Parenteral systemic anti-cancer therapies (SACT) out of hours policy
NHS Borders clinical guidelines
PURPOSE OF POLICY
To provide a concise and clear procedure for the provision of parenteral SACT.
To ensure that SACT is prescribed, dispensed, supplied and administered to standards complying with CEL 30 (2012) at all times.
PERSONS RESPONSIBLE
All staff involved in the prescribing, dispensing, supply & administration of SACT.
PHARMACY SERVICE
All parenteral SACT requiring aseptic manipulation must be dispensed by pharmacy personnel who have undertaken suitable training.
Dispensing must take place within an accredited aseptic unit.
Parenteral SACT must be presented to the clinical area in a ready to use form – no manipulation will take place outwith the aseptic unit.
Aseptic dispensing service for the provision of same day SACT is available 9.00 – 12.00. In an emergency situation same day dispensing can be provided up until 15.30.
Out with these hours an on-call service is provided by one pharmacist, working as a sole practitioner. CEL 30 (2102) states that SACT ‘must be prepared to the same standards within and out of hours’. The out of hours on-call service cannot meet this standard:
- The use of a sole practitioner increases the risk of error.
- Pharmacists do not routinely dispense parenteral SACT & therefore do not fulfil the training requirement.
Due to these unacceptable health and safety risks parenteral SACT cannot be dispensed out of hours.
SPECIALIST NURSE SERVICE
Nursing staff from the cancer unit & wards within the Borders General Hospital where SACT is routinely given have undergone training appropriate to allow the safe administration of parenteral SACT by intravenous infusion.
Only nursing staff from the cancer unit at the Borders General Hospital have undergone appropriate training in the administration of bolus SACT.
Working hours Tuesday and Wednesday 9.00 – 19.00, Thursday and Friday 09.00 -17.00
Out with these hours bolus SACT cannot be given by nursing staff & would be the responsibility of the patient’s consultant.
SACT OUT OF HOURS
Where a regimen has been ordered & dispensed; but the dispensed medication cannot be used at the time of administration e.g. where administration has been delayed and the dispensed medication has expired or the SACT infusion bag has been spiked
If it is still within pharmacy aseptic opening hours & there is capacity to do so, the medication can be re-dispensed.
However, if it is out with pharmacy aseptic opening hours or there is no capacity to accommodate a re-dispensing of the medication then the treatment would need to be delayed.
An appropriate member of pharmacy staff should be contacted to arrange a suitable time for the re-dispensing of the medication.
Where necessary patient’s consultant should be contacted for advice on any further action to be taken in the interim e.g.
- Intravenous fluid hydration
- Supportive medications
If the decision to prescribe parenteral SACT is made out of hours and it is important that the patient receives this medication as soon as possible the on-call pharmacist should be contacted to ensure that this request is actioned as a priority the next working morning & that this is effectively communicated to the appropriate pharmacy personnel.
In exceptional circumstances, where such a delay would be detrimental for the patient a limited supply of pre-filled syringes of certain SACT could be madeavailable via the on-call pharmacist, subject to availability:
- Cyclophosphamide
- 5-fluouracil
- Epirubicin
NOTE: this would require a bolus injection to be administered. There are no nursing staff working out with normal hours who are trained to administer SACT medication by bolus injection. Therefore the administration would be the responsibility of the patient’s consultant.
In such circumstances the prescription & any accompanying information will provide the on-call pharmacist with sufficient clinical information to allow verification; as required by standards of CEL 30 (2012).
NB: the electronic prescribing system; ChemoCare is not available to all on-call pharmacy staff.
Non-urgent requests should be presented to the pharmacy as per normal procedure during working hours