bleeding precautions.

■ Instruct patients to avoid persons with contagious illnesses, especially during nadir period.

■ Anticipate potential treatment with hematopoietic growth factor either at home or in the clinic.

Gastrointestinal Side Effects

■ Monitor for nausea, vomiting, diarrhea, mucositis, stomatitis, and anorexia.

■ Administer and/or provide patient education regarding supportive treatments (e.g., antiemetic and antidiarrheal medications).

■ Instruct patient in eating strategies including: small frequent meals; how to increase fluid intake; eating high calorie, high protein foods; and taking nutritional supplements.

■ Instruct patient to avoid irritants such as alcohol and tobacco.

■ Instruct in regular oral care, avoid commercial mouthwashes, and use soft toothbrush.

■ Notify physician for persistent nausea and vomiting beyond 24 hours, diarrhea lasting 2 to 3 days, fever, mouth/rectal pain or sores, and inability to eat.

Integumentary Side Effects

■ These include alopecia and dermatitis (“hand and foot syndrome,” especially associated with 5-FU infusion).

■ Instruct patient to use mild shampoo, decrease frequency of hair care, avoid permanents and other hair processing, and protect scalp from heat and cold.

■ 166Instruct patient regarding protection of hands and feet during very cold or hot weather conditions and use protection if touching heated cooking utensils or containers from the freezer.

■ Provide patient with information about resources (e.g., American Cancer Society’s Look Good, Feel Better program; www.cancer.org/treatment/supportprogramsservices/look-good-feel-better).

■ When significant hair loss is anticipated, encourage patients to match hair color/style with wig before hair loss occurs (if desired).

■ Report signs of dermatitis such as scaling, peeling, numbness or tingling, redness, and pain; ensure supportive treatments such as pain control, cold compresses, elevation, ointments, and lotions.

Neurological Side Effects

■ Understand the dose-limiting toxicity of vinca alkaloids, cisplatin, and taxol.

■ Monitor for paresthesias, constipation, paralytic ileus, muscle flaccidity, foot drop; report occurrences to physician.

■ Be aware that constipation is often minimized by patients.

■ Instruct patient to increase fluid intake, maintain fiber in diet, and take stool softeners/stimulants (Polovich, Whitford, & Olsen, 2014).

Psychosocial Considerations

Explore and address potential concerns and issues throughout the course of home care.

■ Specific issues may include:

Patient/family goals and expected results