Get agency involved in home chemotherapy
Saying yes to the first patient was the easy part. Making sure everything went smoothly was another story. For home infusion agencies considering getting into administering chemotherapy, Williams says to make sure you don’t put the cart before the horse, says Ann Williams, RN, an infusion nurse with Deaconess Home Medical Equipment and Infusion in Evansville, IN. Here are her suggestions:
• Order spill kits.
"Plan to do this before you get your referral," she says.
For example, Williams had to order a spill kit for her home chemo patient before the drug could be infused. The chances of having one on hand is unlikely if you’re not already providing home chemo, as spill kits aren’t required when administering antibiotics in the home. Williams used spill kits put together by her hospital but says that the Oncology Nurses Society (ONS) in Pittsburgh has information on putting together spill kits for use in patient homes.
"If you’re not working through a hospital, you could probably make one up on your own," says Williams.
• Provide patient education.
Also, there is a lot of specific patient education that addresses much more than the chemotherapy itself. For example, Williams had to instruct the patient and his wife that after using the toilet, it is important to flush twice as a general safety practice to ensure there is no residue of the infused drug remaining in the toilet.
• Find and use available resources.
Having numerous resources is similarly critical. Williams had several such resources at her disposal:
The Intravenous Nurses Society publication Intravenous Therapy Clinical Principles and Practice, published by W.B. Saunders. You can reach the INS by calling (617) 441-3008.
Oncology Nurses Society publication Cancer Chemotherapy Guidelines and Recommendations of Practice. You can call the ONS at (412) 921-7373.
The IV Therapy listserv, an on-line bulletin board that features discussions of infusion therapy topics ranging from clinical to business management. You can subscribe by sending an e-mail to: email@example.com. In the message say "subscribe ivtherapy-l". (Editor’s note: don’t include the quotes, and that’s the lowercase letter "L", not the number 1. If you have difficulties subscribing, contact Sarah Kuykendall, RN, of Oregon Health Sciences University, at firstname.lastname@example.org.)
Williams also frequently went to her hospital chemo instructor for advice.
Williams recommends getting as much information from the above sources and any others available ahead of time to establish your care plan. (See insert for Deaconess’ care plan.) Most of the information used by both Williams and Dussault came from the INS and the ONS.
Self-monitoring and certification
• Create your own standards.
Even with the existence of groups such as the ONS and the INS, there is no national standard or credential that is required for providing home chemotherapy infusions. Both the ONS and the Joint Commission on the Accreditation of Health Care Organizations do, however, require any home care agency providing home chemo to have its own standards.
"There are no standards specific to home care, but it would fall under all our standards pertaining to providing care in the home in the accreditation manual," says Kathleen Brinton, associate director of home care for the Joint Commission. "You have to set your own standards and requirements for staff to provide chemo, which your JCAHO surveyor would then verify you are enforcing."
Brinton adds that your state board of pharmacy may have additional requirements that could affect the standards you establish for nurses who administer chemotherapy in the home.
One source of information when establishing your agency’s standards is the ONS.
"ONS does not offer certification for chemotherapy, but it does offer chemotherapy guidelines," says Santicky. "Each agency does its own certifications. An ONS exam is available, but it in itself is not a license. This must be done by the agency and must be institution driven." (Editor’s note: You can call the ONS at (412) 921-7373, to get a copy of the guidelines.)
• Set education requirements.
She notes that because of the many changes in chemotherapies, many agencies choose to require staff to renew their in-house certifications annually. Williams says that the latest developments often aren’t infused in the home, though.
"A lot of doctors do in-office chemo for new drugs, so the more mild chemo is what is done at the home," says Williams.
That’s not to say that receiving the ONS’ credential wouldn’t be beneficial. It’s just not likely to be required unless your agency decides to.
"If I hired someone, it would be a plus but I wouldn’t require it because we have our own policies and procedures," says Dussault. "We’re JCAHO accredited, and that’s what JCAHO looks for, that you have your own criteria."
Dussault is the only individual providing home infusion chemotherapy for her agency.
For Deaconess, because the referral came up before Williams was able to be credentialed according to the hospital’s standards, it required extra work for the hospital’s oncology nurse.
"She worked with us as far as being on call, and after hours she would have gone out to the patient with us so we could say a certified nurse worked with us," says Williams.
The hospital’s chemo instructor will give Williams and her colleague the two eight-hour classes and a test to meet the hospital’s credentialing requirements.
Williams notes that the two-day class and test are all that are required for a nurse to be chemo-certified for Deaconess. The first day consists of general cancer education, while the second day gets into specifics regarding drugs, reactions, etc. However, she adds that other agencies don’t require a class for nurses who are CRNIs, as that includes education on chemotherapy.
If you’re looking to establish staff education and don’t have the luxury of a hospital educator, Williams recommends calling the ONS and getting its literature on staff education.