European Journal of Oncology Nursing 16 (2012) 17e25
Contents lists available at ScienceDirect
European Journal of Oncology Nursing
journal homepage: www.elsevier.com/locate/ejon
Antineoplastic agents extravasation from peripheral intravenous line in children:
A simple strategy for a safer nursing careq
Daniella Cristina Chanes a, *, Mavilde da Luz Gonçalves Pedreira b,1, Maria Gaby Rivero de Gutiérrez b,1
a
b
Nurse at the Chemotherapy Outpatient Unit, IOP GRAACC UNIFESP, SAO Paulo, Brazil
Federal University of Sao Paulo, 754 Napoleao de Barros Street, Vila Clementino, 04024-002 SAO Paulo, Brazil
a b s t r a c t
Keywords:
Extravasation
Antineoplastic agents
Children
Oncology nursing
Safety
Intravenous therapy
Pediatric nursing
Medication errors
Quality of care
Evidence-based nursing
Purpose: The antineoplastic agents infusion through peripheral lines may lead to several adverse events
such as extravasation that is one of the most severe acute reactions of this sort of treatment. The
extravasation prevention and management must be part of a safe and evidence-based nursing care. Due
to this fact, two algorithms were developed with the purpose of guiding nursing care to children who
undergo chemotherapy through peripheral line. The objectives of this study were to determine the
content validity of both algorithms with pediatric oncology nurses in Brazil and United States of America,
and to verify the agreement between the evaluations of both groups.
Methods and Sample: A descriptive validation study was carried out through the Delphi Technique that
has the following steps: development of the data collection instrument, application to the specialists,
data analysis, algorithms’ review, re-evaluation by the specialists, final data analysis and content validity
determination.
Results: The data analysis was descriptive and based on the specialists agreement consensus equal or
higher than 80% in every step of the algorithms. The process showed that the agreement with both
instruments ranged from 92.8% to 99.0%.
Conclusion: The algorithms are valid for application in nursing care with the main purpose of preventing
and managing the antineoplastic agents’ extravasation.
Ó 2011 Elsevier Ltd. All rights reserved.
Introduction
According to the Oncology Nursing Society, extravasation is the
passage or escape of antineoplastic drugs into the tissue that may
lead to necrosis in severe conditions (Polovich et al., 2005).
However, there are other definitions that consider extravasation as
only the escape of vesicant drugs into the tissue (Infusion Nurses
Society, 2006). Extravasation is described as the most severe
acute complication in the peripheral intravenous therapy with
antineoplastic drugs, resulting in extreme distress and suffering to
the patient and its prevention must be part of nursing care. For that
reason, it is necessary to have the best practice of highly
trained professionals in administering antineoplastic drugs
q This study is part of the Dissertation “Algorithms for Prevention, Treatment and
Follow-up after Antineoplastic Agents Extravasation from Peripheral Intravenous
Line in Children: Content Validation” presented to the Graduate Program in Nursing
of the Federal University of Sao Paulo for obtaining Masters Degree in Nursing UNIFESP, 2009.
* Corresponding author. Tel.: þ5511 55764430.
E-mail addresses: [email protected] (D.C. Chanes), mpedreira@
unifesp.br (M.daL.G. Pedreira), [email protected] (M.G.R. de Gutiérrez).
1
Tel.: þ5511 55764430.
1462-3889/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2011.01.005
(Sauerland et al., 2006; Kassner, 2000). Once extravasation occurs,
it is impossible to completely remove the drug from the tissue;
however, a prompt and consistent intervention within the event
time reduces significantly the risk of permanent injuries and
distress to the patient. In addition, the prompt intervention minimizes possible costs related to treatment and avoids delay in the
chemotherapy treatment which may negatively interfere with the
patient prognosis (Wickham et al., 2006; Kassner, 2000). Furthermore, the tissue destruction caused by the extravasation of antineoplastic drugs is indolent and progressive. Most of the damage is
not always immediately perceived after its occurrence, and it can
remain imperceptible until the patient returns to the treatment
center 24 or 48 h later, showing the first signs of progressive tissue
injury. Due to this fact, either the suspicion or the occurrence of
extravasation should be strictly monitored by the nursing team
(Kumar et al., 2001). Because extravasation is a severe adverse
event with serious consequences to the patient, its occurrence
should be reported. This action allows monitoring of the cases,
investigation of the possible causes involved, and adoption of
procedures to treat the patient. Moreover, it provides important
information to implement prevention strategies for new cases
(Adami et al., 2005).
18
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
Extravasation prevention and control should be part of institutional protocols, reflecting the concern of providing safe nursing
care within the quality standards. Protocols that are easy to follow
and are based on scientific evidence should be adopted in order to
improve nursing care and to assure safety to the patient (Adami
et al., 2005; Hadaway, 2007). Algorithms are one of the main
quality management tools currently used in the development of
Fig. 1. Algorithm for vesicant chemotherapy administration.
Direction signs
protocols and are an important way to organize processes involving
quality (Ishikawa, 1993). Based on the importance to standardize
nursing practices involved in the process of prevention, intervention, follow-up and documentation of this adverse event, two
algorithms were built to achieve this goal by collecting inherent
information and by proper reviewing of literature (Chanes et al.,
2008).
Beginning or end of a process,
Action,
Decision,
Report,
File,
Wait,
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
19
Fig. 1. (continued).
Thus, the main question of the present study is: what is the validity of the algorithms developed for vesicant drugs administration
and for extravasation occurrence intervention and follow-up?
Nursing from the United States of America (USA) and from Brazil
(BR), as well as to identify the common points in the evaluation
performed by both groups.
Purpose
Material and methods
The purpose of the present study was to verify the content
validity of the tools named Algorithm for vesicant chemotherapy
administration (Fig. 1) and Algorithm for intervention in the occurrence of extravasation (Fig. 2) by specialists in Pediatric Oncology
A descriptive study on content validation of measuring instruments was carried out by specialists of the St. Jude Children’s
Research Hospital (SJCRH) in Memphis e Tennessee e USA, as well
20
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
Fig. 2. Algorithm for intervention in the occurrence of extravasation.
Direction signs
Beginning or end of a process,
as by specialists of several Brazilian institutions, all of them
specialized in pediatric cancer treatment. The option chosen by
SJCRH for data collection in the USA was based on the research
partnership between the hospital and the institution where the
researchers work.
Action,
Decision,
Report,
File,
Wait,
Content validation
Validation is defined as the degree to which an instrument is
able to measure what it was intended for. Content validation is
a subjective judgment on whether a measure makes sense
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
intuitively and it refers to the degree to which an instrument
represents a specific domain or the relevance of its elements/items
(Polit et al., 2004; Hulley et al., 2007). Establishing content validation is a vital and rigorous process, in which the final outcome
determines the extent to which the algorithms incorporate most of
the elements and essential processes to the central theme. It can be
determined by different methods, to include Delphi Technique,
which stands out for enabling the consensus from a group of
specialists or experts in a particular area of knowledge regarding
a specific phenomenon (Polit et al., 2004). This technique requires
the use of questionnaires containing scales such as Likert, to obtain
expert opinion on the validity of each item individually and
together (Polit et al., 2004). Thus, in the first step, more general and
comprehensive, a domain is identified, and then items, which will
be part of an instrument are built.
By adopting the Delphi Technique, the idea is to obtain convergent opinions from several experts on the items, so that the validity,
final product of this process, results of group consensus on a specific
subject. The number of experts varies in the literature. According to
Lynn (1986), a minimum of five judges would provide a sufficient
level of control for agreement. On the other hand, the maximum
number of judges has not been established, but it is unlikely to
exceed 10. Consensus is determined in advance by the researcher
and a value is provided. Consensus levels between 50% and 80% are
found in the literature (Polit et al., 2004). For this study, the level of
consensus was pre-established to be equal or higher than 80%.
Sample
In order to be included in this study, the research subjects were
screened based on the following criteria:
To be a nurse;
To have at least five years of experience in the pediatric
oncology area, preferably in the administration of antineoplastic drugs;
To agree to participate in the study by signing the Informed
Consent Form (ICF) in Portuguese or in English, according to
the participant’s mother tongue.
Data collection
The study was approved in accordance with the ethical aspects
by the two institutions involved: Federal University of Sao Paulo UNIFESP and SJCRH. In order to obtain specialists’ analyses, two
instruments were developed, one in Portuguese and one in English,
using a Likert-type scale containing three statements: 1. I totally
agree. 2. I partially agree and 3. I disagree. The participants were
asked to indicate the degree of agreement or disagreement in each
item for both algorithms. The analysis of the instruments also
comprised questions regarding to the specialists’ agreement on
keeping the steps in the algorithm, as well as, keeping the sequence
provided in the instrument. They were also invited to provide
suggestions and/or comments about each step of the algorithms, if
necessary. For the re-evaluation phase, another four instruments
were developed, following the same standard, and the algorithms
were re-submitted with the changes suggested highlighted in the
instruments for the specialists to be able to evaluate the final
version.
Procedure of data collection
1st Phase e validation
The specialists were screened according to the criteria previously mentioned. In Brazil, the screening process was held during
21
the 10th Brazilian Congress on Pediatric Oncology, and in the USA,
during the traineeship held at SJCRH. The experts were personally
invited by the researcher to take part in the study. They were also
provided with information regarding the research objectives and
instructions on how to complete the evaluation of the algorithms.
Following that, all of them signed the ICF. The deadline for
returning the instruments completed was set within five days after
receipt.
2nd Phase e data analysis
All instruments, either totally completed or at least 95%
completed, returned within the five day-period were analyzed.
Descriptive analysis was individually performed in all steps
regarding agreement of Brazilian and US specialists; in addition, the
responses provided by the two groups were also compared. The
comments and suggestions provided to complete or to emphasize
their evaluations were also analyzed.
3rd Phase e algorithm review
All steps were reviewed based on the specialists’ answers,
suggestions and comments, in addition to data from the literature,
and were changed as required.
4th Phase e re-evaluation
After proper changes, the new algorithms along with a new
evaluation instrument were submitted to the specialists either by
e-mail or conventional mail. Along with the algorithms, they were
also given the results of the first phase, a letter describing the main
findings and the objectives of the new phase. The deadline to return
the instruments completed was set within 30 days.
5th Phase e final phase
All steps were individually evaluated regarding the degree of
agreement between the Brazilian and U.S. nurses, in addition to
compare the responses provided by the two groups. The comments
and suggestions provided to complete and highlight their evaluation were also evaluated. Following the descriptive analysis of the
results and based on the consensus of the experts and their opinions the algorithms had their final form set and their validity was
determined.
Results
Characterization of the subjects
The work team comprised 14 pediatric oncology nursing
specialists, with seven Brazilian and seven U.S. professionals, and
all of them were female (Table 1). Brazilian nurse’s average age was
around five years younger than U.S. nurses’, and the average of the
two groups was 42 years old. The average time of experience in
pediatric oncology of the U.S. nurses was about 8 years longer
compared to the Brazilian nurses. It is important to mention that
the specialist with the longest experience was a U.S. nurse who has
been working for 31 years in pediatric oncology. Regarding the
performance area, it is important to highlight that 11 out of the 14
Brazilian and U.S. nurses (78.8%) worked in assistance roles, at
inpatient or outpatient units, bone marrow transplant unit or as
line nurses (responsible for intravenous care). So that, all of them
had experience with antineoplastic agents administration. The
other three nurses worked in teaching and research, with two of
them having previous experience as bedside pediatric oncology
nurses. Overall, from the 14 nurses included in this study, 13 of
them had a large experience related to nursing care in children
undergoing chemotherapy
22
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
Table 1
Characteristics of the Pediatric Oncology Nurses according to gender, age, time of
experience, performance area and working place. Sao Paulo, 2009.
Table 2
Agreement with the steps of the Algorithm for Vesicant Drugs Infusion, according to
American and Brazilian nurses. Sao Paulo, 2009.
n ¼ 14
Categories
Nurses
USA
Gender (n ¼ 14)
Female
Male
Age (n ¼ 14)
30e40years
41e50years
51 a 60 years
Average (DP); min-max
Time of experience (n ¼ 14)
5e15years
16e25years
26e35years
Average (DP); min-max
Performance area (n ¼ 14)
Teaching and research
Assistance
Main activity (n ¼ 14)
Ambulatorial care
Inpatient unit
Bone marrow transplant unit
Line nurse
Teaching and research
n ¼ 14
Steps
Agreement (%)
USA
BR
General
1.0
2.0
2.1
2.2
2.1.1
2.1.2
3.0
3.1
3.2
3.2.1
3.2.2
4.0
5.0
6.0
6.1
6.2
7.0
7.1
7.2
7.2.1
7.2.2
8.0
8.1
8.2
8.1.1
8.2.1
9.0
9.1
9.1.1
9.1.2
9.2
10.0
General
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
85.7
100.0
100.0
100.0
100.0
100.0
85.7
85.7
85.7
85.7
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
97.6
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
85.7
100.0
100.0
100.0
85.7
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
99.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
92.8
92.8
100.0
100.0
92.8
100.0
100.0
92.8
92.8
92.8
92.8
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
98.3
BR
N
%
N
%
7
e
50.0
e
7
e
50.0
e
3
21.4
2
14.3
2
14.3
44.7 (9.2);
32.9e55.6
6
42.8
e
e
1
7.2
39.3 (7.2); 35.0
e54.4
3
21.4
2
14.3
2
14.3
18.6 (8.6);
7.0-31.0
7
50.0
e
e
e
e
10.7 (3.7); 5.015.0
1
6
7.2
42.8
2
5
14.4
35.6
4
e
e
2
1
28.4
e
e
14.3
7.2
2
2
1
e
2
14.3
14.3
7.2
e
14.3
Algorithm validation for vesicant drugs administration
The results regarding the agreement with the procedures
recognized by the Algorithm for Vesicant Drugs Administration were
descriptively and comparatively analyzed between the two groups
of specialists. The agreement with the steps ranged from 85.7% to
100%, and, regarding the evaluation of the instrument as a whole,
the agreement achieved was between 97.6% and 99.0% (Table 2). All
suggestions and comments from the experts were taken into
account, even those related to the steps with high level of agreement. For that reason, the entire instrument was reviewed.
Among these procedures, the items 3.2.1 and 3.2.2 stand out.
Both refer to the intravenous device to be used for peripheral
venous puncture, which are respectively, the needle-catheter and
the catheter over needle. The use of the needle-catheter showed
85.7% of agreement among the Brazilian expert. However, the two
nurses who disagreed stated that this device is not used to
administer vesicant drugs in their institutions. One of the specialists also stated that the needle-catheter increases the risk of antineoplastic drugs extravasation. On the other hand, the use of the
catheter over needle showed 85.7% of agreement among the U.S.
nurses. Two of them stated that this kind of device should not be
used for administration of vesicant drugs. One of the specialists of
the U.S. group recommended the use of the needle-catheter.
A further interesting result concerns the item 6.0, which evaluates the permeability of the catheter while injecting 10 ml of
saline solution with subsequent aspiration to assess the blood
return and the catheter patency. This procedure showed 85.7% of
agreement among the Brazilian experts. The main comments about
this action were regarding the prescribed volume, as some
specialists stated that 5 ml of saline solution would be sufficient to
determine the permeability of the catheter.
Also, regarding the evaluation of the catheter adequacy for
administration of vesicant antineoplastic drugs, the application of
the Infiltration Score of Infusion Nurses Society (INS), in order to
evaluate infiltration signs in the catheterized site, as stated in items
7.0, 7.1 and 7.2, showed agreement of 85.7% among the U.S. nurses.
The main comments were about the unfamiliarity and non-use of
the score in their practice. They were also concerned about the
score content and stated that would be important to simplify it and
train the team for its application. Yet, the removal of the venous
device procedure, in case of infiltration signs, stated in item 7.2.1,
achieved 85.7% of agreement among the U.S. nurses. They pointed
out that it would be necessary to evaluate the need to administer
phentolamine at the extravasation site, and in this case, the venous
device would be required. It is possible to state, based on the final
results, that both analysis, from each group and from the 14 experts,
demonstrated an agreement greater than 85.7%, above the 80% preestablished in this study.
Validation of the algorithm of intervention in the extravasation
occurrence
The results concerning the agreement with the procedures
recognized by the Algorithm of Intervention in the Extravasation
Occurrence were descriptively and comparatively analyzed
between the two groups of specialists. The agreement with the
steps ranged from 74.4% to 100%, and with regard to the evaluation
of the instrument as a whole, the agreement was between 92.8%
and 97.9% (Table 3). As in the previous instrument, we highlighted
the steps contained in the instrument that had, in the comparative
analysis, agreement below 100.0%.
The first step analyzed is item 1.1 referring to immediately stop
the administration of the antineoplastic drug in case of extravasation and to not remove the venous device. Among Brazilian nurses,
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
Table 3
Agreement with the steps of the Algorithm for Intervention after Antineoplastic
Drugs Extravasation, according to American and Brazilian nurses. Sao Paulo, 2009.
n ¼ 14
Steps
1.0
1.1
1.2
1.3
2.0
3.0
3.1
3.2
3.1.1
3.1.2
3.2.1
4.0
4.1
4.2
5.0
General
Agreement (%)
USA
BR
General
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
85.7
100.0
100.0
100.0
85.7
100.0
100.0
97.9
100.0
71.4
71.4
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
85.7
100.0
100.0
71.4
92.8
100.0
85.7
85.7
100.0
100.0
100.0
100.0
100.0
92.8
100.0
100.0
92.8
92.8
100.0
85.7
95.4
the agreement was 71.4% and the main reason was that they would
immediately remove the device in case of extravasation Table 3.
One of them stated that, even in case of blood return, it would not
be prudent to use the venous access and that the amount of drug to
be aspirated would not justify such action, either. As for disconnecting the infusion device delivering the antineoplastic drug
and connecting a new syringe to the catheter to aspire the residual
drug, which corresponds to procedure 1.2, there was an agreement
of 71.4% among Brazilian nurses. These specialists were the same
respondents who disagreed on the step 1.1 and came up with the
same rationale to disagree with item 1.2. Among the U.S. experts,
one of them stated that the residual drug could be aspirated either
by a new syringe or by the device containing the antineoplastic
drug, and the latter would be a more efficient option to save time
for the intervention.
The thermal and positioning interventions, represented by steps
3.1 and 3.2, showed 100% of agreement. However, the elevation of
the affected limb (3.2.1) aroused comments from two Brazilian
nurses who pointed out the need to check the conditions of the
patient before applying this intervention. Also, those experts stated
they did not believe this intervention would be appropriate to be
performed in children.
Regarding the use of hot packs four times a day, during 20 min,
for 48e72 h, in cases of the extravasation of vincristine, vinblastine,
vinorelbine, etoposide and teniposide (3.1.1), there was an agreement of 85.7% among the U.S. nurses. Their main concern was
related to the consequences of applying hot packs to the site, which
could increase the risk of burns and infection.
The monitoring results were pointed out in steps 4.0, 4.1, 4.2 and
5.0. The item 4.0, showed 85.7% of agreement among the Brazilian
nurses. They suggested that the follow-up procedure (type of
intervention and period) should be described in the instrument.
Additionally, patient discharge in case of reduction or disappearance of edema, pain or extension of the extravasation area,
item 4.1, achieved an agreement of 85.7% among the U.S. experts.
Those specialists stated that the tissue necrosis may progress for
over six months and, for this reason, the follow-up with doctor and
nurse appointments is essential. Furthermore, they stated that the
patient should receive written instructions, regarding care and
symptoms to be reported, and they also emphasized the importance to provide instructions to the patient’s family in order to
assist the patient during the home care period, even after the
patient’s discharge.
23
Finally, the documentation of the occurrence, procedure 5.0,
achieved 100% of agreement among the U.S. specialists, whereas
only 71.4% of agreement was obtained among Brazilian nurses, who
stated that the documentation should be done from the very
beginning of the extravasation occurrence, not just after its
resolution.
When analyzing the results of the Algorithm of Intervention in the
Extravasation Occurrence, it is possible to verify that the level of
agreement on each item as well as on the instrument as a whole
was higher than 85.7%, which is above the pre-established goal in
this study (80%).
Results of the re-evaluation phase
The analysis of both algorithms has demonstrated that the
agreement was higher than the pre-established one (80%) for all
items, even those achieving 100% of agreement were re-evaluated.
Such a fact is thought to be due to a number of factors, and one of
them is the increase of knowledge acquired on the subject by the
researchers throughout this study process, which was provided by
proper literature review, opinion from peer-reviewed scientific
journal regarding the stage of building the algorithm, as well as, the
experts’ comments and suggestions.
One of the first points re-evaluated was the title of both
instruments. It is important to mention, at this point, that the titles
had not been part of the analysis in the validation process. However,
one observation that brought this to our attention was the fact that
some nurses were concerned to the issue and suggested some
changes. For this reason, the reformulation of the titles were
considered necessary; thus, based on the available suggestions, the
instruments were changed as follows: Algorithm for Administration
of Vesicant Antineoplastic Drugs in Children Through Peripheral
Venous Access and Algorithm of Intervention in the Occurrence of
Extravasation of Antineoplastic Drugs administered through Peripheral Venous Access in Children.
Furthermore, both analysis of the degree of agreement on the
comments and the suggestions provided by the nurses on the steps
of the instruments were taken into account to maintain and/or
change them in the instruments. Therefore, based on a new literature review and on the comments and suggestions provided by
the professionals involved, it was decided to maintain the original
sequence of the steps, once there was high proportion of agreement
and suitability with the literature. Thus, only the content of four
steps in the Algorithm for Administration of Vesicant Drugs and one
procedure in the Algorithm of Intervention in the Occurrence of
Extravasation were changed. Next, the items of the Algorithm for
Administration of Vesicant Antineoplastic Drugs in Children through
Peripheral Venous Access were submitted to a new analysis, called
re-evaluation. The modified items are presented in their original
and reformulated form, according to Chart 1. With regard to the
Algorithm of Intervention in the Occurrence of Extravasation of Antineoplastic Drugs Administered Through Peripheral Venous Access,
only the action 5.0, regarding the documentation of the event, was
modified. The original presented the action in a simple way. After
reviewe, it emphasizes that documentation should contain information of all stages of the process. All items modified showed 100%
of agreement between Brazilian and U.S. specialists.
Discussion
Health care takes place in a very complex system and has
characteristics, which may predispose to errors and aggravate their
consequences in a level rarely identified in other human activities
(Harada et al., 2006). Safe nursing care is synonym of error-free
care. Such errors could cause negative impact on the patient’s
24
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
Original Content
Final Content
(2.0) Identify if the antineoplastic drug is (2.0) Check the patient´s name, drug,
vesicant
route, dosage and infusion time. Identify if
the drug is vesicant.
(2.1) Identify the infusion technique
(2.1) Verify the infusion technique
(2.1.2) Continuos/ Intermitent INFUSION
(2.1.2) Intermitent INFUSION - Less than
60 minutes
(6.0) Verify catheter patency in the (6.0) Verify catheter patency in the
infusion of 10cc saline solution and infusion of 5 to 10cc saline solution and
aspirate to verify blood´s backflow
aspirate to verify blood´s backflow
Chart 1. Original and final content of the steps sent to re-evaluation from the Algorithm for antineoplastic agent infusion in children through peripheral vein.
quality of life. However, there are a number of factors that may
affect patient’s safety, which is not always under control (Kline,
2004; Stratton et al., 2004).
The expansion of treatment regimens in oncology and the
development of new drugs and combinations require an increasing
number of specialists with knowledge and skills for their administration and control of the risks associated (Jones and Coe, 2004).
The health care professionals should be able to prevent the occurrence of an adverse advent, or even, use their knowledge to abolish
or mitigate its deleterious consequences in case they occur, as it is
the case of antineoplastic drug extravasation (Kloth, 2002).
Aiming to provide the best possible performance, the development and implementation of protocols have been incremented
since the 90’s in order to support administrative and clinic decisions to provide the most appropriate nursing care to the users in
specific situations (Lacey et al., 2006). The use of clinical protocols
based on the existing relationship between care, scientific evidence
and quality of care is essential. Quality can be characterized by the
presence of professionals with high level of competence to perform
their functions, to effectively use the resources, to reduce to the
lowest level the risk of lesions produced or resulted from assistance, to satisfy clients/patients’ demands regarding their expectations and access to health care, and to provide a favorable effect in
the population’s health (Harada et al., 2006). Some authors point
out that the incidence of extravasation in an institution may and
should be used as a quality indicator of the nursing care provided,
and this score should be close to zero (Lacey et al., 2006).
Different factors should be taken into account to evaluate the
quality of health care services and, in order to comprise these
multiple dimensions, aiming to guide and reformulate the strategies for continuous improvement of health services, several indicators of structure, process and results are required to evaluate the
quality of health assistance provided to the patients (Harada et al.,
2006). The use of protocols enables the standardization of practice,
which also provides monitoring of the care implemented and
prevention of waste. A study demonstrated that the standardization of nursing care to patients undergoing antineoplastic chemotherapy by implementing protocols based on evidence was able to
reduce in 50% the incidence of adverse events in a 15-month period
(Leape et al., 2000). Evidence-based care implies the use and
application of research results for decision making. However,
health professionals have broader evidence interests that relate to
the experience of health, illness, and health care. Indeed, it is not
unusual within the broad field of health care to find that best
available evidence on a given topic cannot be reduced to a quantifiable value (Pearson et al., 2008). In this context, the non-identified
extravasation or extravasation wrongly treated may lead to severe
and progressive tissue damage, and many authors consider its
occurrence a medical emergency (Jones and Coe, 2004; Wickham
et al., 2006). Nevertheless, there is a lack of evidence-based
nursing care in the literature regarding antineoplastic agents’
extravasation management. For instance, the Oncology Nursing
Society (Polovich et al., 2005) and the European Oncology Nursing
Society (Wengstrom and Margulies, 2008), describe in their
guidelines the lack of evidence regarding the use of antidotes on
extravasation treatment. The lack of large-scale comparative trials
due to the non-frequent nature of extravasation episodes leads to
the controversial use of those agents. Notwithstanding, some
authors describe and advocate the use of antidotes in contrast to
the recommendations recognized by societies, such as ONS.
The algorithms, main purpose of this study, stand out as an
important tool for extravasation management. The Joanna Briggs
Institute describes evidence-based practice as clinical decision
making, taking into account the best available evidence, the context
in which the care is provided, client preference, and the professional nurse judgment (Pearson et al., 2008). In concern to the
context of care, it is important to emphasize that in developing
countries, such as Brazil, the best practice regarding antineoplastic
drug administration are not yet available to all the patients in all
care settings. So, even taking notice and agreeing with guidelines
from the Centers for Disease Control and Prevention (CDC, 2002),
Oncology Nursing Society (Polovich et al., 2005), European
Oncology Nurses Society (Wengstrom and Margulies, 2008), and
many others, the use of intravenous devices, such as the steel
needle-catheter, is a reality in many pediatric oncology care
institutions.
For that reason, we believe that the algorithms developed and
validated by this study provide a comprehensive and detailed
overview of the processes, both involved in the administration of
antineoplastic drugs and in the interventions in case of extravasation occurrence, and are good measures to assure quality of care and
provide the highest safety as possible to children undergoing
chemotherapy through peripheral intravenous line in developing
countries.
Content validation by Brazilian and U.S. specialists
Brazilian and U.S. nurses have differences that transcend
geographic distance. The professional background in nursing,
concepts and values inherent to the culture of each country, in
addition to the different work environments, make these two
groups quite different from each other. One study demonstrated
that cultural and ethnical differences influence the answers from
specialists involved in the content validation processes (Evans,
2004). In this study, the diversity of cultures and conditions of
nursing practice between U.S. and Brazilian nurses have not
affected the final result, as the answers not only were very similar
but also brought validity to the proposed instruments.
D.C. Chanes et al. / European Journal of Oncology Nursing 16 (2012) 17e25
Conclusion
Based on the results of the present study, it is possible to
conclude that there was no difference in the answers obtained from
Brazilian and U.S. nurses, and that the Algorithm for Administration
of Vesicant Antineoplastic Drugs in Children through Peripheral
Venous Access and Algorithm of Intervention in the Occurrence of
Extravasation of Antineoplastic Drugs administered through Peripheral Venous Access in Children were considered validated, according
to results of a Delphi Technique.
Implications for nursing practice
The standardization of nursing care for children undergoing
chemotherapy through peripheral lines by the use of protocols
based on scientific evidence is essential when quality of care and
patient safety are considered. Therefore, the algorithms suggested
in this manuscript are important tools to prevent and manage the
occurrence of antineoplastic agents extravasation in pediatric
oncology patients as they establish rapid intervention and proper
follow-up for this adverse event.
Funding source
None declared.
Conflict of interest
None declared.
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