ONS 2017: Hospital-Wide Initiative to Standardize the Administration of Vinca Alkaloids Using a Mini-Bag, Side-Arm Technique

Key Points

  • When analyzing 12 months of data at Johns Hopkins Hospital, the researchers found no cases of extravasation among the more than 1,300 mini-bag administrations of vincristine after the practice change.
  • Program facilitators provided background education to provider, pharmacy, and nursing staff that included a review of cases of patient harm with recommended guidelines for prevention and used the same technique that nurses were used to.
  • All nursing staff watched a short video demonstrating the proper side-arm drip administration of vincristine and also attended a hands-on skill lab.

Many patients with cancer who receive vinca alkaloids such as vincristine have a treatment regimen including other chemotherapy drugs that are administered intrathecally. If vincristine is mistakenly administered into the spinal fluid, it is uniformly fatal, causing ascending paralysis, neurologic defects, and eventually, death. This mistake, however, is almost completely avoidable with one small administration change—instead of “pushing” intravenous (IV) vinca alkaloids via syringe, experts now call for these agents to be diluted into mini-IV drip bags.

During the Oncology Nursing Society (ONS) 42nd Annual Congress, MiKaela Olsen, MS, APRN-CNS, AOCNS, of The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, presented results of a center-wide effort to administer vincristine via mini-IV drip bags in a poster presentation (Poster 187).

Study Findings

According to Ms. Olsen and her colleagues, there are a number of barriers to standardizing vincristine administration in mini-IV drip bags. For instance, they noted that nurses may believe the risk of extravasation to be higher than when pushing the agent. However, when analyzing 12 months of data at Johns Hopkins Hospital, the researchers found no cases of extravasation among the more than 1,300 mini-bag administrations of vincristine after the practice change.

“This was a big change in practice for bedside nurses at Johns Hopkins Hospital who had, to this point, always administered vesicants—other than continuous infusion vesicants—as an intravenous push through the side port of a free-flowing line. Using an evidence-based practice approach to tackle this clinical practice issue was key to our success,” said Ms. Olsen. “Just because it was always done a certain way does not mean it is the safest way.”

According to Ms. Olsen, the program facilitators provided background education to provider, pharmacy, and nursing staff that included a review of cases of patient harm with recommended guidelines for prevention and used the same technique that nurses were used to; however, instead of pushing the medication through a syringe, the nurse holds the mini-bag as it runs through the side port of a free flowing line.

“Nurses performed the procedure in a skills lab environment to ensure understanding of proper technique for safe mini-bag administration to prevent extravasation. This approach was key to our success,” said Ms. Olsen.  

Other barriers noted by the researchers include a lack of understanding of the risk of death associated with central nervous system administration of vincristine, as well as a lack of understanding of how to properly administer vinca alkaloids via drip bag.

To thwart these concerns at the time of the administration switch over, a short video was produced for the nursing staff demonstrating the proper side-arm drip administration of vincristine. Nursing staff also attended a hands-on skill lab, wherein they are instructed to remain with the patient during the entire 5-minute administration, checking blood returns every 2 minutes and at the completion of the infusion. Additionally, labeling of vincristine must be clear and stated as such: “For intravenous use only – fatal if given via other routes.”

“At Johns Hopkins Hospital, our pediatric colleagues made this successful practice change first. After thoughtful design of the step-by-step procedure, policy revisions, and collaboration between nursing and pharmacy, the change was implemented in adult oncology,” said Ms. Olsen. “Our staff feel confident that this new procedure is safe and that it is absolutely the right thing to do to prevent patient harm. Once we made the change, we did not look back.  Eliminating the risk of harm was our number one priority.”

NCCN Support and Just Bag It!

This presentation comes on the heels of the National Comprehensive Cancer Network® (NCCN®)’s 2016 Just Bag It! Campaign for the safe administration of vincristine.

“The oncology nursing community plays an imperative role in the day-to-day, hands-on care and protection of patients with cancer. NCCN applauds Johns Hopkins, as well as the staff and faculty of our other Member Institutions, for their dedication to patient safety,” said Robert W. Carlson, MD, Chief Executive Officer, NCCN. “We are pleased that Ms. Olsen has the opportunity to share her findings with the esteemed ONS audience, and hope her work is the impetus for others to change their practices.”

To ensure that vincristine is always administered properly, NCCN has issued guidelines advising health-care providers to always dilute and administer vincristine in a mini-IV drip bag and never use a syringe to administer the medication. This precaution renders it impossible to accidentally administer the medication into the spinal fluid and greatly decreases the chances of improper dosage.

All 27 NCCN Member Institutions, including The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, have adopted policies in line with these guidelines, which are also recommended by the Institute for Safe Medication Practices, the Joint Commission, the World Health Organization, and the ONS.

In March 2017, NCCN issued a challenge to raise the number of reported adopters of these policies to 100 centers or practices. To report adoption of these practices, visit NCCN.org/JustBagIt.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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