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Allied Health: Articles of Interest A practical guide to implementing the Academy’s Immunotherapy Forms In order to enhance the documentation of immunotherapy (IT) and increase the safety of administration of the vaccine extracts by our nursing staff, we customized the forms for our practice. We used the Academy’s Best Practices samples as a template for this purpose. Initially, our IT administration forms were scanned into the computer. We use two forms: one for patients receiving one to three injections, and the other is for those patients receiving four or more injections. Each form has a space for the patient’s full name, date of birth and their individual patient number. It also has our practice name and office site. Next we evaluated the vaccine columns. There is a column for each extract, and our forms have sufficient space to print each extract’s name. Some of our named patients’ vials will be labeled P1G or P1T or P1W, which is a shortened version of pollen mix; year one; grass, trees or weeds. We have made room on our form for the expiration date of the patient’s own extracts and include the vial lot number. The extract labels have all the above information, as well as the patient’s name, ID number and date of birth. We color-code all dilutions using plastic caps and colored labels. During each patient visit, a nurse writes out the complete dose volume (in milliliters), and the dilution, so our space is wide enough for that entry. For the purpose of defining dilutions, we no longer assign a single digit number, such as vial #1, but write out 1 BAU through 1,000 BAU; 1:100,000v/v through 1:10v/v; or whatever the actual dilution is to be administered, for each extract. Extract mixes which are ordered as stocks are printed at the top of their columns. For example: Std.Grass #1 as well as the exclusive ID number (40435) assigned to this mix by the manufacturer, is written out. The arm location (left or right, upper or lower) is printed at the top of the column for each extract. We do not alternate between arm sites, but use the same site each time, as we found less chance for error than when sites were rotated every visit. However, if the injections were administered in a different location, we would mark where it was given on that day. We added space for the date on our form, with the year written out at the top of the date column. There is also space to add the date further down the page as the years change. Our nurses initial their entries and sign their full name and title at the bottom of the page. Next to the signature, they add an equal sign and their initials (E.g. Arline Gerard, RN = AG). We also write the time that the patient is to be checked, post injections. This is a small entry that reads: Arm check @____, and the nurse writes in this time once the patient has received their IT. Any local reaction, for each arm site, is recorded after the prescribed wait. This includes the care administered, such as crème applied or ice given. We expect all our patients to wait, and injections are not given to patients unwilling to do so. We have printed and posted a short questionnaire and ask patients about increased symptoms, including:
For our asthmatic patients, we also check and document the peak flow reading. If they are unable to successfully “blow” 80 percent of their normal best, then we do not administer IT at that visit. (Some practices allow a reduction to 30% below baseline). The routine projected build-up schedule is printed on the reverse side of our IT record. With some patients, we may occasionally proceed by half steps or use a modified schedule. Our maintenance amounts are determined as the patient is approaching the higher dilutions. We underline their maintenance amounts using a red pen, and use pastel markers on the page to enhance each dilution’s color code. When pulling the patient’s chart and vial(s), we carefully check all the above information, and check a second time as we draw up their extract. A third complete review of everything is done before we finally call the patient’s full name, assess his/her status, and then give, or not give the injection(s). We realize that we are human and triple checking is realistic in order to avert mishaps caused by “brain fade.” We openly share our “close call” experiences. Serious reactions are now infrequent in our practice. We average 0.2 doses of epi per 1,000 patient visits. While most of these reactions are considered mild, we give the epi STAT, as necessary, and begin treatment immediately when any patient is having a reaction. A doctor is always available to treat any systemic reactions. We use a separate form to document all reactions and evaluate each one to learn any lessons which may help our practice improve. Following the Academy’s guidelines and skin testing records, as well as complete extract ingredients’ lists, are also part of the injection record paperwork. We are proud to be implementing the joint parameters in our practice. We feel that periodically upgrading procedures is important to improving safety and leading the community standard for professional care of our allergy patients. |
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