Standards for
Chemotherapy Services

in South Australia

November 2010

The South Australian Cancer Clinical Network Steering Committee has overseen
the development of the Standards for Chemotherapy Services in South Australia
2010 with the view that their statewide implementation will support a common
framework for safe, high quality practice. The standards will also enable
monitoring of competence and benchmarking of clinical services against
identified minimal requirements for varying complexities of care.

Prepared by Tracey Doherty: Deputy Chair, Cancer Clinical Network Steering
Committee

Endorsed by the Statewide Cancer Clinical Network Steering Committee on 5th
November 2010

Contents

Executive Summary 4

Scope and Purpose 6

Glossary 8

Background 10

Development of Standards 12

Workforce Implications 13

Implementation and Governance 15

Chemotherapy Risk Stratification 16

Chemotherapy Service Delineation 18

Standards Criteria 26

Appendix 1 Consultations and contributions 45

Appendix 2 Self evaluation and implementation matrix 48

Standards for Chemotherapy Services in South
Australia 2010

Executive Summary

South Australia has an aging population and as cancer is predominantly a
disease of the aging, the number of people with cancer is increasing. This
continues to be a growing challenge for our health system, workforce and
community. The Standards for Chemotherapy Services in South Australia (the
Standards) are one of the first in a group of planned documents designed to
support the health system to meet this growing challenge and ensure that South
Australians have equity of access to high quality cancer care as close to home as
safely possible.

The Standards for Chemotherapy Services in South Australia are designed to
guide the continuous improvement of services by identifying and describing the
minimum workforce, infrastructure and support services necessary to deliver
safe, high quality chemotherapy. They have developed through the review and
incorporation of a range of state, national and international reference documents
and guidelines combined with broad multi-disciplinary consultation across the
South Australian health care system. The South Australian Cancer Clinical
Network Steering Committee has overseen the development of these Standards
with the view that their statewide implementation will support a common
framework for safe, high quality practice and enable monitoring of competence
and benchmarking of clinical services against identified minimal requirements for
varying complexities of care.

The delivery of safe, high quality chemotherapy is reliant on ensuring provision of
care in the most appropriate service setting which has capacity and capability to
meet the individual patients current and anticipated health needs and risks.
These needs and risks are identified through comprehensive clinical assessment
of the patient and in consideration of the known risks and complexities in the
delivery and supportive care requirements of low, medium and high risk
chemotherapy. Service requirements are supported by a chemotherapy service
delineation model to better enable safe and effective cancer care as close to the
patients home as possible. Risk stratification and service delineation are
addressed in section 1 of this document.

Utilisation of statewide chemotherapy standards aim to enable all current and
developing chemotherapy services to meet, monitor and maintain minimum
safety and quality requirements. These standards comprise section 2 of this
document and cover ten key areas:

1. Governance

2. Workforce, education and competency

3. Timely access, integration and coordination of care

4. Multi-disciplinary care, comprehensive patient assessment and
chemotherapy planning

5. Patient/carer education and consent

6. Chemotherapy prescribing

7. Assessment and monitoring of patients on chemotherapy

8. Provision of supportive care

9. Safe handling, administration and disposal of chemotherapy

10. Intrathecal chemotherapy and recommendations to reduce the risk of error
with vincristine

To support the Standards for Chemotherapy Services in South Australia, a self-
evaluation and implementation planning matrix has been developed (appendix 2)
to enable identification and reporting of service improvement achievements and
gaps.

The Standards are intended as a living document and will be reviewed bi-
annually and as required by the Cancer Clinical Network Steering Committee.

Scope

For the purpose of this document the term chemotherapy is inclusive of all drugs
including cytotoxic therapies and other hazardous substances used in the
treatment of cancer such as monoclonal antibodies and kinase inhibitors. It does
not include hormonal therapies.

The scope of the Standards for Chemotherapy Services in South Australia covers
chemotherapy provided to cancer patients of all ages and in any service setting.
It also includes chemotherapy administered for a non-malignant diagnosis (e.g.
Multiple Sclerosis) within a chemotherapy/cancer service.
The underlying quality and safety principles of this document may also be
applicable to other service settings where similar drugs are utilised.

The purpose of this document

The Standards for Chemotherapy Services in South Australia support the aim to
increase the number of patients able to have chemotherapy closer to home whilst
establishing the need for safety and quality as a priority over convenience. They
are designed for services currently providing chemotherapy, as well as services
planning to (re)commence chemotherapy provision.
Standards offer a common framework for safe, high quality practice and enable
monitoring of competence and benchmarking of clinical services against
identified minimal requirements for varying complexities of care.

The Standards of Chemotherapy Services aim to:

&gt; facilitate planning and development of services to the level necessary to
meet the needs of the relevant catchments population

&gt; define relevant areas of responsibility for individual health units within an
integrated health care system

&gt; define the necessary workforce skills within the health services or
accessible to the health service to support the delivery of chemotherapy

&gt; define the necessary infrastructure within the health service or accessible
to the health service to support the delivery of chemotherapy

&gt; define requirements relating to the establishment of referral practices to
facilitate shared care or the timely transfer of care between different health
services/ providers as determined by the patient s needs

Standards may be useful when a regional health service or clinical unit:

&gt; undertakes routine risk assessment, review, monitoring and benchmarking
of its service

&gt; plans to (re)commence providing chemotherapy services
&gt; wishes to commence providing a higher complexity level of care or higher

risk treatment

It is recognised that currently not all sites within the South Australian health
system providing chemotherapy services will completely meet all standards. To
support the principle of providing services as close to home as safely possible, a
self assessment tool has been developed (appendix 2). This tool is intended to
assist sites to identify current capacity for safe service provision and also
highlight areas for improvement initiatives over the following twelve months to
maximise their ongoing chemotherapy service capability.

The Standards are intended as a living document and will be reviewed bi-
annually to reflect updated knowledge, criteria and feedback. The usefulness of
the chemotherapy service delineation, standards and tools outlined in this
document will also be monitored and evaluated.

Glossary
Accreditation - Public recognition of achievement by an organisation, of
requirements of a standard.

Benchmarking - A systematic and continuous measurement process; by means
of comparing and measuring an organization's processes against other
organisations.

Cancer journey - An individual s experience of cancer, from screening and
detection, diagnosis and treatment, to recovery or living with cancer through to
palliative care.

Care coordination - The delivery of services by different providers occurs in a
coherent, logical and timely manner, consistent with the person s medical needs
and personal context.

Credentialing - A formal process for defining the clinical responsibilities of
medical practitioners and other health care providers within a particular health
care institution or wider service. It serves to verify that clinicians are qualified and
competent to undertake specific practices within explicit settings.

Competency - The combination of skills, knowledge, attitudes, values and
abilities that underpin effective and/or superior performance in a
profession/occupational area.

Governance - The set of responsibilities and practices, policies and procedures,
exercised to provide strategic direction, ensure objectives are achieved, manage
risks and use resources responsibly and with accountability.

Infrastructure The building blocks (such as information systems, workforce,
policy and regulatory framework) necessary to accomplish the activities of health
protection, illness prevention and health promotion.

Intrathecal chemotherapy - Treatment with drugs that are injected into the fluid
surrounding the brain and spinal cord (cerebrospinal fluid).

Key performance indicators - quantifiable measurements to periodically
assess the performances of organizations, business units, and their division,
departments and employees.

Monoclonal antibody Highly specific, purified antibody (protein) derived from
only one subset of cells and which recognizes only one antigen or cell binding
site.

Integrated health service A network of specialised health service
components within the general health system, coordinated across inpatient and
community settings, to ensure continuity of care for consumers.

Multidisciplinary care - An integrated team approach to health care in which
Medical, nursing and allied health care professionals consider all relevant
treatment options and develop collaboratively an individual treatment plan for
each patient.

Nurse Practitioner - a registered nurse educated and authorised to function
autonomously and collaboratively in an advanced and extended clinical role.

Performance status - Is an attempt to quantify cancer patients general well-
being.

Regimen - A plan of treatment, including doses, scheduling, and duration of
treatment.

Risk stratification is a medical decision-making tool whereby a constellation
of activities can determine the likelihood of a event or condition.

Scope of clinical practice - The extent of an individual health professional s
clinical practice within a particular organisation based on the individual s
credentials, competence, performance and professional suitability, and the needs
and the capability of the organisation to support the health professional s scope
of clinical practice.

Supportive Care - The prevention and management of the adverse effects of
cancer and its treatment. This includes management of physical and
psychological symptoms and side effects across the continuum of the cancer
experience from diagnosis through anticancer treatment to post-treatment care.

Vesicant - An agent capable of causing tissue destruction.

Background
One in three South Australians experience cancer during their lifetime. South
Australians with cancer receive high quality cancer care. This is reflected in
survival rates comparable with other parts of Australia that are not only at the
high end of the international range but are improving progressively over time.
Nevertheless, with South Australia s aging population and the increasing number
of people with cancer, this continues to be a growing challenge for our health
system, workforce and community1. Strategic service planning aims to better
enable the health system to meet this growing challenge and ensure that South
Australians have equity in access to high quality cancer care as close to home as
safely possible.

South Australia s Health Care Plan

South Australia s Health Care Plan 2007-20162 has been built on a strong
commitment from Government to ensure the future sustainability of quality health
services across the continuum of care from within hospitals extending to
community facilities in South Australia. South Australia s Health Care Plan has
provided the framework and the guiding principles for both health system reform
and reorientation of services to meet growing population demand as well as the
future challenges of health service delivery.

Clinical Service Delineation

The Clinical Service Delineation for Planning of Health Facilities in South
Australia3 document was prepared by SA Health in 2008 to support the
implementation of South Australia s Health Care Plan and to guide the
continuous development within hospital facilities of safe and quality health care
services. It is a living document, responsive to the developing service systems,
new evidence and technologies, and the changing population demands for
services across the continuum of care. The document details the proposed level
of clinical services that may apply within a health facility. The six (6) Clinical
Service Levels provide the descriptors for essential service requirements
dependent on the type of facility, specialty, catchment area and funding, together
with workforce availability currently and into the future. The descriptors outline
the levels of resource requirement across the continuum of care to support a
clinical function with Level 1 services identifying the least complex service in
terms of resources required, up to Level 6 representing the most complex
service. Each clinical service is to be planned and developed within these
parameters, which are specific to the service and the regional services context.

1 Cancer Council South Australia and the South Australian Department of Health (2009), State-wide cancer control plan 2010-2015 ,
Government of South Australia, Department of Health and the Cancer Council South Australia: Adelaide
2 South Australian Department of Health (2007), South Australian Health Care Plan 2007-2016: The South Australian Governments plan
for health care over the next 10 years , Government of South Australia: Adelaide
3 SA Health. Clinical Service Delineation for Planning of Health facilities in South Australia. Adelaide: Government of South Australia;
2008

Statewide Cancer Control Plan

The Statewide Cancer Control Plan 2006 -2009 was developed in response to
the Generational Health Review by the SA Department of Health (SA Health) in
collaboration with the Cancer Council South Australia (CCSA). This plan has
recently been reviewed and the revised Statewide Cancer Control Plan 2011
20154 continues to promote the systematic application of current knowledge and
investment to generate new knowledge and to reduce the impact of cancer. It
articulates principles and sets goals against which strategies in cancer control
should be considered and measured. It recommends priority programs and
services which will accelerate cancer control by reducing cancer incidence,
improving cancer survival and improving the quality of experience and life for
people with cancer, their carers and families. Recommendations of the plan focus
on six (6) key areas:
1. Cancer prevention and early detection

2. Optimising cancer care

3. Infrastructure planning and service development

4. Workforce planning for cancer control

5. Cancer control research

6. Cancer information

Cancer Clinical Network

Clinical Networks were established to increase the level of clinician involvement
in the planning of health services, to find ways to better coordinate the delivery of
those services, to ensure better health outcomes for all South Australians and to
ensure a strong, sustainable health workforce5.

The Cancer Clinical Network is one of the first networks developed within South
Australia (SA) to link doctors, nurses, allied health professionals, pharmacists,
GPs, non-government organisations and consumers to work together to assist in
fully integrating cancer service provision. Implementation of the Statewide
Cancer Control Plan is the primary objective of the cancer network and all
strategies developed and recommended for implementation are in-line with this
plan.

The Cancer Clinical Network Steering Committee has overseen the development
of the Standards for Chemotherapy Services as a first step in cancer quality
improvement planning.

SA Health. Statewide Cancer Control Plan 2011-2015. Adelaide: Government of South Australia; 2008

Government of South Australia, South Australia s Health care Plan 20007 -2016

Development of the South Australian Standards for
Chemotherapy Services
The Standards for Chemotherapy Services have been created in line with South
Australia s Health Care Plan6, the Statewide Cancer Control Plan 2011 - 20157
and Clinical Service Delineation for Planning of Health Facilities in South
Australia8. The standards are also reflective of two recent major reviews of
cancer services within South Australia.

The quality and safety requirements associated with chemotherapy are generally
consistent across the world and tools such as standards, guidelines, and quality
frameworks have been developed by multiple national and international expert
groups. These documents have provided a sound basis for development of the
SA Standards for Chemotherapy within the context of the SA health system.

It is recognised that not all cancers and/or cancer treatments present the same
level of risk and therefore chemotherapy provision should be delineated within
the health regions to ensure that care is provided in an environment that has
adequate infrastructure, workforce, resources and support services to provide
consistent and sustainable care.

It is recommended that these standards be considered by service planners and
clinicians as a companion document to South Australia s Health Care Plan and
Clinical Service Delineation for Planning of Health Facilities in South Australia
when considering provision of sustainable, accessible, safe and quality
chemotherapy services within an Integrated Cancer Service model for South
Australia.

Implementation of these standards will be the responsibility of the each of the SA
Health Regions and oversight of standards implementation will be through the
Cancer Clinical Network Steering Committee to the Clinical Senate.

Chemotherapy provision within an Integrated Cancer Service model

Formalised and clearly defined links between service providers within an
Integrated Cancer Service model will better enable all patients to have timely,
accessible, streamlined, comprehensive and high quality care as close to home
as safely possible.

Chemotherapy treatment will be evidence based and supported through the
implementation of an electronic patient management, decision support and
prescribing system.

South Australian Department of Health (2007), South Australian Health Care Plan 2007-2016: The South Australian Governments plan

for health care over the next 10 years , Government of South Australia: Adelaide

SA Health. Statewide Cancer Control Plan 2011-2015. Adelaide: Government of South Australia; 2008

SA Health. Clinical Service Delineation for Planning of Health facilities in South Australia. Adelaide: Government of South Australia;

2008

Anticipated outcomes from an integrated model include:

&gt; Access to well coordinated, safe, high quality chemotherapy at a location
as close to home as possible

&gt; Maximised access to chemotherapy in most rural and metropolitan
communities for common cancers and patients requiring low risk treatment,
monitoring and support.

&gt; Maximised access to chemotherapy in general hospitals and sites identified
as having necessary specialist workforce and infrastructure for common
cancers requiring moderate risk treatment, monitoring and support.

&gt; Streamlined, well coordinated access to chemotherapy within specialist
cancer services for rare cancers and those requiring high risk or complex
treatment, monitoring and support.

Workforce Implications

The workforce employed to provide chemotherapy services must be credentialed
and/or educated and assessed as competent according to current SA Health
policies, standards and endorsed guidelines or frameworks. Governance and
monitoring of credentials, scope of practice, clinical privileges, education and
competency maintenance remains the responsibility of the employing health
service9. It is anticipated that continuous development of services in-line with the
chemotherapy standards will support progress towards a sustainable and robust
cancer workforce.

In addition to professional qualifications, credentialing and authorisation
requirements, workforce related competency factors that must be considered in
provision of chemotherapy services include, but are not restricted to:

&gt; level of and currency of knowledge and education in cancer, cancer care
and chemotherapy including supportive care (side effects, symptom
management and psychosocial care to address the emotional, social,
spiritual, informational and financial needs of the patient and carer/family)

&gt; level of skill and experience in assessment of the cancer patient,
particularly the patient receiving chemotherapy

&gt; level of and currency of skill, experience and competency in administration
and monitoring of cancer treatment

&gt; access to adequate number and skill mix of staff to consistently provide
required care or service

South Australian Department of Health (2009), The Policy for Credentialing and Defining the Scope for Clinical Practice for Medical and

Dental Practitioner, April 2009: Adelaide

&gt; convenient and immediate access to up-to-date evidence based policies,
procedures and guidelines

&gt; level of skill and/or experience in communication and networking within a
multi-disciplinary framework and across a variety of sites and services

Implementation and governance of the Standards for
Chemotherapy Services in South Australia
Implementation of the Standards within health sites will be the responsibility of
health regions and the Directors of Cancer Services within those regions, with
specific implementation arrangements to be developed by the regions according
to local requirements and processes.

Oversight of this implementation will be by the Cancer Clinical Network Steering
Committee, who will report to the SA Health Clinical Senate. The Cancer Clinical
Network will require health regions to submit a self assessment (as outlined in
appendix 2) within one year of the endorsement of these standards for each site
that is delivering chemotherapy. Each site must demonstrate at least partial
compliance with all standards within this timeframe, and plans for improvement to
progress to full compliance within a further 12 months. An annual review/
confirmation of compliance will be required to be provided to the Cancer Clinical
Network thereafter.

Sites wishing to (re)commence chemotherapy after the endorsement of these
standards will be required to demonstrate at least partial compliance with all
standards before the (re)commencement of chemotherapy service provision, with
a plan to progress towards full compliance within a further 12 months.

An informal review of the usefulness of the chemotherapy service delineation,
standards and tools outlined in this document will be conducted 12 months after
their formal endorsement. A formal review and updating of the chemotherapy
service delineation, standards and tools will occur 2 years after their formal
endorsement, and bi-annually (or as required) after that to ensure they reflect
updated knowledge, criteria and feedback. The review, evaluation and updating
of the standards will be overseen by the Cancer Clinical Network Steering
Committee.

Section 1
Risk Stratification &amp; Chemotherapy Service Delineation
Chemotherapy Risk Stratification

Risk assessment of both the patient and the planned treatment is critical to the
safe provision of chemotherapy services. Risk matrices can aid in the
identification and stratification of anticipated risks (Table 1) and enable the key
factors of patient safety to be considered in a structured and consistent way.
Factors to be considered in the risk assessment for the patient planned for
chemotherapy include:

&gt; patient age, comorbidities and performance status

&gt; patients current and anticipated disease and treatment risks

&gt; ongoing review and monitoring requirements

&gt; route of planned treatment and risks relating to administration

&gt; risk of significant toxicity relating to high dose and/or combination therapy

&gt; complexity of supportive care drugs and/or fluid requirements relating to the
chemotherapy protocol

&gt; patient and clinician familiarity, education and recent experience with
planned chemotherapy protocol

A focus group of South Australian cancer clinicians held in June 2009 aimed to
articulate and clarify the essential factors which contribute to a chemotherapy
protocol being considered as low risk, medium risk or high risk. The following
risk stratification table was initially developed utilising outcomes from the focus
group and then further edited in response to multi-disciplinary feedback on the
draft chemotherapy standards during their development. It is anticipated that this
table will be further refined through utilisation and subsequently revised during
the first planned review of these standards. The table relates to chemotherapy
administration for adults and it is expected that the supervising consultant
oncologist/haematologist would evaluate these risk factors in combination with
individualised clinical assessment of the patient when considering the safety and
appropriateness of chemotherapy administration in various locations.

The vast majority of chemotherapy for paediatrics is considered as high risk at
this point in time.

Table 1 Risk Stratification Matrix

Low Risk Medium Risk High Risk
Chemotherapy regimen
suitable for monitoring via
general practitioner between
less frequent reviews (may be
via telemedicine) by
supervising
haematology/oncology
service
&gt; Patient stable, with

performance status
equivalent to ECOG10 0, 1
or 2.

&gt; Patient not considered at
increased risk due to age or
comorbidities

&gt; No concerns regarding
patients ability to comply
with treatment

&gt; Uncomplicated vascular
access requirements

&gt; Non-vesicant agents
&gt; Single agent chemotherapy
&gt; Standard or low dose

chemotherapy
&gt; Low risk of grade 3 and 4

toxicities
&gt; Low risk of dose limiting

side effects requiring dose
adjustment

&gt; Low risk of adverse drug
reactions

&gt; Low complexity of
premedications,
supplementary treatments
and hydration requirements

&gt; No planned requirement for
blood results within a 24
hour timeframe

Chemotherapy regimen
suitable for monitoring via
general practitioner, nurse
practitioner or general
physician with alternate
reviews (may be via
telemedicine) by supervising
haematology/oncology
service
&gt; Patient stable, with

performance status
equivalent to ECOG 0, 1 or
2

&gt; Vascular access device
(VAD) required

&gt; Vesicant agents included
&gt; Combination chemotherapy
&gt; Standard or low dose

chemotherapy
&gt; Moderate risk of grade 3

toxicities, low risk of grade 4
toxicities

&gt; Moderate risk of dose
limiting side effects
requiring dose delay or
modifications.

&gt; Risk of adverse drug
reaction requiring medical
emergency management

&gt; Complex premedications,
supplementary treatments
and hydration requirements

&gt; Requirement for standard
blood results within 24
hours

Chemotherapy regimen only
suitable for monitoring and
supervision by specialist
haematology/oncology service
&gt; Patient may be medically

unstable with variable
performance status

&gt; Intrathecal chemotherapy
&gt; Intracavity or intravesical

chemotherapy
&gt; High dose chemotherapy
&gt; Moderate to High risk of

grade 3 or 4 toxicities and
side effects

&gt; High risk of requirement for
dose modifications

&gt; High risk of adverse drug
reactions requiring
emergency management

&gt; Complex premedications,
supplementary treatments
and hydration requirements
which may require inpatient
stay

&gt; High intensity phase of
treatment

&gt; Uncommon and highly
specialised drugs

&gt; Anticipated requirement for
urgent blood/pathology
results

10
Eastern Cooperative Oncology Group

Chemotherapy Service Delineation
Within the six service delineation levels described in Clinical Service Delineation
for Planning of Health Facilities in South Australia11, haematology and oncology
services are categorised as medical sub-specialties. To support medical sub-
specialties, general medicine services and clinical support services such as
pharmacy, pathology, emergency department and critical care services at the
relevant level also need to be in place.

Building on the concept of low, medium and high risk chemotherapy as described
in table 1, a clinical service delineation for chemotherapy services (table 2) has
been developed which recommends clinical service delineation levels that may
be better equipped to manage the various levels of chemotherapy risk.

Within the table it is recommended that low risk chemotherapy be provided by
level 1-3 services, medium risk chemotherapy may be provided by Level 4
services and high risk chemotherapy may be provided by level 5 6 services.

All chemotherapy services irrespective of their level must also meet the minimum
chemotherapy standards as outlined in section 2 of this document.

SA Health. Clinical Service Delineation for Planning of Health facilities in South Australia. Adelaide: Government of South Australia;

2008

Table 2 Clinical Service Delineation for Chemotherapy Services
Level 1-3

Chemotherapy Services
Level 4
Chemotherapy Services

Level 5-6
Chemotherapy Services

General
description/summary

&gt; Manage low risk chemotherapy for common
cancers in stable patients

&gt; Standard infrastructure
&gt; General workforce with additional chemotherapy

competencies

&gt; Manage medium risk chemotherapy for
common cancers in stable patients

&gt; Moderate to highly developed
infrastructure

&gt; Specialist workforce

&gt; Manage high risk/complex chemotherapy,
uncommon/rare or high risk cancers and
unstable patients

&gt; Highly developed infrastructure
&gt; Highly specialised workforce

Service setting
examples

&gt; Community Hospitals
&gt; Inner Country Health services
&gt; Local Area hospitals
&gt; Primary health care settings
&gt; Nursing homes
&gt; Patient homes

&gt; General Hospitals
&gt; Community hospitals with well developed

cancer specialist workforce and
infrastructure requirements

Tertiary Hospital providing comprehensive
cancer services with dedicated multi
disciplinary haematology and/or oncology
specialty and supportive care services.

Governance
requirements

Outpatient/community chemotherapy provision must
be under the supervision of a level 5 or 6
Haematology or Oncology service.

Outpatient/community chemotherapy
provision must be under the supervision of
a level 5 or 6 Haematology or Oncology
service.

&gt; Provides supervision of chemotherapy for
other rural and metropolitan services.

&gt; May have state-wide referral and
coordination role

&gt; Some complex and rare cancers and cancer
treatments will be treated / available in level
6 services only.

Types of chemotherapy
provided

Outpatient/community chemotherapy for common
solid tumours and low grade haematological
malignancies

As for level 1-3 plus:
Outpatient chemotherapy for common
solid tumours, some lymphomas and other

As for level 4 plus:
Complex and or high risk inpatient and
outpatient chemotherapy by cancer specialist

Level 1-3
Chemotherapy Services

Level 4
Chemotherapy Services

Level 5-6
Chemotherapy Services

&gt; Low risk oral chemotherapy
&gt; Single agent, non-vesicant, low toxicity parenteral

chemotherapy

common low grade/low risk
haematological malignancies

&gt; Medium - High risk oral chemotherapy
&gt; Combination and/or vesicant parenteral

chemotherapy with moderate complexity
and low to moderate toxicity.

workforce
&gt; Most malignant haematology (acute

leukaemia, high risk lymphomas)
&gt; Bone marrow transplant services
&gt; Majority of acute paediatric oncology &amp;

malignant haematology
&gt; Clinical trials program
&gt; Can provide concurrent radiotherapy

Clinical review and
medical consultation
requirements

&gt; Access (on site, visiting or tele-medicine) to
general practitioner (GP) or cancer nurse
practitioner (NP) or oncologist/haematologist for
clinical review prior to each cycle of
chemotherapy.

&gt; Access (on site, visiting or tele-medicine) to
general practitioner (GP) or cancer nurse
practitioner (NP) or oncologist/haematologist for
surveillance, clinical review and management of
low complexity symptoms of disease and toxicities
of treatment.

&gt; Access (on site, visiting or tele-medicine) to
general practitioner (GP) or cancer nurse
practitioner (NP) or oncologist/haematologist for

As for level 1-3 plus:
&gt; Access (on-site, visiting or tele-medicine)

to a general physician, paediatrician (for
all paediatric patients), haematologist or
oncologist for consultation, supportive
care and outpatient treatment

&gt; Areas of responsibility include monitoring
and surveillance for most cancers

&gt; Inpatient management of chemotherapy
toxicity

As for level 4 plus:
&gt; Onsite oncology and/or haematology

consultants for provision of comprehensive
chemotherapy service and supervision of
care provided at level 1-6 chemotherapy
services (visiting or tele-medicine).

&gt; Onsite paediatric oncology or haematology
consultant for provision of comprehensive
paediatric chemotherapy service and
supervision of paediatric cancer care
provided at level 1- 6 services (visiting or
tele-medicine).

&gt; Onsite access to advanced trainees
(oncology or haematology registrars),

Level 1-3
Chemotherapy Services

Level 4
Chemotherapy Services

Level 5-6
Chemotherapy Services

surveillance, monitoring and survivorship care for
low risk, common cancers.

cancer nurse practitioners (NP) or nurse
practitioner candidates (NPC) for clinical
review prior to each cycle of chemotherapy.

&gt; Onsite access to advanced trainees
(oncology or haematology registrars),
cancer nurse practitioners (NP) or nurse
practitioner candidates (NPC) for
surveillance, clinical review and
management of low complexity symptoms of
disease and toxicities of treatment.

&gt; Monitoring, surveillance and survivorship
care for rare or high risk cancers

Staff chemotherapy
competency
requirements

Chemotherapy competency (see Standard 2) is
essential for all clinicians involved in the
administration of chemotherapy

As for level 1-3 plus:
&gt; On-site access to specialist cancer

nurses with comprehensive
chemotherapy competency

As for level 4 plus:
&gt; Dedicated, on-site specialist cancer

workforce with comprehensive
chemotherapy competency including
medical staff with competency in
administration of intrathecal chemotherapy

Clinical Support Service requirements

Pharmacy
services

&gt; Access to drugs supplied on individual
prescription required

&gt; Service provided on-site, or overseen by
pharmacist located elsewhere

&gt; Community based medication review services
available

On-site or visiting pharmacy service
available and includes

&gt; Pharmacy controlled drug distribution to
inpatients and outpatients

&gt; On-site or regional access to general
clinical pharmacy service for inpatients and
outpatients

&gt; On-site, visiting or remote access to
cancer clinical pharmacist.

&gt; Access (on-site or external contract) to
chemotherapy production services

&gt; Access to drug information.
&gt; Provision of chemotherapy drug

monitoring, utilisation review and adverse
drug reaction reporting

&gt; Additional requirements for moderate-high
risk treatment regimes within this category
include:

&gt; Pharmacist on call for 24 hours

&gt; Clinical pharmacy service provided 7 days a week
including participation in ward rounds, MDT
meetings and outpatient services

&gt; Services include specialist cancer clinical
pharmacists (on-site or visiting)

&gt; Provides clinical consultation to other hospitals as
required

&gt; Has access to sterile manufacturing and IV
admixture service including cytotoxic drug and
parenteral nutrition (on-site or external contract).

&gt; May provide production pharmacy service for other
sites.

Pathology
services

Minimum access requirements include:
&gt; Local access to specimen collection
&gt; Specimens transferred to referral laboratory with

frequency dependant upon available transfer

Minimum access requirements include:
&gt; Testing performed by health workers using

suitable point of care testing devices
&gt; Blood storage facilities available with some

&gt; Comprehensive pathology service providing 24 hour
on-site services

&gt; On-site or visiting Pathologists and Haematologists

schedules
&gt; Storage and packaging for transport in

accordance with regulation and guidelines

on site stock of O negative blood
&gt; QA activities in place under the

supervision of a RCPA/NATA accredited
laboratory

Additional requirements for moderate-high
risk treatment regimes within this category
include:

&gt; On-site core pathology services available
with on call arrangements over 24 hours

Emergency
services

Minimum access requirements include:
&gt; Basic resuscitation equipment and drugs
&gt; Able to resuscitate and provide limited

stabilisation prior to transfer to a higher level of
care

&gt; Have identified referral/transfer pathways for
cancer emergencies

Minimum access requirements include:
&gt; Local GPs rostered to provide 24 hour

cover or on-site medical staffing (subject to
volume)

&gt; Access to a range of specialist
consultation

&gt; Appropriate skilled and experienced
workforce to support service

&gt; Designated Emergency Service with
assessment and treatment area and
separate resuscitation facilities

&gt; Have local policies procedures and
guidelines for management of cancer
emergencies

&gt; Have identified referral/transfer pathways
for cancer emergencies

&gt; Designated emergency extended care service
&gt; Standardised policies , procedures and guidelines

for management of cancer emergencies
&gt; Designated spaces with negative pressure capacity
&gt; Medical staffing provided by experienced

Emergency Medical Officers 24 hours
&gt; Access to on-site specialist services
&gt; On-site IC/HD &amp; CC service capacity
&gt; Capacity for invasive monitoring and assisted

ventilation
&gt; Accepts transfers of appropriately triaged crucial

care retrieval patients from other hospitals
&gt; On-site skilled and experienced multidisciplinary

workforce
&gt; If a combined adult/paediatric service, designated

paediatric treatment area with resuscitation facilities

Critical care
services

Minimum access requirements include:
&gt; Capacity to provide appropriately skilled and

experienced workforce for specialling services
until appropriate transfer can be arranged.

&gt; Identified referral/transfer pathways for critical
care services

Minimum access requirements include:
&gt; Inpatient area suitable for patients

requiring observation over and above that
in general ward area

&gt; 24 hour medical cover to site
&gt; Access to a range of visiting Specialists

including general physician
&gt; Appropriately skilled workforce available to

support service as determined
Additional requirements for moderate-high
risk treatment regimes within this category
include:

&gt; A designated HD Service
&gt; Ability to provide basic, multi-system life

support usually for less than a 24 hour
period

&gt; Ability to provide immediate resuscitation
and short term cardio-respiratory support

&gt; Ability to monitor and prevent
complications in moderate-high risk
chemotherapy patients

&gt; On-site medical staffing

&gt; Has an integrated ICU Service &amp; HD service
&gt; Has a designated CC Service
&gt; Capacity to provide multi-system support
&gt; Extra-corporal renal supports
&gt; Has access to support invasive cardiovascular

monitoring
&gt; Medical staffing provided by on-site medical staff

and Specialists

Supportive
care services

Supportive care services provided on-site or via
partnership arrangement (local or virtual service)
See standard 8

Supportive care services provided on-site or
via partnership arrangement (local or virtual
service) See standard 8

Supportive care services provided on-site and within
community for inpatient and outpatient care See
standard 8

Palliative care
services

Palliative care services provided on-site or via
partnership arrangement (local or virtual service)

Palliative care services provided on-site or
via partnership arrangement (local or virtual
service)

&gt; Palliative care services provided on-site or via
partnership arrangement with local hospital.

&gt; Must include ability to access inpatient palliative
care

Section 2:
Standards Criteria
Utilisation of statewide chemotherapy standards aim to enable all current and
developing chemotherapy services to meet, monitor and maintain the minimum
safety and quality requirements necessary to ensure that known risks relating to
chemotherapy are minimised and safety is maintained for all patients, staff and the
community.

Services providing chemotherapy require a common framework for safe, high quality
practice. The review of state, national and international reference documents and
guidelines has led to the development of quality and safety standards covering ten
key areas.

1. Governance

2. Workforce, education and competency

3. Timely access, integration and coordination of care

4. Multi-disciplinary care, comprehensive patient assessment and chemotherapy
planning

5. Patient/carer education and consent

6. Chemotherapy prescribing

7. Assessment and monitoring of patients on chemotherapy

8. Provision of supportive care

9. Safe handling, administration and disposal of chemotherapy

10. Intrathecal chemotherapy and recommendations to reduce the risk of error with
vincristine

To support the Standards for Chemotherapy Services in South Australia, a self-
evaluation and implementation planning matrix has been developed (appendix 2) to
enable identification and reporting of service improvement achievements and gaps.

1. Governance

1.1. Chemotherapy services have clearly documented local and regional
governance arrangements consistent with the South Australia s Health
Care Plan, the Statewide Cancer Control Plan and recommendations of
the Statewide Cancer Clinical Network.

1.2. In line with clinical service delineation for chemotherapy services, all
services meet the core specialty and clinical support services
recommended to manage the risk level of chemotherapy provided within
that service.

1.2.1. Directors of cancer services oversee and endorse formal links
and memorandums of understanding within and across health
regions to:

&gt; maximise the provision of specialty and support services
as close to home as safely possible

&gt; enable timely access to distant services when required

1.3. Directors of cancer services oversee the continuous development and
implementation of consistent/standardised protocols, procedures and
models of care that support chemotherapy delivery within and across SA
Health regions and service providers.

1.4. There are processes in place to enable monitoring of clinical and service
outcomes including key performance indicators as outlined in the
Performance Indicator Framework for South Australian Cancer Services12.

1.5. Reports on the safety and quality of chemotherapy services are provided
to local and regional clinical governance and contribute to planning for
continuous service development.

1.5.1. Services utilise the Australian Incident Monitoring System
(AIMS) or equivalent to enable risk-free reporting of error or
near misses13.

1.5.1.1. Error and near miss reports are reviewed and evaluated
regularly (bi-monthly) at service level and summary reports are
communicated via clearly identified regional governance
processes.

12
The South Australian Department of Health and The South Australian Cancer Network 2010,

Performance Indicator Framework for South Australian Cancer Services Version 1.0, September 2010
13

Clinical Oncology Society of Australia (2008), Guidelines for the Safe Prescribing, Supply and

Administration of Cancer Chemotherapy, November 2008

1.5.1.2. All serious adverse events are formally reviewed via clearly
identified local and regional governance processes.

1.5.2. Strategic planning for service development occurs in line with
the South Australia s Health Care Plan and the Statewide
Cancer Control Plan.

2. Workforce, education and competency

2.1. The Service has policies and procedures for provision and verification of
credentialing and chemotherapy education and competency for all
clinicians and support staff in line with SA Health policies, procedures,
guidelines and frameworks. Alternatives from other jurisdictions may be
used when a South Australian version is not available or is in need of
review.

2.1.1. Only chemotherapy competent health care professionals
prepare or administer chemotherapy.

2.1.1.1. The Clinical Oncology Society of Australia:
Guidelines for the Safe Prescribing, Supply and
Administration of Cancer Chemotherapy14 list
suggested knowledge and skills applicable to all
health care professionals.

2.1.1.2. Pharmacists complete the SA health central
training manuals for Pharmacy Services and
Production Pharmacy Services as relevant to
scope of work. These manuals are intended to
provide a framework to ensure that all pharmacy
staff receive appropriate levels of training and
support to ensure the opportunity to learn and
develop all the knowledge and skills necessary for
them to fulfil their job role. The manuals are not
intended to substitute the close supervision of
staff undergoing clinical training.

2.1.1.2.1. SA Health Central Training Manual
Clinical Pharmacy Services - Cancer
and Chemotherapy15. This manual is
for all pharmacy staff working in
clinical units caring for patients with
cancer and / or receiving
chemotherapy.

2.1.1.2.2. SA Health Central Training Manual -
Cytotoxic and other hazardous
substances16. This manual is for all
pharmacy staff working in units
preparing parenteral cytotoxic and
other hazardous substances.

14
Clinical Oncology Society of Australia (2008), Guidelines for the Safe Prescribing, Supply and

Administration of Cancer Chemotherapy, November 2008
15

South Australian Department of Health 2010, Draft SA Health Central Training Manual Clinical

Pharmacy Services - Cancer and Chemotherapy, October 2010 version
16

South Australian Department of Health 2010, Draft SA Health Central Training Manual- Cytotoxic

and other hazardous substances, October 2010 version

2.1.1.3. Nurses establish and maintain a minimum level of
chemotherapy competence as outlined in the
State-wide Framework for Chemotherapy
Education and Assessment 201017 (currently
under development).
2.1.1.3.1. Continuing education programs for

nurses in chemotherapy and cancer
care are consistent with the EdCan
framework18.

2.1.1.4. All new clinicians commencing in, or transferring
to, a chemotherapy service or cancer speciality
area must undertake or verify credentialing,
chemotherapy education and competency
assessment relevant to the risk level of
chemotherapy provided within that service or
area.

2.1.1.5. Services must ensure that further education is
readily accessible when new or unfamiliar agents,
protocols or equipment are utilised or when
procedures change.

2.1.2. The service has a standard mechanism for providing
opportunity for, and monitoring of, continuing competency.
Annual competency assessment or verification is
recommended.

2.2. Paediatric chemotherapy administration, especially in the acute phases of
disease is managed by a specialised paediatric health facility, under the
direct supervision of a paediatric oncologist/ haematologist.

2.2.1. When it is in the best interest for a paediatric patient and their
family to access care outside of a specialist paediatric health
facility this must occur in close consultation with a paediatric
consultant and involve education, mentoring and support from
the specialist site.

2.3. Services ensure there is sustainable access to nursing/clinical staff with
skills and expertise in the use and care of Central Venous Access Devices
(CVAD) such as Peripherally Inserted Central Venous Catheters (PICC)
and Infusaports relevant to clinical need.

2.3.1. All services maintain protocols and procedures relating to
insertion and management of CVADs that utilise evidence

17
South Australian Department of Health 2010, State-wide Framework for Chemotherapy Education

and Assessment; an Integrated Model for South Australia, September 2010 version
18

Cancer Australia 2008, The National Cancer Nursing Education Project (EdCaN) (2008). National
Education Framework Cancer Nursing: A national professional development framework for cancer
nursing, Canberra 2008

based guidelines such as the Cancer Nurses Society of
Australia CVAD guidelines19 and the eviQ Cancer Treatments
Online protocols20

19
Cancer Nurses Society of Australia 2007, Central Venous Access Devices: Principles for Nursing

Practice and Education (2007) Guidelines
20

Cancer Institute NSW, eviQ Cancer Treatments Online, accessible online: www.eviq.org.au

3. Timely access, integration and coordination of care

3.1. Services have processes and rationale for care coordination that enables
organised service delivery in accordance with the individual needs of the
patient and in a manner consistent with quality and cost effectiveness
principles.

3.1.1. Processes should ensure a smooth patient journey and
minimise duplication of effort by different health professionals

3.1.2. Services utilise standardised guidelines and procedures to
ensure adequate and timely patient access to clinical advice
and clinical services within and after hours.

3.2. Services enable access to appropriate and cost effective transport and
accommodation facilities are available for those patients needing to
relocate for treatment.

3.3. The health service meets minimum operational and infrastructure
requirements to enable reliable, sustainable and cost effective access to
on-site services. This includes:

3.3.1. Patient, carer and staff accommodation for those who are
required to travel to access or deliver services

3.3.2. Information and communication technology (ICT) services and
processes to;

3.3.2.1. Facilitate remote/virtual access, consultation, team
meetings and networking between sites, regions and
providers

3.3.2.2. Support an electronic patient management system, with
timely access to up to date treatment records and
relevant pathology and radiology investigations for each
patient. Where this is not available electronically, access
to all recent hard copy medical records and results must
be available at each patient presentation.

3.3.3. Local blood and diagnostic collecting facilities with staff trained
in collection and specimen handling techniques. Results for
routine blood tests are available within a 24-hour timeframe for
all patients on medium to high risk chemotherapy and
preferably within 48-hours for low risk chemotherapy.

3.4. Services administering chemotherapy to paediatric patients comply with
the Standards for the Care of Children and Adolescents in Health

Services21 in provision of a child safe and appropriate physical
environment including access to:

3.4.1. natural light and age appropriate decorations/furniture as able

3.4.2. open spaces within a secure environment where a child can be
observed and supervised at all times

3.4.3. provisions for parents to stay if required

3.5. Services have well documented formal communication arrangements
between local practitioners and consultative haematology/oncology
clinicians available 24/7 for advice, consultation and referral.

3.6. Services have standard procedures and processes for efficient and
effective transfer of care to the most appropriate level service.

3.7. Services that do not have an oncology or haematology clinical pharmacist
on-site have documented formal links and agreements with a recognised
oncology clinical pharmacy service within South Australia for clinical
advice, education and remote support.

3.8. Services that do not have specialist cancer nurses on site have
documented formal links and agreements with a recognised level 4 6
chemotherapy service within South Australia for clinical advice, education,
mentoring and support.

3.9. Services have standard communication processes for efficient and
effective discharge planning, transition of care and follow up needs.

3.9.1. Services have established procedures for documentation and follow
up for patients who miss clinic visits and treatments

21
Paediatrics &amp; Child Health Division, RACP, Standards for the Care of Children and Adolescents in

Health Services, Nov 2008, accessible online: www.racp.edu.au

4. Multidisciplinary care, comprehensive patient assessment and
chemotherapy planning.

4.1. All chemotherapy patients have the opportunity to have their case
discussed by a cancer multi-disciplinary team.

4.1.1. Cancer multi-disciplinary teams utilise the South Australian
Cancer Clinical Network endorsed Cancer MDT Terms of
Reference

4.1.2. There is local or virtual access to tumour stream and other
cancer multi-disciplinary teams

4.1.3. Sites maintain up to date contact details and adhere to
standardised referral processes for multi-disciplinary teams

4.2. Prior to prescribing or administering chemotherapy the following
information is available or ascertained:

4.2.1. Pathologic confirmation or verification of the initial diagnosis.

4.2.2. Initial cancer stage or current cancer status.

4.2.3. Complete medical history and examination that includes
height, weight and assessment of organ specific function as
appropriate for the planned regimen.

4.2.4. Complete medication history of all current medications
including over the counter and complementary and integrative
therapies (CIT)

4.2.5. Documentation of history of drug and non-drug allergies and
other adverse drug reactions

4.2.6. Current psychosocial issues which may impact on care
decisions including assessment of patients comprehension
regarding medication regimens, knowledge of disease, ability
to manage self care and knowledge of available carer support
or support services.

4.2.7. All recent investigations and pathology results to enable
adequate assessment of patient response to and tolerability of
previous chemotherapy.

4.2.8. For patients taking oral chemotherapy, the expected frequency
of clinic visits or remote consultation and monitoring that is
appropriate for the drug and the individual needs of the patient.

4.3. Final decisions on the initiation of a chemotherapy protocol or treatment
plan are made at consultant level.

5. Patient/Carer Education and Consent

5.1. Before initiation of chemotherapy via any route, each patient
(parent/caregivers/family as appropriate) is provided with verbal and
written information. It is recommended that this includes the suggested
content outlined in the Clinical Oncology Society of Australia: Guidelines
for the Safe Prescribing, Supply and Administration of Cancer
Chemotherapy22. Additional information recommended includes:
5.1.1. Information regarding diagnosis of cancer23

5.1.2. Current and/or long term goals of therapy

5.1.3. Before initiation of oral chemotherapy, each patient (in
paediatric cases - parent/caregivers/family) is provided with
additional verbal and written information consistent with the
Society of Hospital Pharmacists of Australia (SHPA) Standards
of Practice for the Pharmaceutical Care of Patients Receiving
Oral Chemotherapy24. The SHPA standards are also
summarised in the COSA guidelines25

5.1.4. Education materials must be appropriate for the
patients/carers reading level/literacy, language and
understanding. Details of verbal and written patient education
provided are documented in the patient record.

5.1.5. The education plan includes family, caregivers, or others
based on the patients preference26, age and their ability to
assume responsibility for managing therapy independently.

5.2. The service maintains a policy for obtaining and documentation of consent
for chemotherapy.

5.2.1. The consent process follows appropriate professional and legal
guidelines27.

5.2.2. Informed consent includes details of both common and serious
toxicities of treatment which have been discussed with the
patient (in paediatric cases - parent/caregivers/family).

22
Clinical Oncology Society of Australia (2008), Guidelines for the Safe Prescribing, Supply and

Administration of Cancer Chemotherapy, November 2008
23

Australian Government: Cancer Australia (2010), Assessment of Cancer Care Perceptions and

Experiences of People Affected by Cancer, August 2010

24 Society of Hospital Pharmacists of Australia Committee of Speciality Practice in Cancer Services

(2007), SHPA Standards of Practice for the Provision of Oral Chemotherapy for the Treatment of

Cancer, Journal of Pharmacy Practice and Research, vol. 37, no. 2

25 Clinical Oncology Society of Australia (2008), Guidelines for the Safe Prescribing, Supply and

Administration of Cancer Chemotherapy, November 2008
26

Australian Government: Cancer Australia (2010), Assessment of Cancer Care Perceptions and

Experiences of People Affected by Cancer, August 2010
27

South Australia, Consent to Medical Treatment and Palliative care Act 1995, Version: 1.7.2010

6. Chemotherapy prescribing

6.1. Services comply with the 2009 SA Health Policy Directive to implement
the Australian Commission on Safety and Quality in Health Care National
Standard for Terminology, Abbreviations and Symbols to be used in the
Prescribing and Administering of Medicines in Australian hospitals28
including;

6.1.1. Principles for consistent prescribing terminology

6.1.2. Acceptable terms and abbreviations

6.1.3. Error prone abbreviations, symbols and dose designations to
be avoided.

6.2. The service defines standard chemotherapy regimens by diagnosis with
references readily available29 and/or identifies source(s) for chemotherapy
regimens and approved clinical research protocols. Utilisation of eviQ
Cancer Treatments on-line protocols30 for adults with cancer is a
recommended example

6.2.1. For orders that vary from standard regimens, practitioners
document both the nature of the variation and the supporting
reference and/or rationale for necessary modifications.

6.2.2. The service maintains and utilises standard, regimen-level,
pre-printed or electronic forms for all chemotherapy prescribing
(including oral chemotherapy) including supportive care
medications. Use of a chemotherapy electronic management
system is preferred.

6.2.2.1. Handwritten prescribing of chemotherapy is
replaced as soon as possible by pre-printed
forms or preferably by electronic prescribing
systems

6.3. Original prescribing of a chemotherapy protocol /treatment plan is signed
by a specialist oncologist/haematologist with access to all relevant patient
information. The Clinical Oncology Society of Australia: Guidelines for the
Safe Prescribing, Supply and Administration of Cancer Chemotherapy31
are recommended as an appropriate reference in the development of
local/regional standardised prescribing processes.

28
Australian Committee for Safety and Quality in Health Care, Recommendations for Terminology,

Abbreviations and Symbols used in the Prescibing and Administration of Medicines, December 2008

accessible online www.safetyandquality.gov.au

29 NHS National Cancer Action Team, Chemotherapy Services in England: Ensuring Quality and
Safety A report from the National Chemotherapy Advisory Group Draft for Consultation, November
2008

Cancer Institute NSW, eviQ Cancer Treatments Online, accessible online: www.eviq.org.au
31

Clinical Oncology Society of Australia (2008), Guidelines for the Safe Prescribing, Supply and

Administration of Cancer Chemotherapy, November 2008

6.3.1. Only paediatric haematology/oncology consultants prescribe
chemotherapy for paediatric patients.

6.3.2. All orders for chemotherapy are verified by an appropriately
skilled clinical pharmacist with access to the patient information
relevant to the treatment. The Clinical Oncology Society of
Australia: Guidelines for the Safe Prescribing, Supply and
Administration of Cancer Chemotherapy32 provides a suitable
guideline to aid development of local/regional policies and
procedures for verification of chemotherapy orders.

6.3.3. Subsequent orders for administration of parental and oral
chemotherapy cycles or doses are signed by an appropriately
qualified medical practitioner or authorised nurse practitioner
working in collaboration33 with a specialist
oncologist/haematologist.

6.3.4. Verbal orders are not recommended except to hold or stop
chemotherapy administration. New orders or changes to orders
must be made in writing. Signed electronic, fax and email
orders are considered written orders.

6.3.5. All services maintain a centralised register of staff who have
formally demonstrated competency to prescribe (either first or
subsequent cycles), verify prescriptions and supply
chemotherapy.
6.3.5.1. There is a defined centralised process and

identified personnel within the service and region
for register development and maintenance.

32
Clinical Oncology Society of Australia (2008), Guidelines for the Safe Prescribing, Supply and

Administration of Cancer Chemotherapy, November 2008
33

National Health (Collaborative Arrangements for Nurse practitioners) Determination 2010,

accessible online: http://www.frli.gov.au.

7. Assessment and Monitoring of Patients on Chemotherapy

7.1. The service maintains standardised protocols that determine the
appropriate time interval for regimen specific laboratory and radiological
tests that are:

7.1.1. Evidence based when national guidelines or protocols exist
(eg, NHMRC guidelines, Cancer Clinical Pathways, eviQ
Cancer Treatments Online protocols34) or
7.1.1.1. Determined by consensus of practitioners within the

service.

7.1.1.2. Determined by a treatment protocol within a clinical
trial

7.2. The service has policies and procedures that clarify the roles and
responsibilities of doctors, nurses and pharmacists in patient assessment
and monitoring. These policies and procedures are relevant to workforce
education, knowledge, skills and scope of practice within the local and
virtual/remote environment.

7.2.1. Prior to each cycle of chemotherapy, a chemotherapy
competent clinician (see standard 2) must perform and
document a pre chemotherapy history and clinical assessment
including the following information;

7.2.1.1. Diagnosis and current chemotherapy protocol

7.2.1.2. Current cycle and day of scheduled treatment

7.2.1.3. Relevant changes to height, weight and body
surface area (BSA)

7.2.1.4. Changes in performance status. Use of the
Eastern Cooperative Oncology Group (ECOG)
tool is recommended.

7.2.1.5. Allergies, sensitivities, reactions, and treatment
related toxicities that may impact on the safety of
treatment to proceed or require changes to
supportive care strategies within the
chemotherapy protocol.

7.2.1.6. Effectiveness of prescribed or patients self-
management strategies on symptoms, side
effects and toxicities

34
Cancer Institute NSW, eviQ Cancer Treatments Online, accessible online: www.eviq.org.au

7.2.1.7. Compliance with oral chemotherapy and/or pre-
medications prescribed as part of the
chemotherapy protocol.

7.2.1.8. Relevant pathology and radiology results that may
impact on the safety or appropriateness for
treatment to proceed.

7.2.1.9. Clinical evidence of response to treatment or
suspected disease progression.

7.2.1.10. Patients psychosocial concerns and need for
support including use of a validated tool such as
the Distress Thermometer 35

7.2.1.11. Cumulative doses of those chemotherapy agents
associated with a risk of cumulative toxicity.

7.2.1.12. Confirmation that patient is fit to proceed with
treatment or notification that patient is not fit to
proceed with treatment

7.2.1.13. Ongoing management plan including next review
by specialist oncologist/haematologist.

35
National Comprehensive Cancer Network Inc. 2010, Clinical practice Guidelines in Oncology.

Distress Management V1.2010, accessible online:

http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf

8. Provision of Supportive care

8.1. Services have local, community or remote access to resources that may
be required to support people with cancer and their families and/or
caregivers. This includes management of physical symptoms and the
identification and assessment of psychosocial issues at critical points
along the pathway from diagnosis through treatment to post-treatment
care, survivorship or palliation.

8.1.1. All services maintain or recommend standard, evidence based
protocols (such as eviQ Cancer Treatments Online36) for
managing symptoms of disease and side effects of treatment
including response to haematology/oncology emergencies
(e.g. febrile neutropenia). It is recommended that protocols are
reviewed annually and must include:

8.1.1.1. Documented process on provision of or access to
24/7 triage for advice or clinical review (e.g. hot-
line, on-call practitioner, emergency department) for
management of chemotherapy toxicities

8.1.1.2. Documented process on access to emergency
medicine, infectious diseases unit, acute medicine
and haematology/oncology disciplines

8.1.1.3. Documented processes for efficient and effective
transfer of care to appropriate health services for
those patients deemed to be at risk of serious
adverse events

8.1.1.4. Documented formal protocols to guide staff on
contacting the state-wide retrieval services as
required.

8.1.2. The service has in place validated tools such as the Distress
Thermometer 37 to enable and promote routine assessment
regarding psychosocial concerns and need for support:

8.1.2.1. Staff have access to education locally or remotely in
identifying and responding to supportive care needs
of patients (such as the learning activities and
resources available on Cancer Learning38)

36
Cancer Institute NSW eviQ Cancer Treatments Online access www.eviq.org.au

37
National Comprehensive Cancer Network Inc. 2010, Clinical practice Guidelines in Oncology.

Distress Management V1.2010, accessed online

http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf
38

Australian Government Cancer Australia , Cancer Learning, accessed on-line

http://www.cancerlearning.gov.au/find/suppcare.php

8.1.3. The service has referral processes for timely access to
interpreter, liaison, coordination and support services for
Aboriginal and Torres Strait Islander people

8.1.4. The service has referral processes for timely access to
interpreter services for people from a culturally and
linguistically diverse background.

8.1.5. The service maintains a referral list and referral processes for
psychosocial, nursing, allied health, pharmacy, peer support,
volunteer and other supportive care resources available within
the service, the community or via remote access.

8.1.5.1. There is a defined centralised process and
identified personnel within the service for referral list
development and maintenance.

9. Safe Handling, Administration and Disposal of Chemotherapy

9.1. All clinicians and support staff who may come in contact with
chemotherapy drugs are educated on the safe handling of cytotoxic drugs
and related waste39 as part of service or unit orientation.

9.2. All chemotherapy services have policies and procedures to ensure the
safe handling of cytotoxic drugs and related waste consistent with the
Guidelines for the Safe Handling of Cytotoxic Drugs and Related Waste in
South Australian Health Services 201140 (currently being developed).
Policies and procedures must be relevant to the local care environment
(e.g. hospital, community, patient home) and include:
9.2.1. Legislative requirements
9.2.2. Risk Management
9.2.3. Staff Health
9.2.4. Education &amp; training
9.2.5. Production, labelling and dispensing of cytotoxic drugs
9.2.6. Transport and storage of cytotoxic drugs
9.2.7. Administration of cytotoxic drugs inclusive of all relevant routes

of administration
9.2.8. Personal Protective Equipment (PPE)
9.2.9. Management of extravasation
9.2.10. Management of spills
9.2.11. Management/Transport of waste including contaminated body

waste and laundry

39
South Australian Department of Health 2010, Draft State-wide Framework for Chemotherapy

Education and Assessment; an Integrated Model for South Australia, September 2010
40

SA Health, Guidelines for the Safe Handling of Cytotoxic Drugs and Related Wastes in South

Australian Health Services , Draft version 1.3, October 2010
40

10. Intrathecal chemotherapy and recommendations to reduce the risk of
error with vincristine

10.1. Only level 5 and 6 chemotherapy services are to administer
chemotherapy via the intrathecal route.

10.2. Intrathecal chemotherapy for paediatric patients can only occur within a
dedicated paediatric haematology/oncology service by senior clinicians
formally assessed as competent to administer intrathecal chemotherapy.

10.3. Services have policies and procedures that comply with the
recommendations of the 2005 Australian Council for Safety and Quality in
Health Care Medication Alert41 to reduce the risk of error with vincristine.
These recommendations include;

10.3.1. Vincristine should be dispensed and administered in a minibag,
not a syringe. Use of a minibag aims to design out the error by
preventing connection to a spinal needle.

10.3.2. All vincristine products, including outer wraps, should be
labelled with a prominent warning label stating: FOR
INTRAVENOUS USE ONLY Fatal if given by other routes .

10.3.2.1. Negative labels, such as Not for intrathecal use
should NEVER be used.

10.3.3. The timing and location of vincristine preparation, delivery and
administration should be such that it is separate from all
medicines intended for intrathecal administration.

10.3.4. Medicines to be administered intrathecally must be packaged,
transported and stored separate to intravenous medicines in
specifically designated containers. Vincristine and other
intravenous medicines must have separate packaging and
different containers.

10.3.5. All medicines for intrathecal administration should be labelled
with a prominent warning label, on the syringe and the outer
wrap, stating For intrathecal use .

10.3.6. Only staff specifically trained and experienced in intrathecal
cancer treatments should be designated to prescribe, prepare,
dispense, deliver, receive or administer intrathecal
chemotherapy. This includes senior registrars, consultants,
cancer pharmacists and senior nurses.

41
Australian Council for Safety and Quality in Health Care, Vincristine can be fatal if administered by

the intrathecal route, Alert 2, December 2005 http://www.safetyandquality.gov.au/

10.3.7. Staff administering intrathecal medicines must use formal
checking procedures. This should include a time out involving
at least two health professionals, including an oncology trained
nurse or pharmacist and a doctor. The patient identifiers, drug,
dose, volume, route and rate should be verified against the
medication order immediately prior to administration. Both
health professionals should then sign the order.

Appendix 1: Consultations and contributions

Name Role
Jodie Altshwager Ambulatory &amp; Primary Health Care Directorate, Central Northern

Adelaide Health Service
Mary Amanatidis Project Officer, Department of Health Nursing &amp; Midwifery Office
Monique Anninos CSC Haematology/Oncology, Womens And Childrens Hospital

Campus, Child Youth &amp; Womens Health Service
Jacqui Adams* Clinical Head Oncology, Lyell McEwin Hospital &amp;

Clinical Director of Cancer Services, Country Health SA
Peter Bardy* Chief Medical Officer, Central Northern Adelaide Health Service,

Specialist Haematologist RAH &amp; TQEH
Carol Barnes Director of Nursing and Midwifery, Wallaroo Hospital, Yorke and

Lower North Health Services, Country Health SA
Julie Beaton Personal Assistant to Clinical Director Cancer Services, Adelaide

Health Service,
Jenny Beutel Chief Nurse, Nursing &amp; Midwifery Office, SA Health
Steve Morris and the
members of the Cancer
Pharmacy Workforce
Working Group

Pharmaceutical Services and Strategy Branch, SA Health

Peter Chapman* Chief Medical Advisor Country Health SA
Alwin Chong* Aboriginal Health Council South Australia
Lauren Civetta Senior Project Officer, Planning Unit, Adelaide Health Service, SA

Health
Greg Crawford* Palliative Care Specialist, Calvary North Adelaide Hospital

Mary Potter Senior Lecturer in Palliative Care, University of
Adelaide

Deb Daulby** Senior Project Officer, CanNET SA, Statewide Service Strategy,
SA Health

Nino DiSisto* Executive Director, Country Health SA
Member of the Cancer Clinical Network Steering Committee (frmr)

Tracey Doherty*** Deputy Chair Cancer Clinical Network Steering Committee
Clinical Practice Nursing Director, Cancer Services, Adelaide
Health Service

Cecily Dollman Team Leader, Cancer Services Team, Social Work and
Counselling Service, Royal Adelaide Hospital

Maeve Downes Senior Project Officer, Chemotherapy Administration State-wide,
Nursing &amp; Midwifery Office SA Health

Bev Drummond CSC Ceduna District Health Services, Country Health SA
Lisa Elliott CSC Day Chemotherapy Unit, Royal Adelaide Hospital Cancer

Centre
Catherine Egal Acting Nursing Director, Functional &amp; Clinical Services,

Noarlunga Health Service

Appendix 1: Consultations and contributions

Name Role
Alice Every CSC Ward B6, Royal Adelaide Hospital Cancer Centre
Juli Ferguson* Consumer representative, Cancer Voices SA &amp; Fleurieu Cancer

Network
Carolyn Garbett Smith Social Worker, Royal Adelaide Hospital
Shandelle Hill Regional Outreach Oncology Clinical Practice, Child, Youth and

Womens Health Service
Meryl Horsell Manager, Clinical Service Planning, Statewide Service Strategy,

SA Health
Ann Jackson A/g CSC Haematology/Oncology, Womens and Children s

Hospital, Adelaide
Megumi Kanaike Clinical Oncology/Haematology Pharmacist,

Flinders Medical Centre
Dorothy Keefe* Chair Cancer Clinical Network Steering Committee

Clinical Director Cancer Services, Adelaide Health Service
Bogda Koczwara* Director Cancer Services, Southern Adelaide Health Service
Sheila Lehman CSC Haematology/Oncology, The Queen Elizabeth Hospital
Jude Lees* Senior Pharmacist, Royal Adelaide Hospital Cancer Centre
Kristin Linke* CSC Haematology/Oncology Day Centre, The Queen Elizabeth

Hospital
Gerry Lloyd Director of Nursing/Midwifery, Gawler Hospital, Inner North

Country Health Services, Country Health SA
Melanie McMahon Rural Cancer Care Coordinator, Central Northern Adelaide Health

Service Cancer Services
Ashleigh Moore* Consumer representative, Cancer Voices SA
Steve Morris Chief Pharmacist, Pharmaceutical Services and Strategy Branch,

SA Health
James Moxham* GP Representative, Cancer Clinical Network Steering Committee
Rahul Mukherjee* Radiation Oncologist, Central Northern Adelaide Health Service
Kim Nicolson CSC Coober Pedy Hospital &amp; Health Services, Country Health SA
Lyn Olsen and the
CHSA Nursing and
Midwifery Leadership
Group

Country Health SA

Michael Penniment* Radiation Oncologist, Central Northern Adelaide Health Service
Janette Prouse Geriatric Oncology Nurse, Royal Adelaide Hospital Cancer Centre
Sharon Reinbrecht Rural Cancer Care Coordinator, Southern Adelaide Health

Service
David Roder* Group Executive Research, Development and Statistics, Cancer

Council SA
Dianne Rogowski Executive Director of Nursing &amp; Midwifery Allied Health &amp; Patient

Care, Central Northern Area Health Service
Graham Rumsby Nursing Director, Royal Adelaide Hospital Cancer Centre

Name Role
Rural Divisions of
General Practice

Barossa, Division, Eyre Peninsula , Flinders and Far North,
Limestone Coast, Mid North Rural, Murray Mallee, Riverland,
Yorke Peninsula

Megan Satenak* Director, Dietetics &amp; Nutrition, Repatriation General Hospital

Senior Cancer Nurses
Stakeholder Group

CanNET SA, Statewide Service Strategy, SA Health

Magda Simon Project Nurse Mental Health, Nursing &amp; Midwifry Office, Sa Health
Heather Tapp* Director Cancer Services Children Youth &amp; Womens Health

Service
Suzanne Taylor CSC Haematology/Oncology, Womens And Childrens Hospital

Campus, Child Youth &amp; Womens Health Service
Kate Turpin Nurse Education Facilitator, Department of Clinical

Haematology/Oncology, Womens and Childrens Hospital
Metropolitan Divisions of
General Practice

Adelaide Hills, Adelaide Central and Eastern, Adelaide Northern,
Adelaide Eastern, Southern Division and Adelaide Western

Terry Ventrice CSC Ward C6, Royal Adelaide Hospital Cancer Centre
Ingrid Vogelzang* Network Development Manager, Statewide Cancer Clinical

Network
Alison Walsh CSC Ward B8, Royal Adelaide Hospital Cancer Centre
Deb Warne CSC Surgical Centre, Repatriation General Hospital
David Watson Head, Flinders University Department of Surgery
Brenda Wilson* Chief Executive Cancer Council South Australia
Graeme Young Professor of Gastroenterology and Academic Head of GI Services,

Flinders University of SA

*Member Cancer Clinical Network Steering Committee
**Major contributor
***Principal Editor and project chair

Appendix 2:
Self Evaluation and Implementation Matrix
Key

Full compliance means arrangements / processes exist and are documented and implemented.

These arrangements are comprehensive, regular, formal and consider local, within-region and state-wide relationships.

There is formal evidence and documentation, available including reports where appropriate, to support compliance.

Partial compliance means arrangements/ processes exist, however there is opportunity to improve through one or more of the following:

&gt; Formalising arrangements/ processes
&gt; Documenting arrangements/ processes
&gt; Implementing arrangement/ processes
&gt; Increasing frequency/ regularity
&gt; Increasing the comprehensiveness
&gt; Gathering evidence and documentation to support compliance

Non-compliance means there is work required to develop clear, consistent and documented roles, structures, policies, procedures and processes.

Comments/plan provides supporting information to criteria compliance and plan to achieve as applicable.

Self Evaluation and Implementation Matrix
Standard 1: Governance

Standard

Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

1 Clearly documented governance arrangements exist both locally and regionally.

1.2 In line with clinical service delineation, core speciality and clinical support services exist to manage risk levels of

chemotherapy. Formal MOU exist as required.

1.3 Regional Directors oversee continuous development and implementation of standardised

procedures/protocol/models of care that support chemotherapy delivery.

1.4 Performance indicator framework KPIs are monitored and reported through identified governance processes.

1.5 Safety and Quality complaints and incidents including AIMS reports are monitored and formally reviewed

through identified governance processes. These processes inform strategic planning.

Standard 2: Workforce, training and competency

Standard Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

2.1 Policies and procedures for provision and verification of credentialing and chemotherapy education and

competency exist and are adhered to.

2.1.1 Only chemotherapy competent clinicians prepare or administer chemotherapy.

2.1.2 Service has standard mechanism for providing opportunity for and monitoring continued competency

2.2 Paediatric chemotherapy is managed by a specialised paediatric health facility unless recommended and well

supported by paediatric specialist clinicians.

2.3 Sustainable access to nursing/clinical staff with expertise in CVAD and PICC is available and care is consistent

with evidence based guidelines

Standard 3: Timely access, integration and coordination of care

Standard Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

3.1 Processes exist to ensure care is coordinated in a consistent and timely manner utilising quality and cost

effective principles.

3.2 Access to transport and accommodation is available for patients relocating for treatment.

3.3 Minimum operational &amp; infrastructure requirements including accommodation and ICT are met to maximise local

access to care.

3.4 Services administering chemotherapy to paediatric patients comply with the Standards for the Care of Children

and Adolescents in Health Services.

3.5 Formal communication arrangements between GP s and consultants exist for 24/7 advice/consultation/referral.

3.6 Procedures for efficient and effective transfer of patient care are standardised

3.7 Services without oncology/haematology/pharmacy on site have formal links and agreements with recognised

service for advice, education and support.

3.8 Services without specialist cancer nurse on site have formal links and agreements with recognised service for

advice, education and support Formal links/agreements exist with a recognised L4-6 chemotherapy cancer

nurse for remote support within SA

3.9 Standard processes exist for efficient and effective discharge planning/transition/follow up care

Standard 4: Multidisciplinary care, comprehensive patient assessment and chemotherapy planning.

Standard Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

4.1 All patients have opportunity to have management discussed by a Cancer MDT

4.2 Local policy identifies comprehensive patient information required to be available and documented prior to

prescribing or administering chemotherapy

4.3 Local policy identifies that final decisions on initiation of chemotherapy protocol/treatment plan are made at

consultant level.

Standard 5: Patient Education and Consent

Standard Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

5.1 Guidelines and resources are available to enable standardised and effective provision of verbal and written

information to patients/parents/carers/family prior to initiation of chemotherapy via any route.

5.2 Service maintains a policy for obtaining and documenting patient consent for chemotherapy.

Standard 6: Chemotherapy prescribing

Standard Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

6.1 Service complies with the 2009 SA Health Policy Directive in regard to consistent prescribing terminology and

use of acceptable abbreviations.

6.2 Evidence based, standard chemotherapy regimens are defined and utilised.

6.3 Local policies and procedures identify appropriate prescribing practices and maintain a centralised register of

staff competent to prescribe, verify prescriptions and supply chemotherapy.

Standard 7: Assessment of Monitoring of Patients on Chemotherapy.

Standard Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

7.1 Standard, evidence based protocols are utilised to determine appropriate time interval for regimen specific

laboratory and radiological tests.

7.2 Policy and procedures that clarify roles and responsibilities of doctors, nurses and pharmacists in patient

assessment and monitoring exist and are relevant to local workforce education, knowledge and skill. Clear role

delineation enables comprehensive patient assessment without duplication of effort.

Standard 8 : Provision of supportive care.

Standard

Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/plan

8.1 Services have local, community or remote resources that support patients with cancer and their

families/caregivers.

8.1.1 Standard evidence based protocols are readily accessible and utilised to manage symptoms and side effects

including oncological emergencies.

8.1.2 Evidence based tools to assess and monitor symptom and psychosocial distress are routinely utilised and staff

are educated on responding to supportive care needs of cancer patients

8.1.3 Referral processes to ATSI liaison, coordination and support exist

8.1.4 Referral processes to interpreters and support for CALD peoples exist

8.1.5 Referral processes to supportive care resources are identified and maintained

Standard 9 : Safe Handling, Administration and Disposal of Chemotherapy

Standard

Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/Plan

9.1 Service/unit orientation includes education on safe handling of cytotoxic drugs and related waste

9.2 Services comply with SA Health guidelines on the safe handling, transportation, storage and management of

cytotoxic drugs and related waste.

Standard 10 : Intrathecal chemotherapy and recommendations to reduce the risk of error with vincristine.

Standard

Standard Criteria Full

compliance

Partial

compliance

Non

compliance

Comment/Plan

10.1 Local policies and procedures identify that only Level 5 &amp; 6 chemotherapy services administer chemotherapy

via the intrathecal route.

10.2 Local policies and procedures identify that Intrathecal chemotherapy for paediatric patients occurs only within

dedicated paediatric facilities

10.3 Local policies and procedures exist and adhered to regarding intrathecal chemotherapy and the recognised risk

of error with vincristine.

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