Q:

Is it standard of practice to have a RN and someone who is PALS certified be present in the clinic during allergen skin prick testing? Can it be performed with medical assistants and BLS certification? Our clinic is part of the medical center and recently our nurse (RN) has left. I continue to perform skin testing and only have medical assistants in my clinic. Someone raised the issue that I need a nurse and someone who is PALS certified to perform skin prick testing. I have search the practice parameter but can't locate the specific about recommendation for necessary personnel. Please advice. Thank you

A:

Thank you for your recent inquiry.

Unfortunately there is no definitive answer to your question. You are correct in that the Allergen Immunotherapy Parameters do not speak specifically to this issue. The best inference we can draw from this document is the personnel they suggest to be available for a clinic administering allergy injections. Even regarding this question, there is a great deal of leeway given in the Practice Parameters.

We have answered two questions previously regarding personnel suggested for offices administering allergy injections. For your convenience, I have copied both inquiries and the responses below.

Since, of course, an allergy injection would be more likely to cause an anaphylactic episode than skin testing, the standards for personnel would at least intuitively be higher than that for skin testing. Thus any standard set for personnel in an office where injections are administered should be sufficient for an office where skin testing is done. But even when one looks at the requirements for personnel related to the administration of allergy injections, they are not specific in this regard, and do not speak to your specific inquiry. Thus, a great deal is left to the judgment of the physician in charge.

The answer to the inquiries regarding personnel required for injections, since these inquiries were submitted before the most recent Update on Immunotherapy were taken from the 2007 Immunotherapy Parameter. For your convenience, I have also copied below two statements applying to personnel that should be available when allergy injections are administered that were taken from the January 11, 2011 Update of this Parameter.

Looking at all of this information, one would not be able to find any mandate that gives you a specific answer to your question about "PALS certified."

Thus, in the final analysis, there is, as noted, a great deal of leeway in the Parameters regarding this issue, and the final judgment is left to the physician in charge of the clinic. The answer would therefore be how comfortable that physician is with the personnel available and their ability to manage an episode of anaphylaxis.

Thank you again for your inquiry and we hope this response is helpful to you.

Personnel necessary to administer allergen immunotherapy
11/2/2010
Question:
Can I hire a Medical Assitant that is not certified and teach her how to give allergy injections?

Answer:
Thank you for your recent inquiry.

I have copied below the statement from the most recent Practice Parameter on allergen immunotherapy (1).

Quote: "Regardless of the location, allergen immunotherapy should be administered under the supervision of an appropriately trained physician and personnel."

As you can see, the Parameter states only that the person administering immunotherapy be "appropriately trained." It does not specify that this person should have any particular degree. This would imply, therefore, that an appropriately trained medical assistant could be used to administer injections.

Thank you again for your inquiry and we hope this response is helpful to you.

Reference:
1. Cox L, et al. Allergen immunotherapy: a practice parameter, second update. The Journal of Allergy and Clinical Immunology, September 2007; Volume 120 (3), page S25-S85.

Sincerely,
Phil Lieberman, M.D


10/13/2009
Question:
We are updating our allergy injection protocol and we currently require that a physician be available on site prior to giving the shots. I am the only physician at our health clinic but there are 2 nurse practitioners available when I am not here. I have read that a "licensed physician extender" may also supervise. Does that mean that a nurse practicioner can supervise? Is there certain training required to legally supervise?

The whole staff is aware of our anaphylaxis protocol and there is an ER across the street from our office. We do not have the equipment to maintain an airway, we only have oxygen by mask. Our current protocol is to give epinephrine (IM), antihistamine (IM) and oxygen (via mask). Our plan is to call 911 and have the patient transported to the ER. Our office is small but we do give allergy injections as ordered by the patients alllergist and I wanted to make sure our protocol is appropriate. Thank you for your time.

Answer:
Thank you for your recent inquiry.

The best answer to your question can be obtained from the reference noted below (1). The issues involved are discussed in detail on Page S62 of this publication.

I will briefly summarize this reference for you. A more detailed discussion, which would be helpful to you, can be obtained from the reference itself.

The administration of allergen extracts in physician offices other than the office of the physician preparing the extract is in common practice. It certainly fits within the standard of care in the United States. The reference noted below states, "The preferred location of allergen immunotherapy administration is in the office of the physician who prepared the patient's allergen immunotherapy extract. The physician's office should have the expertise, personnel, and procedures in place for the safe and effective administration of immunotherapy. However, in many cases it might be necessary to administer the allergen immunotherapy extract in another physician's office. Allergen immunotherapy should be administered with the same care wherever it is administered. A physician or qualified physician extender to treat anaphylaxis should be in the immediate vicinity when immunotherapy injections are administered."

The term "qualified physician extender" would apply, in my opinion, to a nurse practitioner.

The document further states, "Regardless of the location, allergen immunotherapy should be administered under the supervision of an appropriately trained physician and personnel.

The physician and personnel administering the immunotherapy should be aware of the technical aspects of the procedure and have available appropriately trained personnel, resuscitative equipment/medicines, and storage facilities for allergen immunotherapy extract.

The healthcare professional and staff should be able to recognize early signs and symptoms of anaphylaxis, and administer emergency medications as necessary."

From your description, I believe that your site does meet the qualifications listed in this evidence-based, consensus document.

In addition, most extracts, sent by a physician to another facility, does give instructions as to the procedure to follow should there be a reaction. You might check the extracts you receive for such information, and if there is any question, consult the physician who forwarded the extract for further instructions.

Thank you again for your inquiry and we hope this response is helpful to you.

Reference:
1. Cox L, et al. Allergen immunotherapy: a practice parameter, second update. The Journal of Allergy and Clinical Immunology, September 2007; Volume 120 (3), page S25-S85.

Statements:

Cox L et alAllergen immunotherapy: A practice parameter third update. Journal of Allergy and Clinical Immunology Vol. 127, Issue 1, Supplement, Pages S1-S55, 2011.

"Appropriate personnel, equipment, and medications should be immediately available to treat anaphylaxis, should it occur."

"Supervising medical personnel Summary Statement 62: Regardless of the location, allergen immunotherapy should be administered under the direct supervision of an appropriately trained physician, qualified physician extender (nurse practitioner or physician assistant), or both in a facility with the appropriate equipment, medications, and personnel to treat anaphylaxis."

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology