We Got You Covered: Chemotherapy Practices

Methodist Hospital (San Antonio, Texas)

CSI Summary

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CSI Presentation

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Project Topic

Safe handling of chemotherapy

Hospital Units

Adult Oncology Service Line (3 inpatient units and 1 ambulatory clinic)

CSI Participants

Amanda Biggers, BSN, RN, CPHON
Angela Chun, BSN, RN
Sandra Hegar, BSN, RN, OCN
Anna Manolis, ADN, RN, OCN

Project Goals/Objectives

  1. To improve staff knowledge of safe handling practices for chemotherapy through personal protective equipment (PPE) use and excreta and linens disposal protocols
  2. To achieve greater than 50 percent compliance in safe handling practices at three months and greater than 90 percent compliance at six months in both RN and patient care technician (PCT) staff

Project Outcomes

  1. Increased staff knowledge of safe handling practices through in-services, an educational video and printed guides
  2. Achieved greater than 90 percent compliance at the six-month mark for both pre-administration and administration observations, and over 80 percent compliance for discontinuation observations
  3. Increased compliance for safe handling of excreta and linens to 50 percent at the six-month mark

Project Overview

The purpose of this initiative was to implement a model for improving personal protective equipment (PPE) utilization through education, audits and feedback. We conducted a baseline safe handling surveys, then provided staff with training on the correct handling of chemotherapy and body fluids for patients undergoing oncology treatment. We also performed audits and provided feedback on compliance rates for all activities over a six-month period.

Staff members were given an opportunity to provide feedback on our processes and equipment to improve PPE compliance. At the end of the six months, the initial survey was re-administered to all staff to evaluate changes in knowledge related to safe handling as well as self-reported compliance with PPE utilization.

We plan to sustain our efforts by submitting a proposal to the oncology clinical educator about including safe handling practices in quarterly “blitzes” and by exploring development of a learning management system offering of our initial in-service, to reach additional staff.

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