CLINICAL PRACTICE GUIDELINES

AND SCOPE OF PRACTICE

FOR

NURSE PRACTITIONER IN ONCOLOGY

KEITH COX All NP clinical guidelines on this site have been developed for use in a particular Area Health Service and for specific Nurse Practitioner positions in that AHS, and therefore reflect the specific scope of practice of the position and the operation of the AHS. Therefore, prior to use by Nurse Practitioners in other positions, the guidelines will need to be reviewed and adapted as necessary to address local scope of practice and Area Health Service needs. The adapted guidelines must also be approved in writing by the AHS CE, as required by the Nurse/Midwife Practitioner Policy Directive 2005_556 prior to use.

JUNE 2006 For Review in September 2007

CONTENTS Foreword: .............................................................................................................................................................1 1. Introduction..................................................................................................................................................2

1.1 Advanced Nursing Practice ..............................................................................................................3

2. Sydney South West Area Health Service - Eastern Zone...........................................................................4

2.1 Demographics...................................................................................................................................4 2.2 Sydney South West Area Oncology Service ....................................................................................4 2.3 Oncology Facilities ...........................................................................................................................5 2.4 Specialised Programs and Teams ...................................................................................................5

3. Practice Environment ..................................................................................................................................6

3.1 Royal Prince Alfred Hospital.............................................................................................................6 3.2 RPAH Oncology Department............................................................................................................6 3.3 The Oncology Department Clinical Team ........................................................................................6 3.4 The Oncology Nurse Practitioner in the Oncology Department .......................................................6 3.5 Referral Process for Oncology Nurse Practitioner in RPAH Oncology Department ........................7

4. Scope of Practice ........................................................................................................................................7

4.1 Side effects of Chemotherapy ..........................................................................................................7 4.2 Febrile Neutropenia ..........................................................................................................................8 4.3 Symptom Management ....................................................................................................................8 4.4 Pain Management ............................................................................................................................8 4.5 Ascites ..............................................................................................................................................8 4.6 Additional groups of patients who are referred include: ...................................................................8

5. ...................................................................................................................................9Legal Considerations

5.1 The NSW Occupational Health and Safety Act. ...............................................................................9

6. Diagnostic Tests ........................................................................................................................................10 7. Prescribing by the Oncology Nurse Practitioner .......................................................................................11

7.1 Legal grounds for prescribing .........................................................................................................11 7.2 Formulary........................................................................................................................................11 7.3 Drug Information.............................................................................................................................13

8. Referral Processes....................................................................................................................................55 9. Outcome Measures for the Oncology Nurse Practitioner..........................................................................55 10. Clinical Indicators ..................................................................................................................................55 11. References............................................................................................................................................56 Appendix (A) - Adverse reactions to chemotherapy drugs ................................................................................58 Appendix (B) - Job Description ....................................................................................................................60 Acknowledgements ............................................................................................................................................66

Foreword: The Committee for the Development of Oncology Nurse Practitioner (ONP) Guidelines in the Oncology Departments of Royal Prince Alfred Hospital The Following clinical practice guidelines have been devised by Keith Cox, ONP. They incorporate current and relevant nursing, medical and allied health literature. They are also consistent with both NSW and Commonwealth government initiatives. Formulation of these guidelines has involved collaboration and contributions from the following department representatives who have formed the guidelines committee: • Catherine Murray Clinical Manager, Cancer and Cardiovascular Services, Sydney South

West Area Health Service – Eastern Zone • Michael Boyer Area Head, Medical Oncology Department, Sydney South West Area Health

Service

• Lydia Visintin Clinical Nurse Consultant, Sydney Melanoma Unit, Sydney South West Area Health Service – Eastern Zone

• Alison Cavill Pharmacist, Cytotoxic Pharmacy, Sydney South West Area Health Service –

Eastern Zone

• Gina Svolos, Cancer Support Program Coordinator, Sydney South West Area Health Service – Eastern Zone

The ONP guidelines provide a clinical practice framework for assessment and management of oncology patient presentations to the Oncology Departments of Royal Prince Alfred Hospital. They are an extension on the statement of duties included in the ONP Job Description (Appendix A). They may be reviewed, altered or updated as required. The ONP will also operate under the following guidelines: i) The Cancer Nurses Society Australia; ii) The Code of Ethics for Nurses in Australia; iii) The Code of Professional Conduct for Nurses in Australia; and iv) The Australian Council for Nurses National Competency Standards for Registered and

Enrolled Nurses.

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1. Introduction In October 1998 the Nurses Amendment (Nurse Practitioners) Act was passed by both houses of the New South Wales Parliament. The Amendment allowed for the Nurses Registration Board to authorise certain registered nurses to practice as nurse practitioners and for the Director General of the Department of Health to approve guidelines relating to the functions of nurse practitioners, including the prescription of certain substances. The Amendment also prevents an unauthorised person from using the title ‘nurse practitioner’ (Adrian and O’Connell 2000). Recently the NSW Parliament Legislative Council Select Committee on Nursing (2002) raised the prospect of nurse practitioners working in different areas of nursing. It was the view of the Committee that the health system must begin to appreciate and reward the various skill levels within nursing and that the creation of a variety of career pathways would promote nursing as a dynamic and innovative profession. The Committee noted that improved status and remuneration must be a part of such initiatives. The Select Committee therefore recommended “That the minister for health immediately appoint authorised Nurse Practitioners and that the positions with in-principle approval be considered for appointment as a matter of urgency” (Australian Health Ministers Advisory Council National Working Group – 1997 – National Standard for Mental Health Services, Australiana Government Publishing Service. Canberra). A Nurse/Midwife Practitioner/Advanced Practice Nurse/Midwife is a registered nurse or registered midwife who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Masters level degree is recommended for entry level.( International Council of Nurses, 2003) Advanced practice incorporates the ability to provide care to a range of clients at a level that demands: • A repertoire of therapeutic responses; • Insightful sophisticated clinical judgements; • Clinical decision-making justified by application of advanced knowledge. (Nurses and

Midwives Board of New South Wales, 2003, Nurse/Midwife Practitioner Information Brochure. Sydney; NSW NMB)

Being an expert-by-experience in a speciality is not on its own sufficient for advanced nursing/midwifery practice. Nor is accepting more delegated medical tasks or technical procedures. Advanced practice differs from expert practice or extended roles in its scope of sphere of influence and its application of advanced nursing/midwifery knowledge. ( New Zealand Nursing Office, 2000, Advanced Nursing Practice, NZNO position statement). Nurse practitioners are registered nurses working at an advanced practice level that have attained appropriate accreditation with the NSW Nurses and Midwives Board. Nurse practitioners provide expert nursing care in collaboration with other health professionals in a variety of clinical settings (NSW Health 2003a). The nurse practitioner assists nursing and medical colleagues in clinical decision-making for care and intervention. Despite their expanded role, nurse practitioners are nurses, and they approach the provision of primary care with a unique nursing perspective (Patterson and Haddad 1992). This also ensures that nurse practitioners avoid simply carrying out tasks that junior doctors are too busy to do (Walsh 1999). The nurse practitioner therefore does not attempt to replace or replicate medicine but rather complements the specialised health care available to patients. Healthcare is an expanding universe, as new discoveries, techniques and challenges continually present themselves. Other professional groups can widen their practice without threatening the viability of medicine because the whole field of healthcare is expanding at a dramatic rate. The

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patient’s best interests are the focus of healthcare, Therefore care should be delivered by whoever is most appropriate, acceptable to the patient and best trained for the role (Walsh 1999). 1.1 Advanced Nursing Practice

Pearson (1984) states that nurses are the humanisers of the health care team. He suggests that patients expect nurses to be ‘with them’ emotionally and physically. Nurses support individuals as they try to make sense of and come to terms with the situation they face. Truly holistic nursing care is highly skilled, requires a sound knowledge base and is a highly developed advanced practice. Benner’s (1984) seminal work “From Novice to Expert: - Excellence and Power in Clinical Practice” explored the phenomenon of experience and expertise in clinical practice, based on the Dreyfus model of skill acquisition. Benner’s structural explanation of her findings is presented as five stages of gaining experience in clinical practice: describing the nurse in a particular clinical situation as a novice, advanced beginner, competent, proficient or expert. These stages infer that a noticeable change occurs in the individual’s practice as skills, knowledge, experience and performance grow. Awkward beginners develop to become, in time, highly integrated and “intuitive” practitioners. At the expert level, the nurse no longer relies on consciously recalling rules, guidelines or maxims to understand a given situation but rather, incorporates an enormous background of experience and knowledge into practising at an automatic level. Patterson and Haddad (1992) identify the key attributes of the Advanced Nurse Practitioner (ANP) as a risk taker, visionary, with an inquiring mind, flexibility, the ability to articulate and leadership skills. These attributes of the ANP are demonstrated by a number of behaviours which include: identifying and developing a nursing perspective in new areas of health care, identifying and commenting on current issues in nursing, participating in nursing research, and demonstrating the use of theory based practice to other nurses. The Australian Oncology Nurses Society Standard of Practice (1999) has an advanced practice standard. The Cancer Nurses Society of Australia (CNSA) is committed to achieving and promoting excellence in cancer Care. To achieve this aim, the Outcome Standards for Australian Cancer Nursing Practice were developed by the then COSA Nurses Group. These education standards, known as the Australian Standards for Specialist Cancer Nursing Education Programs have been developed to articulate with the practice standards by providing a framework for evaluating the structure, process and content of cancer nursing education programs. The CNSA believes that education programs that develop the knowledge, skills and attitudes necessary for specialist cancer nursing practice will enhance professional practice and optimise the quality of cancer nursing care. It is planned that the next phase in the CNSA commitment to advancing cancer nursing will be the development of outcome standards for advanced practice in cancer nursing. Specialist practice differs from generalist cancer nursing practice in that it is characterised as being: • Specialised in terms of focus and population served. • Expanded in terms of knowledge and skills • Complex in terms of clinical challenges and clinical judgement • Independent in terms of decision-making (Styles MM (1997), Conceptualizations of

advanced nursing practice in A Hamric, J Spross and C Handson. Advanced Nursing Practice: An Integrative Approach. Philadelphia: WB Saunders)

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2. Sydney South West Area Health Service - Eastern Zone Sydney South West Area Health Service (SSWAHS Eastern zone) manages all public health facilities within its geographic boundaries of central and inner West Sydney. This includes 71 suburbs and a diverse range of community and inpatient services. The Area Health Service manages a range of inpatient and community facilities and provides services to children, adolescents, adults and older people. 2.1 Demographics

The SSWAHS Eastern Zone covers 10 local government areas – Ashfield, Burwood, Canterbury, Concord, Drummoyne, Leichhardt, Marrickville, Strathfield and parts of Sydney and South Sydney. The population of the SSWAHS Eastern Zone area is approximately 500,000 people representing 7.5% of the NSW population. Forty percent of residents are born overseas and 82% of overseas born residents are born in non-English speaking countries. The most common country of birth is China followed by United Kingdom, Italy, Greece, Lebanon and New Zealand. Forty four percent of the SSWAHS (EZ) population speak a language other than English at home. About 10 percent of residents have poor English language skills and require a professional interpreter and culturally appropriate health programs (Based on the 2001 Australian Bureau of Statistics Census). The most frequently spoken languages, after English, are: i) Chinese 7.9% ii) Arabic 5.8% iii) Greek 5.6% The SSWAHS (EZ) area contains a large aging population and a range of affluent and disadvantaged areas. Canterbury is the most populous and ethnically diverse of the local government areas. In general, local residents of Canterbury have poorer health outcomes than other Australians in relation to lung cancer, prevalence of tobacco smoking, cervical cancer, high blood pressure, and motor vehicle accident mortalities (based on 2001 Australian Bureau of Statistics Census). 2.2 Sydney South West Area Oncology Service

The Sydney South West Area Cancer Services (SSWACS) is part of the SSWAHS. The Area Cancer Service provides inpatient, outpatient and community care to patients through a variety of specialised programs and services. The Royal Prince Alfred Hospital Department of Medical Oncology forms part of the Area Cancer Service. It takes responsibility for the medical management of patients with a broad range of malignant diseases at Royal Prince Alfred Hospital. In conjunction with surgical, gynaecological and radiation oncologists, several multidisciplinary clinical management and research groups have developed, namely: i) Gynaecological Oncology Unit ii) Soft Tissue and Bone Tumour Unit iii) Head and Neck Tumour Unit iv) Gastrointestinal Unit v) Thoracic Oncology Group vi) Sydney Melanoma Unit vii) Neuro-Oncology Group

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The Department is involved with health research covering a wide variety of clinical and non-clinical areas. This includes participation in clinical trials supported by the pharmaceutical industry, trials of National and International groups, as well as the development of local clinical trials. The Department is also a member of the Cancer Therapeutics Research Group (CTRG), which coordinates clinical trials in Singapore, Hong Kong and Australia. The Department has a major research interest in the development and evaluation of new anti-cancer drugs, the interaction between anti-cancer drugs and radiation therapy, in communication between doctor and patient and in the pharmacology of anti-cancer drugs. 2.3 Oncology Facilities

Inpatient Wards (Oncology, and additional wards as requested) Outpatient Departments (Medical Oncology Outpatient Department, Sarcoma, Radiation Oncology & Haematology Clinic and additional clinics as required). 2.4 Specialised Programs and Teams

There are nine clinical streams within Cancer Services they are the following; Medical Oncology, Haematology, Radiation Oncology, Palliative Care, Breast Surgery, Melanoma, Urology, Head & Neck, Gynaecological Oncology and Dermatology. Cancer Services has close links with cardiothoracic and colorectal services. These services all have a team leader and a nurse co-ordinator or Clinical Nurse Consultant as part of that team. All streams hold multi-disciplinary meeting (MDT) on weekly bases. Members of the teams can include doctors, nurses, social workers, dentists, pharmacists, dieticians, pathologists and psychologists. The MDT meetings are patient focused with discussions held on all relevant patients within their clinical streams that require input from members of the team. The MDT meetings enable complex treatments to be decided upon and this enhances the patient’s journey and support through their treatment plan.

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3. Practice Environment 3.1 Royal Prince Alfred Hospital

Royal Prince Alfred Hospital (RPAH) is a large inner city teaching hospital of the University of Sydney with its own unique context. RPAH has approximately 700 inpatient beds. The particular characteristics of the setting include: a dense urban population, a large multicultural mix, including a substantial indigenous Australian population, a broad range of sub-cultures (including students, gay community and minority ethnic groups), a diverse socio-economic population, a high level of boarding house population/supported accommodation, a high prevalence of mental illness/disorder, psychosocial issues and substance abuse and, an established network of oncology services, both inpatient and community, government and non government (Wand and Happell 2001). 3.2 RPAH Oncology Department

The Medical Oncology staff supervise approximately 25 inpatients under direct care, normally on 7E1 at Royal Prince Alfred Hospital (usually up to 15 patients), and in Ward 5 East at Concord (usually up to 10 patients). In addition a consultative service is provided for other hospital inpatients. The senior medical staff receive approximately 1600 - 1700 new patient referrals per year. Over 200 ambulatory patients are seen at RPAH each week. A senior staff member together with one of the registrars holds a weekly outreach clinic at Dubbo Base Hospital. A full range of malignant disease is treated at RPAH. The model of care used is that of a multidisciplinary team, and the staff from the medical oncology department form a core component of these teams. The malignancies treated include those of the respiratory systems (lung cancer, mesothelioma), the upper and lower gastrointestinal systems, breast cancer and gynaecological cancers, head and neck cancers, genitor-urinary cancers, skin cancers and soft tissue and bone sarcoma. 3.3 The Oncology Department Clinical Team The Medical Oncology Department clinical team consists of the following disciplines: • Oncology Nursing Staff – Nurse Unit Managers, Clinical Nurse Consultants, Cancer Care

Coordinators, Clinical Nurse Educators, Clinical Nurse Specialists, Registered and Enrolled Nurses

• Oncology Medical Staff – Staff Specialists, VMOs, Registrars, Residents and Interns • Psycho-Oncology Service – Social Worker, Clinical Psychologist • Allied Health Service – Pharmacist, Dietician, Occupational Therapist, Physiotherapist,

Speech Therapist 3.4 The Oncology Nurse Practitioner in the Oncology Department The Cancer Institute of NSW and the Dept of Health of NSW supports the principles of cancer prevention, early detection, early intervention, health promotion, increased cancer survival, reduced cancer incidence, improve the quality of life of cancer patients and their carers, and provides expert advise to patients, the public, health care professionals and the Government (Cancer Institute NSW – NSW Cancer Plan 2004-2006, Page 13). The Standards require Cancer services to “identify and respond to the Cancer problems as early as possible”. The strategy also calls for services to share expertise to promote “inter-agency collaboration” and sharing of resources. The Oncology Nurse Practitioner (ONP) service developed at RPAH is a collaborative initiative within the SSWACS. Importantly, the ONP is based in the Medical Oncology department and is viewed as a member of the team. The ONP provides timely access to clinical expertise for patients and their families and support for the Oncology staff. The Medical Oncology Nurse Practitioner at Royal Prince Alfred Hospital:

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• Provides advanced nursing care for people over the age of 15 years of age presenting to the Oncology Dept of RPAH. This is accomplished through direct contact with patients, family and significant others, as well as providing support, education, and advice to other healthcare professionals.

• Provides a link between other services, community organisations, General Practitioners (GPs), and mainstream medical services.

• Actively promotes cancer awareness and primary prevention. • Facilitates equity of access to medical care for people with cancer. • Utilises a repertoire of behavioural and psycho educational interventions to assist individuals

to gain greater personal understanding and self-mastery with issues related to their treatment and symptom management.

• Demonstrates a high standard of professional evidence based practice and clinical leadership that incorporates education and research.

• Maintains involvement in organisational and professional matters between other services, providing input on working parties and training programs as well as providing clinical supervision for cancer nurses within SSWAHS.

The principles underpinning the role of the Oncology Nurse Practitioner (ONP) are that: • Patient care will be enhanced through an improved triage process, with patients being

referred for medical assessment and consultation, or to allied health or other members of the health care team. This intervention will be enhanced by ONP intervention.

• The effectiveness and efficiency of the Oncology Dept is improved by the utilisation of the ONP’s assessment skills, ie. advanced knowledge of chemotherapy drugs, there use and known side effects, advanced interpersonal skills and care coordination.

• The ONP is involved in the multidisciplinary team, coordinating a system of education and training for Oncology staff, through in-service programs.

• Knowledge and awareness of cancer issues for both patients and staff is improved through health promotion, policy and guideline development, role modelling and clinical teaching by the ONP.

• The ONP maintains regular communication and close clinical cooperation with the other teams and staff of the Oncology Dept.

3.5 Referral Process for Oncology Nurse Practitioner in RPAH Oncology Department The ONP attends to patients with cancer, over the age of 15 years. This includes all cancer types, patients undergoing chemotherapy, psychosocial issues and patients who may be having difficulty coping with their diagnosis referred to the ONP by nurses, doctors and social workers. The ONP is available Monday to Friday. The ONP provides education and consultation when requested to nurses on general hospital wards on topics such as cancer, chemotherapy and venous access devices. This is detailed below, in Section 4. Scope of Practice. 4. Scope of Practice

The role and scope of the ONP in the Oncology Dept will be broad. The main role will involve review of patients who arrive unwell to the chemotherapy unit. They could include the following: 4.1 Side effects of Chemotherapy Patients may present to the chemotherapy suite with nausea and vomiting following the administration of chemotherapy. The ONP assesses the patient and takes a medical history. A diagnosis of dehydration based on the clinical assessment will require treatment. Intravenous fluids

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must be commenced, together with anti emetics. A blood sample will be collected and sent for biochemistry (electrolytes) and full blood count analysis. Further treatment may be required pending results. 4.2 Febrile Neutropenia Patients may present to the chemotherapy suite 7-14 days post chemotherapy unwell with a history of fevers and or rigor. The ONP will collect a patient history and perform a physical assessment. Bloods for haematology, biochemistry and blood cultures will be collected. A chest x-ray and a sputum culture must be ordered before the commencement of IV Fluids. Results will be reviewed, and if a diagnosis of febrile neutropaenia is made, antibiotics will be commenced as per unit protocol. 4.3 Symptom Management

These patients may present with shortness of breath (SOB), lethargy, nausea or pain. A patient history and a physical assessment will be performed. If the patient has SOB, they may require a chest x-ray to assist with a diagnosis. If the patient is diagnosed with a pleural effusion they will be referred to a Medical Oncology Registrar.

4.4 Pain Management

If the presenting problem is pain, the ONP will perform a pain assessment and if required will order appropriate pain relief, within agreed guidelines. If the patient has severe or uncontrolled pain they will be referred to a Medical Oncology Registrar. (As per hospital guidelines and policy.) 4.5 Ascites If a patient with abdominal distention is diagnosed with ascites, it may need to be drained by a Medical Oncology Registrar. If the patient has an intra peritoneal port the ONP may access the port and drain the fluid. 4.6 Additional groups of patients who are referred include: i. The Chemotherapy nurse will review patient’s who are receiving chemotherapy on Day’s 8,

15 & 21, if there are any problems regarding side effects or abnormal blood results the ONP will be contacted. The blood results will be checked and a patient assessment will be performed. The review may involve changing the antiemetics or omitting treatment due to abnormal blood results.

ii. The ONP will coordinate the treatment plan for all new patients diagnosed with sarcoma,

testicular cancer, germ cell tumors, and patients receiving combined chemotherapy and radiotherapy treatment. This will also involve the planning of diagnostic tests and appointments.

iii. Patients who require Venous Access Devices (VAD’s) will be referred to the ONP.

Education will be given to the patients, and the necessary appointments made for the insertion of either a Port-a-Cath or Picc Line.

iv. Patients can be referred to the ONP to discuss infertility. Male patients wishing to father a

child in the future have the option of sperm banking prior to the commencement of chemotherapy. The ONP will organise the appointments and educate the patients regarding sperm collection and storage.

v. Patients requiring an audiogram will be referred to the ONP who will perform the audiogram.

The results will be assessed and any changes or abnormalities will be reported to the

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Medical Oncology Consultant. The ONP will organise an appointment with the Audiology Department if necessary.

vi. The ONP is available to administer intra-pericardial chemotherapy via the catheter that has

been inserted by the Cardiologist, following unit protocol.

vii. The ONP may administer intra-thecal chemotherapy via an Ommaya Reservoir or lumber puncture (LP), if the needle has been placed by a Radiologist in the Radiology Department. This procedure must be witnessed by a Level 4 accredited Chemotherapy Nurse.

viii. The ONP may administer intra-arterial chemotherapy if the catheter has been placed by a

Radiologist in the Radiology Department. These patients may be treated in the Radiology Department or on the ward. The chemotherapy may be supervised by the ONP, or given by the ONP under the supervision of the Radiologist.

5. Legal Considerations 5.1 The NSW Occupational Health and Safety Act. The Occupational Health and Safety Act (2000) aims to promote the health, safety and welfare of people at work and overrides all other legal statutes and regulations. All staff need to consider their own safety as a priority and not place themselves at risk of being a casualty (NSW Health 2003b). Occupational Health and Safety Regulation 2002. Circular No 98/99 NSW Health Department: Policy and Guidelines for the administration of Intravenous Medication in NSW and Community Health Services.

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6. Diagnostic Tests The Oncology Nurse Practitioner may order the following blood and radiology tests for patients: Blood

Chemical

EUC (including glucose) LFT (excludes AST) Aspartate Aminotransferase (AST) Calcium (corrected) includes albumin Magnesium Phosphate Uric Acid Lactate Dehydrogenase Protein Cholesterol Triglyceride Haematology / Coagulation FBC (includes count & differential) Coagulation (INR, APTT) ESR

Serology HIV (1&2) Antibody Hepatitis B Surface Antigen Hepatitis C Antibody Microbiology Blood cultures Micro urine Sputum Wound Swabs Endocrinology CA125, PSA, Beta HcG AFP, Testosterone, Prolactin Gastroenterology CEA

Radiology X-Rays All plain x-rays Insertion of Port-a-Cath’s or Pas-Ports Ultrasounds

CT Scans Head, Chest, Abdomen, Pelvis MRI Scans As required for suspected cord compression

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7. Prescribing by the Oncology Nurse Practitioner 7.1 Legal grounds for prescribing This formulary below provides a list of the poisons and restricted substances that may be processed, used, supplied or prescribed by the nurse practitioners under section 17a of the Poisons and Therapeutic Goods Act 1966 and forms part of the approved nurse practitioner guidelines, in accordance with section 78a (2)(a) of the nurses act (1991). Note, the nurse practitioner cannot administer medications they do not have the appropriate accreditation or credentials for undertaking. The ONP may authorise the continuation of existing medications (as per the formulary) for patients and will document, maintain and up date medical records for all medication changes. The ONP will observe, record, report the patient’s condition and any drug reactions of treatment to the attending medical officer. 7.2 Formulary Drug Route Therapeutic

Class Dose Poisons

Schedule Augmentin Duo Forte

PO Antibiotic 875mg bd S4

Bleomycin IM/IV Cytotoxic 15,000-30,000 Units S4 Capecitabine Oral Cytotoxic 1,000-1250mg/m2 BD S4 Carboplatin IV Cytotoxic AUC2-6 S4 Cefepime IV Antibiotic 1-2grams bd S4 Ciprofloxacin PO Antibiotic 750mg bd S4 Cisplatin IV, IA, IP Cytotoxic 20-150mg/m2 S4 Cyclophosphamide PO/IV Cytotoxic 100-1000mg/m2 S4 Dacarbazine IV Cytotoxic 400-1000mg/m2 S4 Dexamethasone IV/oral Steroid 4-20mg S4 Diphenhydramine Oral Antihistamine 50mg S2 Docetaxel IV Cytotoxic 30-100mg/m2 S4 Dolasetron IV/oral Anti-emetic 100-200mg S4 Doxorubicin IV Cytotoxic 20-75mg/m2 S4 Epirubicin IV Cytotoxic 20-100mg/m2 S4 Etoposide PO/IV Cytotoxic 50-120mg/m2 S4 Etoposide Phosphate

IV Cytotoxic 50-100mg/m2 (113.6mg = 100mg etoposide)

S4

Fluorouracil IV Cytotoxic 200-2400mg/m2 S4 Gemcitabine IV Cytotoxic 1000-1250mg/m2 S4 Gentamicin IV Antibiotic 4-7mg/kg daily S4 Hydrocortisone IV, PO Steroid 4 mg-100mg S4 Ifosfamide IV Cytotoxic 1.8g-2g/m2, over 3-5

days S4

Leucovorin Calcium IV/PO/IMI Vitamin 10-400mg/m2 S4 Liposomal Doxorubicin

IV Cytotoxic 20-50mg/m2 S4

Loratadine Oral Antihistamine 10mg S2 Lorazapam SL / PO anxiolytic 1-2mg S4 Methotrexate IV/Oral/IMI Cytotoxic 40mg/m2, to 3g/m2 S4 Metoclopramide IV/oral Anti-emetic 10-20mg S4 Mitomycin C IV/Intra-

vesical Cytotoxic 6-20 mg/ m2 IV,

40mg intra-vesically S4

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Morphine PO/SC/IMI Analgesic 2-20mg BD S8 Morphine Sulfate slow release

PO Analgesic 5-30mg S8

Oxaliplatin IV Cytotoxic 85mg – 100mg/m2 S4 Oxycodone PO Analgesic 5-10mg S8 Paclitaxel IV Cytotoxic 50-200mg/ m2 S4 Paracetamol PO Analgesic 500mg-1000mg unscheduled PEG Filgrastim (Neulasta)

SC Human growth factor

6mg S4

Prochlorperazine Oral/PR/IV Anti-emetic 10mg PO, 25mg PR, 12.5mg IV

S4

Ranitidine IV/oral H2 Antagonist 50mg IV, 150mg PO S2 Rituximab (Mabthera)

IV Monoclonal antibody

375mg/m2 S4

Trastuzumab IV Monoclonal antibody

4mg/kg 1st dose 2mg/kg thereafter weekly 8mg/kg 1st dose 3weekly then 6mg/kg thereafter 3 weekly

S4

Vincristine IV Cytotoxic 1.4mg/m2 (max 2mg) S4 Vinorelbine IV Cytotoxic 25mg-30MG/M2 S4

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7.3 Drug Information

7.3.1 Lorazepam (Ativan) Antianxiety agents Consumer Medicine Information: Available Pregnancy Category: C *Uses/Indications: Anxiety disorders or short-term relief of symptoms; anxiety associated with depressive symptoms; preop medication. Also has anti-nausea activity and can be used for

nticipatory nausea and vomiting. a Contraindications: CAL with respiratory failure; sleep apnoea Precautions: Prolonged use; abrupt withdrawal; hypotension sensitive conditions; myasthenia gravis; narrow angle glaucoma; cardiorespiratory, renal, hepatic impairment; depression, psychosis, schizophrenia; epilepsy; addiction prone; elderly, debilitated; pregnancy, lactation, children < 16 ears y

Adverse Reactions: CNS disturbances incl. impaired alertness, sedation, dizziness, weakness, unsteadiness; amnesia; dependence, tolerance; others, see full PI Drug Interactions: CNS depressants; alcohol; anticholinergics; anticonvulsants Tablet description: 1 mg (white), 2.5 mg (yellow); scored; gluten free; Dose: May be taken with or without food. Anxiety 2-3mg daily in divided doses. Insomnia 1-2mg at night. Also may be given sublingual 0.5mg-2mg prior to chemotherapy.

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7.3.2 Capecitabine (Xeloda) Antimetabolites Consumer Medicine Information: Available Pregnancy Category: D Uses/Indications: Locally advanced, metastatic breast cancer after failure of taxanes and anthracycline containing chemotherapy; with docetaxel in locally advanced, metastatic breast cancer after failure of anthracycline containing chemotherapy; adjuvant treatment in Dukes' stage C

nd high risk stage B colon cancer; advanced or metastatic colorectal cancer a Contraindications: Reactions to fluoropyrimidine; hypersensitivity to fluorouracil; severe renal

pairment; dihydropyrimidine dehydrogenase deficiency; pregnancy, lactation im Precautions: Coronary artery disease; hepatic, renal impairment; elderly, children Adverse Reactions: GI upset; hand foot syndrome; stomatitis; decreased appetite; cardiac effects; haematological changes; hyperbilirubinaemia; abdo pain; dermatitis; headache; dizziness; taste

isturbance; insomnia; hypo, hyperaesthesia; oedema; fatigue; paraesthesia; others, see full PI d Drug Interactions: Warfarin ; phenytoin; poss CYP450 2C9 metabolised drugs; sorivudine, related analogues eg brivudine Dose: 1000mg to 1250mg/m2 PO BD for 14 days followed by 1week rest, repeat every 21 days.

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7.3.3 Bleomycin Antibiotic cytotoxics Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Palliative and adjuvant to surgery and radiation therapy: squamous cell carcinomas of skin, head and neck; oesophagus; penis, larynx and uterine cervix; bronchus; choriocarcinoma and embryonal cell carcinoma of testis; advanced Hodgkin's disease, other

mphomas; mycosis fungoides, sclerosing agent in malignant pleural effusion. ly Contraindications: Acute pulmonary infection; severe lung function impairment. For repeat ourses: signs of pneumonitis, decreased lung function c

Precautions: Monitor pulmonary function; lymphoma patients: pre-existing pulmonary disorders; previous chemo, radiotherapy, smokers; lung cancer; anaesthesia; high dose; severe renal

pairment; elderly (> 70 years); pregnancy, lactation im Adverse Reactions: Anaphylaxis; pulmonary, renal, hepatic toxicity; dermatological toxicity/ changes; Pulmonary toxicity in approx. 10% of patients may progress to pulmonary fibrosis and

eath; fever; headache; GI upset include anorexia; tiredness; others, see full PI d Drug Interactions: Digoxin; phenytoin; other antineoplastics; granulocyte colony stimulating factor Phenytoin- Serum concentrations of phenytoin may be decreased due to decreased absorption or increased metabolism of phenytoin. Cisplatin – reduces clearance of bleomycin and increases the risk of pulmonary toxicity, patients

eed to be monitored closely n Dosage and Administration Bleomycin may be given by the intramuscular, intravenous, subcutaneous, intra-pleural or intra-arterial routes. 10,000units –30,000 units. Maximum cumulative dose 300 000 – 400 000 international units.

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7.3.4 Carboplatin Platinum Compound Pregnancy Category: D * Uses/Indications: Advanced ovarian cancer (epithelial origin), Non small cell carcinoma, Small

ell Lung Carcinoma and Head and Neck tumours C Contraindications: Severe renal impairment, myelosuppression; platinum hypersensitivity;

regnancy, lactation p Precautions: Monitor blood counts, renal function, neurological status, auditory function; extensive

rior chemotherapy; debilitated; elderly p Adverse Reactions: Haematological, hepatic, neurological, renal, oto toxicity; GI upset; electrolyte

isturbance; alopecia; flu-like symptoms; local reactions d Drug Interactions: Other myelosuppressive drugs; nephrotoxic drugs eg aminoglycosides; Dose: AUC 2-6 Calvert’s formula -Dose= AUC x (creatinine clearance + 25) Cockcroft – Gault Formula: Creatinine Clearance

Male = 88.4 x(140-age) x weight 72 x serum creatinine

Female= 75.23 x(140-age) x weight

72 x serum creatinine

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7.3.5 Cisplatin Platinum Compound Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Platinum compound. Single or combination treatment of metastatic nonseminomatous germ cell carcinoma, advanced refractory ovarian carcinoma, advanced efractory bladder carcinoma, refractory squamous cell head and neck carcinomas r

Contraindications: Renal impairment (Creatinine Clearance <30ml/min or serum creatinine > 200 micromol/L); hearing disorders; pre-existing bone marrow depression; platinum hypersensitivity;

regnancy, lactation p Precautions: Hepatic dysfunction; monitor renal, hepatic, auditory, haematological, neurological unction; electrolyte levels; ensure adequate hydration f

Adverse Reactions: Nephro/ oto/ neurotoxicity; hyperuricaemia; leucopenia, thrombocytopenia, anaemia; severe nausea, vomiting; hypomagnesaemia, hypocalcaemia, SIADH; peripheral neuropathy; blurred vision, optic neuritis, papilloedema, cortical blindness; cardiac disorders; alopecia; pulmonary toxicity (with bleomycin or 5-FU); myalgia; decrease fertility (male); pyrexia;

jection site reactions eg phlebitis; anaphylactic-like reactions in Drug Interactions: Nephro/ ototoxic drugs; aluminium containing administration equipment Dose and Administration: Typical doses and schedules are: 50 to 100 mg/m2 as a single intravenous (IV) infusion over 1 to 2 hours. 20 to 25 mg/m2 for 3 – 5 days as a single intravenous (IV) infusion over 1 to 2 hours. Combined with radiotherapy: 30 to 40 mg/m2 weekly Hydration: Pre and Post hydration MUST be administered as per unit protocol.

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7.3.6 Cefepime hydrochloride (Maxipime) Cephalosporins Consumer Medicine Information: Available Pregnancy Category: B1 Uses/Indications: Infections due to susceptible organisms including pneumonia, UTI, skin, intra-

bdominal, gynaecological infections, septicaemia; febrile neutropenia a Contraindications: Hypersensitivity to cephalosporins, penicillins, other beta-lactams Precautions: GI disease (esp colitis); prolonged use; renal impairment; allergic history; elderly monitor renal function), pregnancy, lactation. (

Adverse Reactions: Pseudomembranous colitis; superinfection; encephalopathy; fits; myoclonus; neutropenia; rare blood dyscrasia injection site reactions (IV); GI upset; headache; rash; fever;

thers, diarrhoea o Drug Interactions: Nephrotoxic drugs eg aminoglycosides; potent diuretics, Probenicid increases the length of activity. Dose: Adults: admin IM, IVI or infusion; usual dose 1 g – 2g every 12 hours.

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7.3.7 Ciprofloxacin hydrochloride (Ciproxin) Quinolones Consumer Medicine Information: Available Pregnancy Category: B3 Uses/Indications: Urinary tract infections, gonorrhoeal urethritis and cervicitis, gastroenteritis, bronchial infections, skin and skin structure infections, bone and joint infections due to susceptible organisms, chronic bacterial prostatitis of mild to moderate severity; inhalational anthrax postexposure); see full PI (

Contraindications: Quinolone hypersensitivity including nalidixic acid; concurrent tizanidine Precautions: Cystic fibrosis (Ps. aeruginosa resistance); prolonged use; CNS disorders, epilepsy, myasthenia gravis; photosensitivity; alkaline urine (crystalluria), ensure adequate hydration; renal,

epatic impairment; elderly; prior corticosteroids (see full PI); pregnancy, lactation, children h Adverse Reactions: Superinfection; pseudomembranous colitis; tendon rupture; CNS stimulation;

paired alertness; anaphylactoid reaction; GI upset; rash; others, see full PI im Drug Interactions: Tizanidine (see Contra); CYP1A2 metabolised drugs eg theophylline, methylxantines, caffeine; probenecid; anticoagulants; cyclosporin; metoclopramide; glibenclamide; NSAIDs; methotrexate; iron; sucralfate; antacids (containing Mg, Al, Ca); highly buffered drugs Dose: Oral tablets 250 – 750mg bd Tablets should be taken on an empty stomach (i.e. at least one hour before food) IV infusion 200 – 300mg bd (check renal function)

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7.3.8 Loratadine (Claratyne) Antihistamines Pregnancy Category: B1 Uses/Indications: Antihistamine for pre-medication before Taxanes, monoclonal antibodies, easonal and perennial allergic rhinitis, relief of chronic urticaria s

Contraindications: Syrup: Sodium benzoate sensitivity Precautions: Hepatic impairment; pregnancy, lactation, children < 1 year Adverse Reactions: Headache; fatigue; dry mouth; anxiety; hyperkinesia Dose: Adults: 10mg po daily. As pre-medication:10MG PO 1 hour prior to chemotherapy or monoclonal antibodies.

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7.3.9 Dexamethasone sodium phosphate Adrenal steroid hormones Consumer Medicine Information: Available Pregnancy Category: C Uses/Indications: Replacement therapy in adrenocortical insufficiency; anti-inflammatory, immunosuppressant (see full PI); perioperative support; shock, prevention / treatment of hemotherapy induced nausea and vomiting; pre-medication for prevention of drug reactions c

Contraindications: Systemic fungal infection; peptic ulcer; concurrent live virus vaccines; yasthenia gravis; osteoporosis; psychosis m

Precautions: High dose, prolonged use; abrupt withdrawal; diabetes; systemic infection; masks infection; CHF; chronic renal failure; latent TB; ocular herpes simplex; diverticulitis; hypertension; keratitis; epilepsy; local infection, unstable joints (intra-articular injection); elderly; pregnancy; lactation; others, see full PI Administration of live vaccines Adverse Reactions: Fluid and electrolyte, musculoskeletal, GI, skin, neurological, haematological,

ndocrine, ocular, metabolic disorders, large doses can cause behavioural and personality changes e Drug Interactions: Immunisation (see Contra); barbiturates, phenylbutazone, phenytoin, rifampicin; cyclosporin; anticoagulants; K+ depleting diuretics; NSAIDs; lab results; others, see full PI Dose: 4 –20mgs For prophylaxis of nausea and vomiting: 8 – 16mg (IV/PO) pre chemotherapy then 4–8mg orally once or twice daily for 2 –4 days post chemotherapy. For prevention of drug reactions: 8 – 20mg IV, 30 minutes prior to treatment

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7.3.10 Diphenhydramine hydrochloride (Unisom sleep gels) Sedatives, hypnotics Consumer Medicine Information: Available Pregnancy Category: A Uses/Indications: Short-term relief of insomnia, antihistamine, pre medication for taxol and

onoclonal antibodies. m Contraindications: Acute asthma; narrow angle glaucoma; prostatic hypertrophy, bladder obstruction; peptic ulcer; pyloroduodenal obstruction; concomitant antidepressants;

remature/newborn infants p Precautions: Cirrhosis; history of asthma; lactation, children < 12 years Adverse Reactions: Drowsiness, dizziness; anticholinergic effects; GI disturbances Drug Interactions: CNS depressants incl. alcohol; MAOIs Dose: Adults: 50mg orally daily. Pre-medication 50mg one hour prior to chemotherapy / monoclonal antibodies.

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7.3.11 Dolasetron mesylate (Anzemet) Noncytotoxic and supportive therapy Consumer Medicine Information: No Pregnancy Category: B1 Uses/Indications: 5HT3 antagonist. Prevention, treatment of nausea, vomiting induced by cytotoxic hemotherapy and postoperative nausea, vomiting c

Precautions: Rapid IV admin; cardiovascular disease, conduction disturbance; electrolyte isturbance; pregnancy, lactation, children d

Adverse Reactions: Headache, dizziness; diarrhoea; brady/tachycardia, hypotension; raised LFTs; CG changes; pruritus; others, see full PI E

Drug Interactions: Class I, III antiarrhythmics Dose: Chemotherapy patients: 100mg IV or 200 mg PO, 30-60 minutes before treatment, then 200mg PO daily for 1-2 days post chemotherapy.

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7.3.12 Cyclophosphamide Alkylating agents Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Nitrogen mustard analogue. Myeloproliferative and lymphoproliferative disorders; disseminated neuroblastoma; ovarian adenocarcinoma; retinoblastoma; breast and lung carcinoma;

utoimmune disease; transplant rejection prevention a Contraindications: Infection (active, systemic, UTI); recent surgery (4-8 days); severely depressed bone marrow function (esp prior radiotherapy, cytotoxins); urinary outflow obstruction; haemorrhagic ystitis; pregnancy (1st trimester), lactation c

Precautions: Carcinogenic potential; adrenalectomised; adequate hydration, frequent voiding; electrolyte imbalance; adequate contraception; previous X-ray, radiotherapy or cytotoxic therapy; haematological monitoring; tumour cell infiltration of bone marrow; hepatic impairment; renal impairment dose will need to be reduced, leucopenia, thrombocytopenia; cardiac disease;

orphyria. p Adverse Reactions: Haemorrhagic cystitis; gonadal suppression; pigmentation, rash; cardiotoxicity; fluid retention; poor wound healing; hyperuricaemia; GI upset; nephrotoxicity; hepatotoxicity; pulmonary fibrosis; secondary malignancy, infection; alopecia; haematological effects; veno-occlusive disease. Alopecia, nausea and vomiting, anorexia, mylosuppression,

aemorrhagic cystitis h Drug Interactions: Drugs that induce, inhibit liver enzymes eg phenobarbitone, imipramine, phenothiazines, barbiturates; allopurinol; suxamethonium; indomethacin; cardiotoxic drugs; insulin, other hypoglycaemics; anthracyclines; hydrochlorothiazide; phenytoin; benzodiazepines; other cytotoxics, immunosuppressants; digoxin; mesna; corticosteroids; anticoagulants; vaccines; alcohol; grapefruit; skin tests, Pap test Dose: 600mgs –1500mg/ m2 Intravenous. 50 –75 mg/m2 Oral May need extra fluids, mesna and hydration with high dose therapy.

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7.3.13 Doxorubicin hydrochloride Liposomal (Caelyx) Antibiotic cytotoxics Consumer Medicine Information: Available Pregnancy Category: D Uses/Indications: Breast cancer (monotherapy); advanced epithelial ovarian cancer after failed platinum based chemotherapy; AIDS related Kaposi's sarcoma in patients with low CD4 counts, extensive mucocutaneous or visceral disease; AIDS related Kaposi's sarcoma refractory or

tolerant to prior combination chemotherapy in Contraindications: AIDS related Kaposi's sarcoma responsive to local therapy, systemic alpha-interferon; intramuscular, subcutaneous use; pregnancy (for 6 months post-therapy including female

artners of treated males), lactation p Precautions: Impaired cardiovascular function/ disease (frequent ECG monitoring necessary); prior

ediastinal radiotherapy; diabetes; children m Adverse Reactions: Myelosuppression; cardiomyopathy, CHF; GI upset; rash; opportunistic infections; palmar-plantar erythrodysaesthesia; infusion reactions; extravasation injury; others, see ull PI f

Drug Interactions: Other cytotoxic agents (especially myelotoxic, cardiotoxic agents); other anthracyclines; cyclophosphamide; 6-mercaptopurine Dose: 20mg/m2 IV every two weeks or 30mg/m2 IV every three weeks or 40 - 50 mg/m2 IV every four weeks.

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7.3.14 Dacarbazine

Synonyms: DIC or DTIC Other antineoplastic agents Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Metastatic malignant melanoma and various sarcoma, Hodgkin’s disease. Contraindications: Previous severe myelosuppression; pregnancy, lactation Allergic reaction to dacarbazine. Precautions: Haematological monitoring; restrict food intake 4-6 hours prior to therapy; ensure oral hygiene; skin, eye contact; renal, hepatic impairment; polio immunisation in personal contacts;

ental work d Adverse Reactions: Bone marrow depression; hepatic dysfunction; GI upset; flu-like syndrome; hypotension,; ECG changes; CNS disturbances; Budd-Chiari syndrome (rare); inj site pain; others, ee full PI s

Drug Interactions: Hepatic enzyme inducers; mercaptopurine; azathioprine; other marrow depressants, radiotherapy; allopurinol; fotemustine; levodopa; viral vaccines within 3-12 months of treatment Dose: Melanoma 850 - 1000mg/m2 as a single dose. Hodgkins disease 375mg/m2

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7.3.15 Augmentin Duo Forte Tablets Pregnancy Category: B1 Uses/Indications: Short-term treatment of infections due to susceptible organisms: UTIs; lower respiratory tract infections (including community acquired pneumonia, exacerbations of chronic bronchitis); URTIs (including sinusitis, otitis media, recurrent tonsillitis); skin structure infections; see ull PI f

Contraindications: History of amoxycillin/ clavulanic acid associated jaundice or hepatic ysfunction; allergy to beta-lactams d

Precautions: Renal, hepatic dysfunction; prolonged use; infectious mononucleosis; lymphatic ukaemia; elderly; pregnancy, labour, delivery, lactation le

Adverse Reactions: Sensitivity phenomena (including anaphylaxis); pseudomembranous colitis; uperinfection; hepatic disturbances; GI upset; others, see full PI s

Drug Interactions: Allopurinol; probenecid; alcohol; OCs; urine glucose tests Dose: Adults oral: 875mg BD for 5-7 days

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7.3.16 Docetaxel (Taxotere) Antimetabolites Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Taxane. Breast cancer (selected patients); non-small cell lung cancer; metastatic

varian cancer; androgen independent prostate cancer o Contraindications: Neutrophil count < 1.5 x 109/L; severe hepatic impairment; pregnancy,

ctation, Allergy to solubilising agent or taxane la Precautions: Monitor haematological, hepatic function; give corticosteroid premed; elderly Adverse Reactions: Rash, sensitivity phenomena; alopecia; hand-foot syndrome (combination therapy); haematological effects; oedema; GI upset; hypertension, hypotension; neurosensory ymptoms; inj site reaction; lacrimation +/- conjunctivitis; visual effects; others, see full PI s

Dose: 30mg-40MG/m2 Weekly,75-100mg/m2 every 3 weeks Pre-medicate: with dexamethasone 8mg BD po the day before treatment, on the day of and the day after treatment. Weekly treatment: pre-medicate with 8mg dexamethasone on the day of treatment.

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7.3.17 Gentamicin sulfate Aminoglycosides Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Aminoglycoside antibiotic. Infections due to susceptible organisms; bacteraemia; respiratory tract infections; persistent urinary tract infections; skin, skin structure, bone infections;

eritonitis; septic abortion; burns complicated by sepsis p Contraindications: Previous toxic reaction (oto/ nephrotoxicity) to aminoglycoside therapy Precautions: Renal impairment; long-term (> 10 days) therapy; high doses; dehydration; monitor blood levels, renal, auditory function; topical application; neuromuscular disorders incl myasthenia

ravis, parkinsonism; elderly; pregnancy, lactation; neonates, infants, children g Adverse Reactions: Oto/ neuro/ nephrotoxicity; allergic reactions; superinfection; rash, purpura; respiratory effects; increased serum transaminases, bilirubin; GI upset; anaemia; leucopenia; granulocytopenia; transient agranulocytosis; change in reticulocyte counts; thrombocytopenia; low erum Mg, Ca, K; inj site reaction; others, see full PI s

Drug Interactions: Penicillins; diuretics (eg ethacrynic acid, frusemide); neuromuscular blocking drugs; citrated blood transfusion; opioids; inhalational anaesthetics; cephalosporins; vit K; other aminoglycosides, oto/ neuro/ nephrotoxics (see full PI); antineoplastics Dose: Administration by IMI or IV infusion; complex, see full PI. Normal renal function: IM/IV, 4–7 mg/kg once daily. Use the higher dose for young adults and the lower dose for the elderly. Gentamicin levels should be monitored with continuing therapy > 48 hrs, measure drug concentrations and calculate creatinine clearance every 3–5 days in clinically stable patients. Obtain these results daily if clinical state (especially renal function) is unstable; consider use of alternative antibiotic.

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7.3.18 Doxorubicin hydrochloride (Adriamycin) Antibiotic cytotoxics Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Anthracycline. Used in numerous neoplastic conditions: Contraindications: Marked myelosuppression; severe stomatitis; previous treatment with full cumulative doses of doxorubicin and daunorubicin; severe hepatic impairment; generalised infection; anthracycline, anthracenedione hypersensivity; pregnancy, lactation. IV admin: severe arrhythmias; MI; myocardial insufficiency; IV `push'. Intravesical admin: tumours invading bladder

all; UTI; bladder inflammation; catheterisation eg due to massive intravesical tumours w Precautions: Monitor haematology, LFTs, cardiac function; cardiac disease; radiotherapy especially mediastinal; obesity; prior cytotoxic therapy; This drug is a vesicant and should avoid extravasation; hepatic impairment; ensure male patients use effective contraception; monitor urine ytology, cystoscopy (intravesical use); increasing dose c

Adverse Reactions: Cardiotoxicity (this may be delayed); mucositis; myelosuppression; injection site reaction; red urine; male infertility; premature menopause; thromboembolism; alopecia;

norexia; GI upset, abdo pain; hyperpigmentation; dehydration; flushing a Drug Interactions: Cyclophosphamide in combination cause increased risk of cardiac toxicity and haemorrhagic cystitis, heparin; propranolol; other cardiotoxic, cardioactive drugs include Ca antagonists (in patients with cardiac risk factors); additive effects esp with other myelotoxic drugs; 6-mercaptopurine; other DNA damaging agents; radiotherapy Dose: 20mgs- 75mg/m2 IV Drug to given via the side arm of fast running IV of Normal Saline. Caution necessary as drug is a vesicant. Maximum cumulative dose 550mg/m2, 400-450mg/m2 if elderly or given with high dose cyclophosphamide.

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7.3.19 Epirubicin hydrochloride Antibiotic cytotoxics Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Anthracycline. Breast, gastric, ovarian cancer; small cell lung cancer; non-Hodgkin's lymphoma; advanced/ metastatic soft tissue sarcoma; superficial bladder cancer;

apillary bladder cancer (recurrence prevention) p Contraindications: Persisting myelosuppression or severe stomatitis from previous drug or radiotherapy; generalised infections; urinary infections, catheterisation problems, bladder inflammation, invasive bladder tumours (intravesical use); cardiac, marked hepatic impairment; past max cumulative dose of mitozantrone, mitomycin or other anthracyclines; IM, SC admin;

nthracycline, anthracenedione hypersensitivity; pregnancy, lactation; others, see full PI a Precautions: Concomitant/ previous cardiac irradiation, cardiotoxic drugs; high doses; monitor ardiac, renal, hepatic, haematological function; hyperuricaemia; hepatic, renal impairment c

Adverse Reactions:Cardiotoxicity, extravasation of vescicant drug, central nervous system toxicities, cardiovascular toxicity, bone marrow suppression Dose: 30mg – 90mg m2 IV Given as a bolus via the side of a fast running IV Normal Saline. Caution necessary as drug is a vesicant. Maximum cumulative dose 700 – 1000mg/m2. (caution in elderly when exceeding 500mg/m2). Monitor left ventricular ejection fraction.

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7.3.20 Etoposide phosphate (Etopophos) Other antineoplastic agents Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Podophyllotoxin derivative. Small cell carcinoma of the lung; acute monocytic

nd myelomonocytic leukaemia; Hodgkin’s disease; non-Hodgkin’s lymphoma; testicular tumours a Contraindications: Severe hepatic or renal dysfunction; intra-cavity injection Allergy to polysorbate80, etoposide or etoposide phosphate Precautions: Haematological monitoring; infection; extravasation; skin contact; monitor hepatic and renal function; combined chemotherapy; adequate contraception; renal impairment;

ypoalbuminaemia; pregnancy, lactation, children h Adverse Reactions: Anaphylaxis; myelosuppression; GI upset; asthenia, malaise; chills/fever; dizziness; alopecia; hypotension; Stevens-Johnson syndrome. Dose: 113.6mgs of Etoposide Phosphate is equivalent 100mg Etoposide, Etoposide dose 80mgs –120mg/m2 Administration: as it is an irritant, it is given via the side arm of a fast running intravenous infusion of

ormal saline over 5-10minutes. n

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7.3.21 Etoposide Other antineoplastic agents Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Podophyllotoxin derivative. Small cell carcinoma of the lung; acute monocytic

nd myelomonocytic leukaemia; Hodgkin's disease; non-Hodgkin's lymphoma a Contraindications: Severe hepatic dysfunction; severe bone marrow depression not due to

alignant disease; intrapleural or intraperitoneal inj m Precautions: Haematological monitoring; infection; acute reactions; extravasation; combined chemotherapy; renal, hepatic dysfunction; hyperuricaemia; adequate contraception; pregnancy,

ctation, children la Adverse Reactions: Myelosuppression; GI upset; alopecia; hypotension; others, Dose: Intravenous: 50mg – 120 mg/m2/day for 1-5 days Orally: 100mg – 200mg/m2/day for 1 –5 days IV Administration – Infuse over 1 hour to avoid hypotension and bronchospasm.

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7.3.22 Fluorouracil (5FU) Antimetabolites Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Uracil analogue. carcinomas of the breast, colon, rectum, stomach or pancreas Contraindications: Poor nutritional state; bone marrow depression; serious infection; pregnancy Precautions: Pelvic irradiation; prior alkylating agents; previous fluorouracil cardiotoxicity; other tressful treatment or nutritional problem; renal, hepatic impairment; elderly esp female; lactation s

Adverse Reactions: GI upset; myelosuppression; cardiotoxicity; rash; Sun sensitivity ,neurotoxicity; ocular toxicity; with levamisole: multifocal inflammatory leucoencephalopathy;

fertility (possible);Hand foot Syndrone more common with continues infusion than bolus, see full PI in Drug Interactions: Folinic acid; allopurinol (decreases myelosuppression); methotrexate; metronidazole; cimetidine; chemotherapy, radiotherapy; other myelosuppressive treatment; levamisole; thyroid function tests Dose 200mg-2400mg/ m2 Administration may be by Infusion, Bolus or via an ambulatory pump

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7.3.23 Hydrocortisone (Solu-Cortef) Adrenal steroid hormones Consumer Medicine Information: Available Pregnancy Category: A Uses/Indications: Glucocorticoid anti-inflammatory. Replacement therapy in Addison's disease, chronic adrenocortical insufficiency secondary to hypopituitarism. Pre-medication for, or treatment of

rug reactions. d Contraindications: Uncontrolled infections Precautions: High doses, prolonged use; abrupt withdrawal; mask infection; ocular herpes simplex; herpetic ulcers; renal insufficiency; cirrhosis; hypothyroidism; hypertension; osteoporosis;

yasthenia gravis; elderly, lactation, Glaucoma, see full PI m Adverse Reactions: Fluid and electrolyte, musculoskeletal, GI, skin, neurological, endocrine,

cular, metabolic disturbances; others, see full PI o Drug Interactions: OCs; barbiturates, phenytoin; rifampicin; other hepatic enzyme inducers; digoxin; K depleting diuretics Dose: Pre-medication: 100mg IV prior to chemotherapy. Hypersensitivity reactions: 100mg IV stat.

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7.3.24 Ifosfamide Alkylating agents Consumer Medicine Information: Available Pregnancy Category: D Uses/Indications: Nitrogen mustard analogue. Sensitive tumours (incl germ cell tumours, arcomas, lymphomas; ovarian, cervical, lung, breast cancer) s

Contraindications: Severe bone marrow impairment especially with other cytotoxics, radiotherapy; renal, severe hepatic impairment; urinary obstruction; bladder inflammation, cystitis; acute

fections; pregnancy, lactation in Precautions: Give prophylactic antiemetic prior to administration; ensure concomitant mesna; unilateral nephrectomy; renal, hepatic, cardiac, haematological impairment (monitor); diabetes; recent surgery (within 10-14 days); oral hygiene; urinalysis; ensure adequate hydration, electrolyte balance; carcinogenic potential, adequate contraception; high tumour burden; low serum albumin; pelvic tumours; alcohol abuse; elderly; children; Heart Failure patients may not tolerate high fluids. Adverse Reactions: Urotoxicity especially haemorrhagic cystitis; nephrotoxicity; CNS disturbances incl encephalopathy, drowsiness; immunosuppression; myelosuppression; alopecia; fever; infection; ec malignancy; delayed wound healing; impaired spermatogenesis; GI upset; others s

Drug Interactions: Cytostatics, irradiation; nephrotoxics incl cisplatin; vaccines; anticoagulants eg warfarin; oral hypoglycaemics; antiemetics, tranquillizers, narcotics, antihistamines; bupropion; grapefruit; allopurinol; hydrochlorothiazide; Dose: 1.6 –2 g/m2 daily over 3-5 days, give with Mesna and ensure adequate hydration. See specialist protocol

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7.3.25 Metoclopramide hydrochloride (Maxolon) Antiemetics, antinauseants Consumer Medicine Information: Available Pregnancy Category: A Uses/Indications: Adults: control of nausea and vomiting (not of labyrinthine origin); adjunct to X-ray exam of stomach and duodenum; to assist intestinal intubation; to facilitate absorption of other drugs; management of gastric retention; diabetic gastroparesis. Young adults < 20 yrs and children: severe intractable vomiting of known cause; cytotoxic or radiotherapy associated nausea, vomiting;

id to GI intubation a Contraindications: Phaeochromocytoma; patients in whom GI stimulation may be dangerous Precautions: Establish diagnosis; reassess persistent vomiting; epilepsy; GI surgery; prolonged

se; hepatic, renal impairment; rapid admin; elderly; pregnancy, lactation, children, young adults u Adverse Reactions: Dystonic reactions; increased prolactin levels; CNS disturbances including

paired alertness; tardive dyskinesia; see full PI im Drug Interactions: Neuroleptics eg phenothiazines; other centrally active drugs; anticholinergics; narcotic analgesics; CNS depressants; may affect drug absorption Dose: Adult:Cancer Chemotherapy IV/PO 10-20mg every 4 hours

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7.3.26 Gemcitabine hydrochloride (Gemzar) Antimetabolites Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Locally advanced or metastatic non-small cell lung cancer; locally advanced or metastatic pancreatic adenocarcinoma; fluorouracil refractory pancreatic cancer; bladder cancer (alone or with cisplatin); unresectable, locally recurrent or metastatic breast cancer relapse after adjuvant/ neoadjuvant chemotherapy, incl an anthracycline (with paclitaxel); epithelial ovarian arcinoma recurrent/ relapsed > 6 mths of platinum based therapy (with carboplatin) c

Precautions: Prolonged infusion time, increased dose frequency; renal, hepatic impairment; monitor haematology, renal, hepatic function; alcoholism; concomitant radiotherapy; pregnancy,

ctation, children la Adverse Reactions: Flu-like syndrome; oedema; hepatic, cardiac, blood disorders; somnolence; GI upset; pulmonary effects; proteinuria, haematuria; rash (severe skin reactions, rare); pruritus;

lopecia; mouth ulceration; others, see full PI a Dose: 800mgs – 1250mg/ m2 Administration in 100ml Normal Saline over 30mins. Irritant drug may need side arm of Normal Saline

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7.3.27 Trastuzumab (Herceptin) Other Monoclonial Antibody Consumer Medicine Information: Available Pregnancy Category: B2 Uses/Indications: Metastatic breast cancer exhibting HER2 overexpression as monotherapy (if prior chemotherapy) or with taxanes. Adjuvant breast cancer is combined with chemotherapy. Contraindications: Hypersensitivity to Chinese hamster ovary cell protein Precautions: Pretreatment physical (especially cardiac) exam; symptomatic heart failure, coronary artery disease, hypertension (or history); lung disease, tumour with dyspnoea at rest; monitor ardiac function; pregnancy, lactation, children c

Adverse Reactions: Hepatic, cardiotoxicity; hypotension; respiratory, nervous system effects; aematological changes; rash; GI upset; chills, fever, infection; oedema; asthenia; others, see full PI h

Drug Interactions: Paclitaxel; anthracyclines Dose: weekly: 4mgs/kg iv loading over 90mins then 2mgs/kg iv over 30mins or 3weekly: 8mg/kg loading dose over 90mins then 6mg/kg iv thereafter over 30-60minutes.

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7.3.28 Methotrexate Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Folic acid analogue. Neoplasia incl breast cancer, gestational choriocarcinoma, chorioadenoma destruens, hydatidiform mole; leukaemia, lymphosarcoma, osteogenic sarcoma; bronchogenic carcinoma; epidermoid cancer of head, neck; severe debilitating psoriasis, Ectopic

regnancy. p Contraindications: Pre-existing blood dyscrasias, myelosuppression; immunodeficiency; radiotherapy (with intrathecal methotrexate); severe renal impairment; serious infection; pregnancy (including female partner of male patient) for greater than or equal to 3 months after treatment, lactation. Psoriasis patients: also severe hepatic disease; alcoholism; alcoholic liver disease; peptic ulcer; ulcerative colitis Precautions: Monitor haematological, pulmonary, hepatic (including pretreatment), lymphatic function; hepatic, renal impairment; folate deficiency; infection; peptic ulcer; debility; high doses; ulcerative colitis; third space compartments; prolonged use; ensure adequate hydration, urinary

lkalinisation; avoid UV exposure; elderly; children a Adverse Reactions: Myelosuppression; pulmonary toxicity; nephrotoxicity Dose: 30mg- 3000mg/ m2 oral, IMI,IV 12mg- 15mg Intrathecal twice weekly. High dose Methotrexate requires hydration, urinary alkalinisation and folinic Acid (Leucovorin) rescue. Measure Methotrexate levels if appropriate.

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7.3.29 Oxaliplatin( Eloxatin) Other antineoplastic agents Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Platinum compound. In combination with fluorouracil, folinic acid: adjuvant treatment stage III (Duke's C) colon cancer after complete resection of primary tumour; treatment

dvanced colorectal cancer a Contraindications: Myelosuppression; peripheral sensory neuropathy with functional impairment; evere renal impairment; pregnancy, lactation, previous allergy to oxaliplatin s

Precautions: Platinum allergy; monitor blood counts, neurological status; moderate renal, severe epatic impairment; extravasation; children h

Adverse Reactions: Haematological, neuropathy ( sensory peripheral neuropathy), GI, pulmonary, hepatic toxicity; alopecia; fever, febrile neutropenia; altered renal function; taste perversion;

rthralgia; back pain; rash; others, see full PI a Drug Interactions: Fluorouracil; incompatible with chlorides, basic solutions Dose: 85mg-100mgs /m2 to be given in 5%dextrose. Incompatible with Normal Saline, IV line to be primed with dextrose. When used in combination with 5FU, give Oxaliplatin first. May be administered concurrently with folinic acid.

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7.3.30 Stemetil (Prochlorperazine ) Tablets Injection Suppositories Antiemetics, antinauseants Consumer Medicine Information: Available Pregnancy Category: C * Uses/Indications: Nausea and vomiting; vertigo Contraindications: Circulatory collapse; CNS depression; bone marrow depression; administration

f discoloured (darkened) injection solution; rectal, IM adminstration in children o Precautions: Epilepsy; hypocalcaemia; renal, hepatic impairment; Parkinson's disease; hypothyroidism; myasthenia gravis; phaeochromocytoma; prostatic hypertrophy; spinal anaesthesia; Reye syndrome; risk of QT prolongation eg bradycardia, hypokalaemia; may mask diagnosis of GI

bstruction, brain tumour, drug overdose; elderly; pregnancy, labour, lactation, children o Adverse Reactions: Cardiac, anticholinergic effects; CNS disturbances incl impaired alertness, drowsiness, akathisia, parkinsonism, tardive dyskinesia, life threatening acute dystonic reaction (children); hypothermia; neuroleptic malignant syndrome; QT interval prolongation; blurred vision;

thers, see full PI o Drug Interactions: CNS depressants incl alcohol; desferrioxamine; anticholinergics; TCAs; procarbazine; phenytoin, other anticonvulsants; l-dopa; oral anticoagulants; thiazide diuretics; guanethidine; propranolol Dose: May be taken with or without food. Adults. Nausea and vomiting, chronic: 5-10 mg 2-3 times daily; Acute: 20mg orally at once then 10mg 2hrs later. IV/IM 12.5mg 8hourly prn. Rectal 25mg 6hourly.

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7.3.31 Mitomycin C Antibiotic cytotoxics Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Palliative treatment: carcinoma of stomach, pancreas, colon, lung (non-small ell), breast, cervix, head and neck, liver, bladder c

Contraindications: Thrombocytopenia; increased bleeding tendency Precautions: Monitor haematological status, renal function; admin. (IV only); impaired renal unction; pregnancy, lactation f

Adverse Reactions: Renal, hepatic, pulmonary toxicity; cellulitis; fever; GI upset; myelosuppression; haemolytic uraemic syndrome; CHF (rare) Dose 6-20mg/m2 IV Given via the side arm of a fast running Normal saline. Caution necessary as drug is a vesicant. Intravesical 40mg instilled into the bladder as per protocol

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7.3.32 Morphine Sulfate Injection Narcotic analgesics S8 Drug Consumer Medicine Information: Available Pregnancy Category: C * Uses/Indications: Narcotic agonist. Moderate to severe pain unresponsive to nonopioids; preop

edication; analgesic adjunct in GA m Contraindications: Acute/ severe asthma; respiratory insufficiency, depression; severe CNS depression; diabetic acidosis; severe hepatic disease, incipient hepatic encephalopathy; anastomosis, biliary tract surgery postop; biliary colic; GI obstruction; MAOIs (concurrent or in previous 14 days); arrhythmia; cor pulmonale; alcohol intoxication, delirium tremens; head injury; brain tumour; raised intracranial, cerebrospinal pressure; fits; tetanus; strychnine poisoning; premature infants, during premature delivery. Patient controlled analgesia: children < 6 yrs, adults

ith poor cognitive function. Continuous IV infusion: renal, hepatic disease w Precautions: Large doses, rapid admin; abrupt withdrawal; hypovolaemia; shock; cardiopulmonary, renal, hepatic impairment; hypothyroidism; Addison's disease; prostatic hypertrophy; urethral stricture; toxic psychosis; myasthenia gravis; acute abdominal conditions; obstructive, inflammatory GI disease; pancreatitis; epilepsy; supraventricular tachycardia; hypoxia; elderly, debilitated;

regnancy, labour, lactation, neonates p Adverse Reactions: Respiratory depression, apnoea, cardiac arrest; impaired alertness;

ependence; GI upset; hypotension; sweating; others, see full PI d Drug Interactions: MAOIs (see Contra); alcohol; CNS depressants; muscle relaxants; mixed agonist/ antagonist opioids (eg pentazocine, buprenorphine); cimetidine; diuretics; acidifying, alkalising agents; beta-blockers; TCAs; antihypertensives; others, see full Pi Dose: should be titrated depending on patient’s response to pain and whether they have previously received opioids. Given IV, IMI, S/C and Infusion Acute Pain 0.5-2mg every 3-4 hours IV,2.5-10mg every 2 hours PRN S/C IMI depending on age. Chronic Pain, titrate according to response.

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7.3.33 MS Contin ( Morphine Sulphate) Narcotic analgesics Consumer Medicine Information: Available sustained release product Pregnancy Category: C * Uses/Indications: Opioid responsive, chronic severe pain Contraindications: Acute asthma, obstructive airway disease, acute respiratory depression; cor pulmonale; cardiac arrhythmias; acute alcoholism; delirium tremens; severe CNS depression; convulsive disorders; raised cerebrospinal or intracranial pressure, head injury, brain tumour; suspected surgical abdomen; paralytic ileus; severe hepatic disease, incipient hepatic encephalopathy; severe renal dysfunction; concomitant MAOIs (Phenelzine and Tranylcpromine) +/- 14 days); chronic pain (nonmalignancy) with prior history of substance, alcohol abuse (

Precautions: Tolerance, dependence, chronic nonmalignant pain; epilepsy; abrupt withdrawal; pain transmission interruption surgery; impaired respiratory function; hypotension; hepatic, renal impairment; risk of abuse; Addison's disease; biliary colic, surgery; acute pancreatitis; ulcerative colitis; hypothyroidism; prostatic hypertrophy, urethral stricture; elderly, debilitated; pregnancy,

bour, delivery, lactation la Adverse Reactions: Respiratory, circulatory depression; hypotension; sedation; GI upset; weating; others, see full PI s

Drug Interactions: MAOIs (see Contra); acidifying/ alkalinising agents; amphetamines, chlorpromazine, methocarbamol; CNS depressants; pyrazolidone antihistamines; beta-blockers; alcohol; anticoagulants; cimetidine; zidovudine; ritonavir MS CONTIN (Tablets) S8 Morphine sulfate; 5 mg (white), 10 mg (tan), 15 mg (light green), 30 mg (purple), 60 mg (orange), 100 mg (grey); 200 mg (green); lactose (5 mg, 10 mg, 15 mg, 30 mg and 60 mg tablets only); f-c controlled release; gluten free; Dose: May be taken with or without food. Individualise dosage. Adults: initially 10-30 mg every 12 hrs; depending on the pain. Tablets must be swallowed whole, do not crush; see full PI

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7.3.34 Paracetamol (Panadol)

Simple analgesics and antipyretics Consumer Medicine Information: No Pregnancy Category: A Uses/Indications: Pain and fever Precautions: Hepatic, renal impairment; restricted salt intake (Soluble, Rapid tabs) Adverse Reactions: Rare: dyspepsia; nausea; allergy; haematological changes Drug Interactions: Anticoagulants; chloramphenicol; drugs affecting gastric emptying; hepatic enzyme inducers including alcohol, anticonvulsants Dose: Tablets, may be taken with or without food. Take with water. Adults, children > 12 yrs: 1-2 tabs every 4 hrs; max 8 tabs/day of 500mg 4grams /day. or Suppositories

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7.3.35 Pegfilgrastim (Neulasta) Noncytotoxic and supportive therapy Consumer Medicine Information: Available Pregnancy Category: B3 Uses/Indications: Colony stimulating factor. Decrease duration of severe neutropenia following hemotherapy c

Contraindications: E. coli derived protein, filgrastim hypersensitivity Precautions: Sickle cell disease; sepsis; mod-severe organ impairment; myelodysplasia; chronic

yeloid leukaemia; pregnancy, lactation m Adverse Reactions: Bone, back, limb pain; myalgia; arthralgia; splenic rupture; leucocytosis;

thers, see full PI o Drug Interactions: Chemotherapy (within 24 hours); radiotherapy; thrombocytopenic drugs Dose: 6 mg/chemo cycle by SCI; give approx 24 hours after chemotherapy. Store in Fridge (2-8 degree C)

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7.3.36 Premethazine Hydrochloride (Phenergan) Antihistamines Consumer Medicine Information: Available Pregnancy Category: C * Uses/Indications: Allergies; URTI; antiemetic; sedation; pre-medication for prevention of drug eactions r

Contraindications: High doses of other CNS depressants; coma; jaundice induced by henothiazines; subcutaneous admin; children < 2 yrs p

Precautions: Hypertensive crisis; epilepsy; narrow angle glaucoma; prostatic hypertrophy; cardiovascular disease; impaired hepatic, respiratory function; obstructive GI or urinary tract onditions; Reye's syndrome (children, adolescents); elderly; pregnancy, lactation, children c

Adverse Reactions: Dry mouth; GI upset; anorexia; epigastric discomfort; sedation; restlessness; dizziness; incoordination; fatigue; blurred vision; agranulocytosis; anaphylaxis; QT prolongation;

thers, see full PI o Drug Interactions: CNS depressants eg alcohol, barbiturates, hypnotics, opioids, anxiolytics, neuroleptics; antimuscarinics eg atropine, TCAs Dose: Pre-medication: 12.5-25mg IV/IM 30 minutes prior to treatment Nausea and vomiting: 25mg po 4-6hourly prn Max 100mg daily. IM/IV = 12.5mg – 25mg 4-6hourly PRN

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7.3.37 Ranitidine (Zantac)

Hyperacidity, reflux and ulcers Pregnancy Category: B1 Uses/Indications: Histamine 2-receptor antagonist. Proven duodenal ulcer (short-term treatment/ prevent relapse); proven gastric ulcer (short-term treatment/ prevent relapse (< 1 year)); reflux oesophagitis (short-term symptom treatment if unresponsive to conservative measures/ prevent relapse); gastrinoma (Zollinger-Ellison syndrome); scleroderma oesophagitis Contraindications Acute porphyria; pre-medication for prevention of Taxol drug reactions Precautions: Cardiac arrhythmia predisposition; exclude malignancy; history of acute porphyria;

tubated ICU patients; hepatic, renal impairment; elderly; pregnancy, lactation, children in Adverse Reactions: Headache; GI, CNS disturbances; rash; others, see full PI Drug Interactions: Sucralfate; others, see full PI Dose: Acute duodenal or gastric ulceration: 300 mg once daily or 150mg BD. Pre-medication: 150mg PO 1hour prior to Taxol or 50mg IV 30 minutes prior to Taxol

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7.3.38 Rituximab(Mabthera)

Other antineoplastic agents Consumer Medicine Information: Available Pregnancy Category: C * Uses/Indications: Previously untreated stage III/IV follicular, CD20 positive, B cell non-Hodgkin's lymphoma (+ chemotherapy); relapsed, refractory low grade or follicular, CD20 positive, B cell non-Hodgkin's lymphoma; CD20 positive, diffuse large B cell non-Hodgkin's lymphoma (+ hemotherapy) c

Contraindications: Hypersensitivity to murine proteins Precautions: High tumour burden, high circulating malignant cell count; pulmonary, cardiac disease; neutrophils < 1.5 x 109/L, platelets < 75 x 109/L; monitor blood counts; immunisation;

epatitis B history; pregnancy, lactation, children h Adverse Reactions: Severe cytokine release syndrome (dyspnoea, fever, chills, rigors, urticaria, angioedema); tumour lysis syndrome; hypotension; bronchospasm; arrhythmias, monitor cardiac function; anaphylaxis, hypersensitivity phenomena; GI upset; LDH incr; fatigue; headache; disease ite pain; others, see full PI s

Drug Interactions: Poss antihypertensives, vaccines; other monoclonal antibodies Administration: The Mabthera solution for infusion should be administered intravenously through a dedicated line. As with all parenteral products, appropriate aseptic technique should be used during the administration of Mabthera. Do not administer as an intravenous push or bolus. Hypersensitivity reactions may occur whenever protein solutions such as Mabthera are administered (see Precautions). Premedication, consisting of an analgesic/ antipyretic such as paracetamol and an antihistamine such as diphenhydramine, should always be administered 30 to 60 minutes before each infusion of Mabthera. Premedication with corticosteroids should also be considered. Since transient hypotension may occur during Mabthera infusion / rapid infusion, consideration should be given to withholding antihypertensive medications 6 to 24 hours prior to and during Mabthera infusion (see Precautions). First infusion. The recommended initial rate of infusion is 50 mg/hour. If hypersensitivity or infusion related events do not occur, escalate the infusion rate in 50 mg/hour increments every 30 minutes, to a maximum of 400 mg/hour. If hypersensitivity or an infusion related event develops, the infusion should be temporarily slowed or interrupted (see Precautions). The infusion can continue at one-half the previous rate upon improvement of patient symptoms. When used in combination with chemotherapy, Mabthera should be administered prior to the administration of chemotherapy. Any infusion related reactions should have settled before chemotherapy is instituted. Subsequent infusions. Subsequent Mabthera infusions can be administered at an initial rate of 100 mg/hour and increased by 100 mg/hour increments at 30 minute intervals, to a maximum of 400 mg/hour. 90 minute protocol : After the patient has received one course of Mabthera without any reaction, the subsequent infusions may be administered over 90 minutes. Premedication would be the same as for the standard infusion, plus Hydrocostisone 100mg IV 30

inutes prior to Mabthera. m

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7.3.39 Paclitaxel (Taxol) Antimetabolites Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Taxane antimicrotubule antineoplastic agent. Primary treatment of ovarian cancer in combination with a platinum agent; non-small cell lung cancer; 2nd line treatment of metastatic ovarian or breast carcinoma; adjuvant treatment of node +ve breast carcinoma; primary reatment (with trastuzumab) of metatastic overexpressed HER-2 cancer t

Contraindications: Severe neutropenia; sensitivity to PEG-35 castor oil Precautions: Premedicate, observe for possible hypersensitivity; monitor haematology; hepatic

pairment; serious cardiac conduction defects; neuropathy; pregnancy, lactation, children im Adverse Reactions: Hypersensitivity phenomena; myelosuppression; infection; hypotension, bradycardia; ECG changes; peripheral neuropathy; altered LFTs; arthralgia; GI upset, bowel

erforation; phlebitis; alopecia; others, see full PI p Drug Interactions: Cisplatin; ketoconazole; doxorubicin; hepatically metabolised drugs eg erythromycin, CYP2C8, CYP3A4 substrates, inhibitors; trastuzumab; filgrastim 5Flurououril may inhibit cytotoxic action of Paclitaxel ,avoid combining Cisplatin,Vincristine ,May add to neurotoxic effects –Monitor for neuropathy DOSE: 50mg-80mg/m2 over 1 hour weekly, 175mg -200mg/m2 over 3 hours every 3 weeks. Administration: Use non PVC administration sets with 0.22 micron inline filter. Taxol supplied in glass infusion bottles. Pre-medication: All patients should receive pre-medication with ranitidine, dexamethasone and loratadine. Loratadine: 10mg PO 1 hour prior to Taxol Ranitidine: 150mg PO 1hour prior to Taxol or 50mg IV 30 minutes prior to Taxol Dexamethasone: 8-20mg IV 30 minutes prior to Taxol

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7.3.40 Vincristine sulfate Vinca alkaloids Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Acute leukaemia; others see full PI Contraindications: Intrathecal admin; demyelinating Charcot-Marie-Tooth syndrome; radiation therapy through liver ports; lactation Precautions: IV use only; hepatic impairment; CNS leukaemia; infection esp herpes zoster, chicken pox, leucopenia; previous or concomitant cytotoxic, irradiation therapy; pre-existing neurological, neuromuscular disease; gout, urate stones; pulmonary disorders; reproductive potential;

xtravasation; eye contact; vaccination; monitor haematology; elderly; pregnancy e Adverse Reactions: Neurotoxicity; hepatic effects; leucopenia; GI upset incluses constipation; hyperuricaemia; urinary retention; hypo/hypertension; shortness of breath, bronchospasm; alopecia;

eafness; others, Jaw pain after 1st or 2nd doses only see full PI d Drug Interactions: Allopurinol; asparaginase; isoniazid; doxorubicin + prednisone; methotrexate; oral quinolones; phenytoin; nifedipine; digoxin; other neurotoxic drugs; mitomycin; live virus vaccines; polio vaccine in close contacts; CYP3A inhibitors (eg itraconazole); ototoxic drugs; bleomycin + cisplatin or etoposide; uricosuric antigout agents Administration. Vincristine injection must only be administered by the intravenous route. Intrathecal administration has resulted in death. Improper administration of Vincristine may result in extravasation causing local tissue necrosis and/or thrombophlebitis. Dose: 0.4 to 1.4 mg/m2 (MAX 2mg)

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7.3.41 Vinorelbine (Navelbine) Vinca alkaloids Consumer Medicine Information: Available Pregnancy Category: D * Uses/Indications: Advanced breast cancer if standard therapy fails; advanced non-small cell lung ancer c

Contraindications: Neutrophils < 1000 cells/mm3; severe infection sec to neutropenia; severe epatic insufficiency; intrathecal admin (may be fatal); pregnancy, lactation h

Precautions: Haematological monitoring; hepatic impairment; poor bone marrow reserve; oncomitant mitomycin, radiotherapy of liver; eye contact; ischaemic heart disease; children c

Adverse Reactions: Myelosuppression; vesication; bronchospasm; chest pain; neuropathy; constipation; GI upset; alopecia; rash; inj site reactions; fatigue; others, see full PI Administration: Navelbine injection must only be administered by the intravenous route. Intrathecal administration of other vinca alkaloids has resulted in death. Improper administration of Navelbine may result in extravasation causing local tissue necrosis and/or thrombophlebitis (see Dosage and Administration, Administration precautions). Give via the side arm of a fast running infusion of Normal Saline. Dose: Single agent treatment is usually given at 25 to 30 mg/m2 weekly. Following administration flush line with at least 250mL of normal saline to reduce thrombophlebitis.

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7.3.42 Leucovorin Calcium Calcium folinate Pregnancy Category: A Sport Category: Permitted in sport Uses/Indications: Folic acid antagonist neutralisation; high dose methotrexate therapy, leucovorin rescue; methotrexate OD; impaired methotrexate elimination; in combination with 5FU to improve

fficacy e Contraindications: Vit B deficiency anaemias 12 Precautions: Concurrent systemic methotrexate; pregnancy, lactation Adverse Reactions: Sensitivity phenomena; seizures; syncope; GI upset; leucocytopenia, hrombocytopenia (high doses) t

Drug Interactions: Fluorouracil; phenobarbitone, phenytoin, primidone; folic acid antagonists; intrathecal methotrexate Dose: For leucovorin rescue post high dose methotrexate (<3g/m2), give 15mg – 30mg orally every 6 hours for 12 – 16 doses (beginning 24 hours after the start of the methotrexate infusion). Higher doses may be required, depending on Methotrexate serum levels. In combination with 5FU: 20 – 400mg/m2 IV given prior to 5FU

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8. Referral Processes Following assessment and intervention the ONP will facilitate appropriate referral to departments or teams within the healthcare system. Referrals may be made to the following services and organisations: • Social Worker • Psychologist • Psychiatrist • Care Coordinators/Clinical Nurse Consultants/Specialised Nurses • General Practitioners • Community Health Team, including community nurses • Occupational Therapists • Support groups • Dietitians • Physiotherapists • Pharmacists • Medical staff

9. Outcome Measures for the Oncology Nurse Practitioner • Prompt treatment and intervention for symptom management for patients attending the

chemotherapy treatment area within 1 to 2 hours of the patient arrival • Prompt and appropriate referral to medical practitioners or other healthcare providers within

hours of the patient requiring medical assist. • Patient satisfaction survey to evaluate the education of patients and others in management

of side effects of chemotherapy and radiotherapy • Ongoing development of audit tools to evaluate the effectiveness of the ONP role. 10. Clinical Indicators Decrease admission rates due to early intervention for patients presenting for symptom management who are receiving chemotherapy. The number of admissions to RPHA of patients with side effects of chemotherapy over the number of patients treated with chemotherapy. The development of an audit tool to reflect the increase in documentation of patient’s toxicities from treatment when seen on days 8 and 15.A regular audit of patient’s notes would be performed. The total number of patients with febrile neutropaenia would be audited to see whether the patients seen by the ONP had a decrease rate of patients being admitted for the above symptom or shorter length of stay.

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11. References Adrian A and O’Connell J (2000) Nurse practitioners. In Lumby J & Picone D (eds) Clinical Challenges Allen & Unwin:Sydney Australian Nursing &Midwifery Council. National Competency Standards for the Nurse Practitioner (April 2006) Australian Health Ministers Advisory Council National Working Group – 1997 – National Standard for Mental Health Services, Australiana Government Publishing Service. Canberra Based on the 2001 Australian Bureau of Statistics Census Benner (1984) From novice to expert: Excellence and power in clinical nursing practice Addison-Wesley, Menio Park, California Cancer institute NSW both the annual report and web site Cancer Institute NSW – NSW Cancer Plan 2004-2006, Page 13). Cancer nurses society of Australia Clinical Practice Guidelines Department of Medical Oncology Royal Prince Alfred Hospital Information Handbook (2004) Department of Medical Oncology Royal Prince Alfred Hospital Protocol Book (2006) Handbook of Cancer Chemotherapy 6th Edition Roland T.Skeel International Council of Nurses (ICN), 2003. Definition of characteristics for NP/ Advanced Practice Nursing. www.icn-apnetwork.org MIMS Online NSW Health (2003a) Implemention of Nurse Practitioner positions. Nursing and Midwifery Office National Nursing and Nursing Education Taskforce. Australian Health Ministers Advisory Council. Myth Busters (February 2006) Nurses and Midwives Board of New South Wales, 2003, Nurse/Midwife Practitioner Information Brochure. Sydney; NSW NMB. Nursing Practitioners Guidelines. Role and scope of practice – Pain Management Nursing Practitioners Guidelines. Role and scope of practice – Emergency Mental Health Liaison The Australian Bureau of Statistics (2001) Census of population and housing New Zealand Nursing Office, 2000, Advanced Nursing Practice, NZNO position statement. Occupational Health and Safety Regulation 2001, clause 158 (listing Cyclophosphamide as a Notifiable Carcinogenic)

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Patterson C, Haddad B (1992) The Advanced Nurse Practitioner: Common attributes Canadian Journal of Nursing administration Nov/Dec 18-22 Pearson A (1984) The essence of advanced nursing is being there Nursing Mirror 159 160 • SHPA Committee of Specialty Practice in Oncology, Journal of Pharmacy Practice and

Research, SHPA Standards of Practice for the Safe Handling of Cytotoxic drugs in Pharmacy Department Vol 35, No 1, March 2005 pp44-52

Styles MM (1997), Conceptualizations of advanced nursing practice in A Hamric, J Spross and C Handson. Advanced Nursing Practice: An Integrative Approach. Philadelphia: WB Saunders (Wand and Happell 2001).The mental health nurse: contributing to improved outcomes for patients in the emergency department Accident and emergency nursing 9,1-11 Walsh M (1999) Introduction. In Walsh M, Crubmei A and Reveley S (Eds) Nurse Practitioners, Clinical Skills and Professional Issues. Butterworth, Heineman Oxford

Workcover guidelines on Occupational Health and Safety in relation to Cytotoxic Drugs (1997) Work Cover NSW Guidelines for handling cytotoxic drugs and related waste in health care establishments, 1997: • Work Safety Victoria Handling Cytotoxic drugs in the workplace, 2003 • Occupational Health and Safety Regulation 2002 • Circular No 98/99 NSW Health Department: Policy and Guidelines for the Administration of

Intravenous Medication in NSW and Community Health Services. Nurse Practitioner Guidelines utilized in the development of these Guidelines 1. SSWAHS Mental Health service Emergency Department Mental Liaison. 2. SSWAHS Pain Management

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Appendix (A) - Adverse reactions to chemotherapy drugs The following procedure should be followed for the treatment of patients following allergic reactions to administered intravenous infusions of blood products, cytotoxic or other anti-cancer medications under the care of all oncology medical officers as per policy Please note:

1. Oncology Department nursing staff accredited to administer intravenous medications and chemotherapy may follow the following Standing Orders.

2. Nursing staff are to be accredited for chemotherapy administration once annually. 3. Standing Orders are reviewed annually and signed and dated by the Head of the Oncology

Department 4. Intravenous medication administered by accredited Oncology Department Nursing Staff

must be entered and signed for in the patients’ medication chart. 5. The Oncology Nurse Practitioner or Medical Officer must countersign there phone orders of

medications given as per Standing Orders within 24 hours. 6. Patient assessment must be continued following any intervention and documented in the

patients notes 7. Interventions as listed below will cease upon the return of physical symptoms to an adequate

level or as directed by the Oncology Nurse Practitioner or Medical Officer MEDICATION STANDING ORDER DETAILS: As per policy

1. A patient who develops acute shortness of breath, increased heart rate, facial flushing associated with the administration of intravenous infusions of blood products, cytotoxic or other anti-cancer medications but with no change in level of consciousness:

a. Give 100mg hydrocortisone IV as a slow injection into a cannula over one minute or longer.

b. Consider rash or Shortness of Breath give 12.5mg promethazine IV diluted in 5ml normal saline as a slow injection into a cannula over 30 seconds or longer.

2. A patient who develops an acute decreased level of consciousness, oxygen saturation of 90% or less, respiration rate of 10 per minutes or less, heart rate greater than 120 per minutes or less that 40 per minute associated with the administration of an intravenous infusion of blood products, cytotoxic or other anti-cancer medications:

a. Give 100mg hydrocortisone IV as a slow injection into a cannula over one minute or longer.

b. Give 12.5mg promethazine IV diluted in 5ml normal saline as a slow push.

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GUIDELINES FOR THE MANAGEMENT OF ALLERGIC REACTIONS

Medical Oncology and A&E Protocol

MILD

Local skin reaction No changes in LOC Vitals within

normal limits

MODERATE

LOC unchanged, but increased anxiety

May experience some SOB

Flushed face HR 100-120 SaO2 90%-100 RA Systolic >90

SEVERE

Decreased LOC Assess airway for

oedema & ability to maintain own airway

SaO2 <90% RA RR <10 HR >120, <40

TREATMENT

Stop infusion: do not Remove IVC

Inform ONP or Medical Staff

Assess need for Oral antihistamine

Can be treated in Recliner

TREATMENT

Stop infusion: do not Remove IVC

Maintain airway Get help Apply O2 Administer 100mg

Hydrocortisone & 12.5mg Phenergan IV

Arrest trolley & Adrenaline

Get patient onto a hard flat surface

TREATMENT

Stop infusion: do not Remove IVC

Ask for help: inform ONP or medical staff

Apply O2 Administer 100mg

Hydrocortisone +/- 12.5mg Phenergan IV

REASSESS SEVERE

Call 222 Treat as per

Australian Guidelines For basic life support

Patient should be on a Hard flat surface. If on a recliner, slide Patient onto floor as Per manual handling Guidelines

MILD/MODERATE

D/C HOME +/-oral Antihistamines

Have ONP assess to Rechallenge

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Appendix (B) - Job Description

Royal Prince Alfred Hospital

JOB DESCRIPTION

IDENTIFICATION Title: Nurse Practitioner – Chemotherapy / Medical Oncology Classification: NP Year Division: Cancer Services Department: Medical Oncology Award/Agreement: NSW Nurses State Award” Position Number: “Position Number if applicable” Cost Centre Number: – Cancer services 22383” SUMMARY

The Oncology Nurse Practitioner is an advanced clinical practitioner who functions both autonomously and as an integral part of the Cancer Services team. This position is directly involved with clinical practice of patients receiving chemotherapy and is involved with research and education. The Oncology Nurse Practitioner provides clinical leadership through demonstration of clinical and professional standards of practice, utilises expert assessment, diagnosis and evaluation skills in providing health care to oncology patients.

KNOWLEDGE, SKILLS AND QUALIFICATIONS Essential Criteria

• Registered Nurse NSW. • Authorised as a Nurse Practitioner through the Nurses Registration Board of NSW • RN, with 7 years full time post registration experience • 5 years full time post registration experience in Cancer Nursing / Chemotherapy • Approved Post Graduate Nursing qualifications relevant to the field or such qualifications or

experience deemed appropriate by the Area Health Service. • Tertiary qualifications in relevant clinical specialty (or working towards). • Demonstrated excellent written & oral communication skills, Computer literate • Demonstrated excellent understanding of oncology nursing and current chemotherapeutic

management • Excellent clinical skills related to procedures involved in the care of cancer patients receiving

chemotherapy • Proven ability to consult, review, and develop, both new and existing policies and

procedures with the relevant specialties • Experienced in clinical research • Tertiary qualifications in relevant clinical specialty (or working towards).

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• Demonstrated commitment to professional development of self and others. • Demonstrated involvement in Quality Improvement activities. • Counseling experience Desirable Criteria

• Membership of professional specialty association. • Evidence of active involvement in the advancement of the Cancer nursing profession.

• Demonstrated skills in the development and delivery of educational programs • Demonstrated computer skills • Ability to maintain a data base

RESPONSIBLE TO Clinical Manager, Cancer Services RESPONSIBLE FOR The provision of high quality nursing expertise in the holistic management, education and care of Cancer patients undergoing chemotherapy and support and education the staff and carers. AIMS:

• To provide an advanced role in which appropriate skilled and authorised nurses can practice • Promote and maintain collaborative partnerships with all health care professionals involved

in care delivery. • Acts as a role model for advanced nursing practice. • Improve access to Cancer patients via the Emergency Department and Rural referrals • To provide expert nursing clinical support to patients receiving chemotherapy

HOURS OF WORK: Monday - Friday. PERFORMANCE APPRAISAL: Three months from commencement date, then annually

thereafter.

CONTINUUM OF CARE

To promote and develop the working model for advanced nursing practice

• Ability to act as an autonomous practitioner as well as an integral part of the multidisciplinary team.

To achieve high standards of nursing care at the level of advanced clinical practice.

• Undertakes autonomous patient care within the approved scope of practice. • Identifies and adopts innovative clinical practice models. • Actively participates in the formulation of relevant standards, policies and

procedures within the Cancer setting. • Engages in ethical decision-making and bases nursing actions on these decisions. • Uses multiple approaches to decision making.

To improve service delivery for patients and their families

• The Nurse Practitioner is a patient advocate who ensures that patients understand their rights, treatment and ongoing management.

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• Ensure a patient centred practice within the clinical environment involving patients and family as appropriate.

• Identifies new directions for the Oncology Department in line with SSWAHS strategic plan.

• Acts to promote the protection and safety of patients, self and others. • Accommodates spiritual, cultural and emotional needs of individuals/groups.

To abide by the SSWAHS Code of Conduct.

• Uphold Area, Hospital, Nursing and Departmental practices/policies. Engages in collaborative practice to provide better health care for patients.

• Consults with and refers to a range of health care professionals. • Participates in multidisciplinary clinical decision-making. • Collaborates with other staff to solve problems related to patient care as needed. • Delivers education on clinical issues to patients and carers. • Facilitates patient discharge and ongoing management through education and

appropriate referral. LEADERSHIP AND MANAGEMENT

• Instills confidence and trust in colleagues • Establishes positive relationships with colleagues • Facilitates the development of colleagues practices • Acts as a role model and consultant for colleagues • Takes a leadership role in the nursing management and care of Cancer presentations. • To ensure familiarity with, and adherence to, relevant NSW Health Department,

SSWAHS and Facility / Services policies and procedures that are relevant to the performance of the duties specified in this Job Description.

• A commitment to reduce wastes generation and segregate general, clinical and recyclable waste for safe disposal. Participate in waste reduction strategies which avoid, reduce recycle and re-use waste.

• Comply with Privacy legislation and corresponding SSWAHS policies and procedures. • To ensure staff has access and adheres to, policies and procedures required for the

performance of their duties. • To facilitate staff consultation and participation in the workplace.

HUMAN RESOURCE MANAGEMENT

Maintaining an effective personal and professional development programme by:

• Continuing professional development through identification of personal strengths and weaknesses.

• Attending and participating in educational activities, e.g. in-service, seminars, workshops, mandatory training programs, i.e. Fire & Safety.

• Utilising educational resources to enhance the knowledge base and skills of self and peers.

• To abide by E.E.O. principles and policies. • To promote, implement and evaluate EEO and Affirmative Action policies and strategies.

To maintain and promote professional development of self and others.

• Displays a commitment to the professional development of staff in the within Cancer services.

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• Collaborates with others in the development and delivery of education programs. • Demonstrates a commitment to personal & professional development to maintain best

practice. • To participate in the SSWAHS Performance Management program.

• Demonstrates effective communication, using verbal, written and information

technology. • Ability to represent the nursing profession and Oncology Department in a range of

forums (Local, State and National) and to communicate the outcome of deliberations with nurses and other health professionals.

• Provide ongoing comprehensive analyses of current practice and the impact of new directions on the clinical service.

• Utilises research and relevant theoretical frameworks to inform and guide nursing practice.

INFORMATION MANAGEMENT

SAFE PRACTICE & ENVIRONMENT

• To ensure compliance with the following:

- Occupational Health and Safety Act (2000) and amendments. - Workers’ Compensation Act 1987 and amendments. - Workplace Injury Management and Workers’ Compensation Act 1998

and amendments - NSW Health Department Guidelines - Australian Standards

• To ensure all accidents and incidents are reported, recorded, investigated and analysed and short and long-term corrective action is taken and its effectiveness evaluated.

• To participate in the Workplace Rehabilitation Program. • To notify the Rehabilitation Co-ordinator of all injuries and ensure effective rehabilitation

of injured workers. • To ensure regular workplace inspections are conducted and recorded and all reported

risks are assessed and appropriate action taken to manage risks and evaluate its effectiveness.

• To ensure staff are familiar with emergency procedures by organising attendance at appropriate training (for example: Fire Safety Training).

• To abide by the CSAHS Smoke Free Environment Policy.

Child Protection Guidelines: • To facilitate staff awareness of the NSW Health, CSAHS and local service child

protection policies and procedures, including reporting requirements. • To facilitate staff attendance at appropriate training programs for Child Protection. • To facilitate provision of appropriate supervision / support to staff who are involved in

critical incidents / child protection issues. • To report any suspected fraud in the workplace. • To minimise the incidence of corruption and fraud within the workplace. • To instigate investigations into any suspected incidences of fraud and corruption.

Maintaining a safe and secure environment by: • Using equipment safely and appropriately.

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• Removal of environmental hazards. • Maintaining standard precautions.

IMPROVING PERFORMANCE

Quality Improvement:

• To implement quality activities to guide service delivery and continued improvement. • To facilitate work practice reviews to ensure current standards are maintained and

technological changes are incorporated to reflect corporate objectives. • To implement recommendations which emanate from work practice reviews. • To ensure compliance with the standards contained within the Australian Council on

Health care Standards guidelines for Accreditation. To produce measurable quality outcomes and research articles.

• Develops and monitors measurable outcome indicators. • Provides outcome measures to appropriate bodies as required. • Plans, monitors and evaluates performance utilising identified indicators. • All projects undertaken will have a Quality Framework. • Initiates and/or participates in Quality projects.

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KEY RESULT AREAS

Continuum of Care:

• The standard of Patient Care delivered appropriate to the level of the professional role. • Awareness of identifying education needs of patient and significant other. • Quality of consultancy to other Health Professionals as measured by frequency and

appropriateness of request and poor feedback. • Improve access to the Oncology Department.

Leadership and Management:

• Upholding Area, Hospital and Departmental policy and procedures.

Human Resource Management: • Maintaining personal ongoing professional growth and development.

Information Management: • The accuracy and appropriateness of communication.

Safe Practice and Environment: • The maintenance of a safe and secure environment.

Improving Performance: • Demonstrated participation in Departmental and Hospital quality improvement activities

and EQuIP preparation. I have read this job description, understand its requirements and agree to fulfil its functions to the standard outlined. PRINT NAME: ………………………………………………………………………………… EMPLOYEE’S SIGNATURE: ……………………………… DATE: ………………... DIRECTOR OF NURSING: ……………………………… DATE: ………………...

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Acknowledgements Professor Kate White Professor Cancer Nursing Sydney University Carl Schneider Pharmacist Guideline Committee Head of Medical Oncology Professor Michael Boyer ______________________ Date_________ Clinical Manager Catherine Murray ___________________________ Date_________ Clinical Nurse Consultant Lydia Visintin ______________________________ Date_________ Oncology Pharmacist Alison Cavill _______________________________ Date_________ Cancer Support Program Coordinator Gina Salvos _______________________________ Date_________ Collaboration and consultant with the following Heads of Departments Department Head Professor Douglas Joshua _________________Date_______ Laboratory Service John Boyd ____________________________ Date_______ Radiology Dept Richard Waugh______________________________ Date______

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