Are You Allergy STRONG?

1. Are You Allergy STRONG? Claire Murphy, NP-C BUSM Instructor of Medicine Clinical Director Allergy VA New England Healthcare

2. Objectives As a result of attending this session, the learner will: • 1.Recognize contributing factors that elicit symptoms of local and systemic reactions in your patient receiving immunotherapy. • 2. Design interventions to address existing barriers to immunotherapy adherence.

3. Faculty Disclosure Claire Murphy, RN, MSN, NP-C Faculty: Genentech Speaker Bureau

4. Only an Allergy Nurse could appreciate this…… One day a gentleman visited a bar and in conversing with fellow patrons, the subject of allergy came up. Each tried to outdo the others with stories of how allergic they or an acquaintance might be. The best of these was the fellow who exclaimed that his wife was allergic to everything - in fact her nose was so stuffed that if he kissed her on the lips, she would suffocate! So… he made sure he let her know just how much he loved her and kissed her as often as he could!

5. Overview • Please don’t have a reaction on my time…. • Competencies • Oh yea….the 5 Rights • Who’s in charge? • Do we have a plan? • Barriers… Nurse vs Patient • Getting through IT safely and effectively Your nose is running? Well hurry up and catch it!

6. Why Consider? • Immunotherapy • Desensitization of those allergens resulting in decreased allergen specific IGE Inhibits the seasonal increase in allergic specific IGE • Demonstrated decrease in symptoms • Typically 5-6 yr course of treatment • Monoclonal Antibodies (anti-IGE) • Prevents binding of IGE • Demonstrated decrease in symptoms

7. So…it’s looking like a local reaction • Red, swelling, itching, pain • √ size and consider dosage reduction next visit • ***pollen season • Tx: Antihistamines, topical steroids, NSAIDs, cold pack

8. Systemic reaction • Hives, recurrent sneezing, diffuse itching, wheezing, difficulty breathing, throat tightness, throat swelling, abdominal cramping, dizziness, loss of consciousness, or shock: • Sometimes it is as simple as “my throat feels funny” or “I just don’t feel right”…………..

9. Systemic reaction (2) • Delegate another member of staff to NOTIFY THE COVERING ALLERGY PROVIDER IMMEDIATELY. • Administer EPI-Pen* IM to the mid-anterolateral thigh of the patient while he/she is lying supine (if tolerated) or at least sitting *(1:1000 stock) in a dose of 0.01ml/kg (usually 0.3-0.5ml for adults) • Obtain vitals signs (continuous), including oxygen saturation • Supplemental oxygen as needed • Maintain airway management • As directed by covering provider • Benadryl 50 mg by mouth • Albuterol Sulfate 90 mcg/metered inhalation (2 inhalations)

10. Contributing Factors • I NEED to sleep with Fluffy… • I ran out of my allergy meds • These shots really don’t fit into my schedule.. • I just can’t wait that long after my injection • I know I don’t feel good…just give me my shot

11. What about us? • I know her dose… I don’t need to check it. • Hey Susie…let me tell you what happened last night… • mmmm…you are wheezing but I would hate for you to miss your injection • You have missed several doses… I think you should be receiving this dose..

12. Could we have done something different? • Severe or poorly controlled asthma and administration errors are responsible for fatal systemic reactions”1. • “ Those patients who demonstrate larger reactions during skin testing are atincreased risk of systemic reactions during immunotherapy.2 1.Cadarso et al. Risk Factors for Systemic Reactions to Allergen Immunotherapy. Curr Opin Allergy Clin Immunol. 2011;11(6):579-585 2. DaVeiga SP, Liu X, Caruso K, et al: Systemic reactions associated with subcutaneous allergen immunotherapy: timing and risk assessment. Ann Allergy Asthma Immunol. 2011;106:533-537.

13. What about…. • The 5 Rights • Assessment of the patient • Following the correct order for dosing • Avoiding non-related conversation • Quiet place without interruption to draw up extract

14. Immunotherapy Process….It really is all about You IT (Immunotherapy) Administration • Calculation • Technique • 5 Patient Rights • Review of IT dose order • Symptom review of previous dose • Drawing up of dose • Second person check for dose • Post-injection Process and Measurement • EPI-pen on person • Mandatory wait time 30 mins. Xolair- one hour • Documentation and Encounter • AMA • Safety, Safety, Safety,

15. Show me the facts! Aaronson et al in their e-mail survey of 1717 allergists, looking at immunotherapy errors. • 58% noted wrong patient errors • 74% noted an incorrect amount of vaccine (local reactions to one fatality). • Suggested nurse education in compliance with the recommendations in the "Allergen Immunotherapy: A Practice Parameter" • Utilizing patient-specific vials • standardized dosing med sheets • implementation of triple-checking of identity to make sure the correct patient is receiving the correct injection. Aaronson DW et al. Incorrect allergy injections: allergists' experiences and recommendations for prevention. J Allergy Clin Immunol. 2004 Jun;113(6):1117-21

16. Background of the VA Experience Boston VA Allergy/Immunology Program is the sole provider of Allergy consultative services including but not limited to, the prescribing of Immunotherapy and administration of allergy skin testing, throughout New England.

17. In the beginning…….. • Program revamped 3/09. Allergy site relocated • New Allergist on Board “Peels back the Layers”………not looking pretty… • NP “borrowed” from Pulmonary • NP hired from BU • RN hijacked from Nursing • Dilemma about ordering extracts • God Bless Walter Reed!

18. How Bad Can it Get? • Policies and Procedures among the missing • Can I just give one shot from each of the “nice colors”? • All IT on hold

19. The Strategy • Educational mandate • Site evaluations to determine capacity • Allergy Directive • On site training • New P/P designed • Allergy Competence Day • Didactic • Clinical

20. Allergy Competence • Pre-Test • Objectives • Pathophysiology of Allergy • Review of Allergy Guidelines • Patient Presentation • Consult Process • Treatment • Immunotherapy Process • Station 1 : Review of Dosing Orders • Station 2: Calculation and Administration of IT • Station 3: Review of Adverse Event Procedures • Station 4: Patient Simulation • Wrap-Up • Post-test • Evaluation

21. Results Twenty five nurses participated in the training. The average pre-test score (± std error) was 76.1±0.27%. The average post-test score was 93.6±0.27%. Using a two sample t-test, the difference between pre- and post-training mean test score was statistically significant (P<0.00002). Additionally, nurses completing the training report greater competence in the administration of immunotherapy and confidence in managing adverse reactions.

22. Abstracted Presented at AAAAI and WAO • Title: Delivering an Educational Model for Allergy Immunotherapy • Authors: CMurphy1, SYoon1, MAllen1, SHoff1, DSloane1, RBreslow1,S. Cieri1 RGoldstein1. VA Boston Healthcare Network. Boston, MA. • Rationale: Recent re-structuring of the Boston Veteran’s Administration Allergy program, including a new method of immunotherapy extract delivery, necessitated a VISN-wide educational programto teach effective allergy evaluation and safe administration of immunotherapy. We investigated the effectiveness of this program in improving participants’ knowledge about immunotherapy. • Methods: A Site Capacity Assessment/ Educational Venue was designed to educate and train clinical staff to ensure compliance with best practices for immunotherapy administration. Six sites within VA Boston Healthcare were identified for training. Registered Nurses administering immunotherapy participated in an Allergy Nurse Competency Training program consisting of didactic lectures and practicum training. Pre and post-testing exams conducted assessed the short term impact of the program. • Results: Twenty five nurses participated in the training. The average pre-test score (± std error) was 76.1±0.27%. The average post-test score was 93.6±0.27%. Using a two sample t-test, the difference between pre- and post-training mean test score was statistically significant (P<0.00002). Additionally, nurses completing the training report greater competence in the administration of immunotherapy and confidence in managing adverse reactions. • Conclusions: Standardization of didactic and practicum training expands nurses’ comprehension of current practice standards for safe and effective administration of immunotherapy. This educational model now adopted nationally by the Veteran’s Administration Allergy Consortium to facilitate standardization of training, is currently being integrated throughout the United States Veteran’s Administration Allergy sites as a component of the VA Allergy Strategic Plan.

23. Just a quick thought…… Another way to say that medications for allergic diseases are expensive: Robbing Peter to pay for Pollen

24. Barriers to Immunotherapy • Commitment to weekly injections • Competing priorities work, school, kids • Fear of injections • Fear of reactions • 30 min wait time • Access to the office/hospital, ie. parking • Time, Time, Time

25. Other Strategies..besides arm twisting to Enhance IT Adherence… • Value of the customer (patient) • Unnecessary waiting time • Early/later scheduled appts • 2x weekly IT • Incentives (parking) • Evening clinic • Weekend clinic • What are your ideas????

27. Summary • 5 Rights • Patient education • Reinforce adherence • Have a plan for treating allergic reaction • Safety, Safety,Safety • Have Fluffy sleep somewhere else ..”the daily chatter of imperfect systems is not unavoidable noise to be griped about or ignored; it is a stream of messages telling us where we can improve.” (Steven Spear 2009)

28. Sites of Reference • Aaronson DW et al. Incorrect allergy injections: allergists' experiences and recommendations for prevention. J Allergy Clin Immunol. 2004 Jun;113(6):1117-21 • American Academy of Allergy Asthma & Immunology http://www.aaaai.org/ Allergen Immunotherapy. Am FamPhysician. 2004 Aug 15;70(4):689-696 http://www.aafp.org/afp/2004/0815/p689.html • Allergy Nurse http://www.aaaai.org/professionals/school_tools.stm • Risk Factors for Systemic Reactions to Allergen Immunotherapy. Curr Opin Allergy Clin Immunol. 2011;11(6):579-585 • Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127:S1-S55 • Phillips JF et al. Systemic reactions to subcutaneous allergen immunotherapy and the response to epinephrine. Allergy Asthma Proc. 2011 Jul-Aug;32(4):288-94. doi: 10.2500/aap.2011.32.3446

29. Time to Stop Listening To This Great Speaker…What’s On Your Mind??? THANK YOU! Clairem@bu.edu Claire.Murphy@va.gov