Avoiding Allergic Reactions: Caring for Patients with Drug, Food, and Latex Allergies

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A teenager presents at an ambulatory clinic with rapid heart rate, sweating, and panic after taking the second dose of a new asthma medication.A child breaks out in hives an hour after a bandage is placed over the site of a blood test.A hospital inpatient has trouble breathing after eating a turkey dinner that includes dressing made with chestnuts.

Allergic reactions such as these can range from mild to life threatening, and any number of products may be responsible. The risk to patient safety occurs when health care professionals inadvertently allow the patient to come in contact with potentially dangerous allergens.This can occur when health care professionals are unaware of the patient’s allergies or even when the allergies are known.

Determining whether patients have actual allergies or simply intolerances, making all caregivers aware of known allergies,and preventing contact with known allergens presents a challenge for any organization.This article addresses the three most common groups of allergens to which patients can be exposed in health care organizations: latex, medications, and food.

Ensuring a Latex-Safe Experience
Allergy to latex began gaining notoriety in the early 1990s, perhaps as a result of the increased use of latex gloves and health care workers’ resulting sensitivities.However, the use of latex is not confined to gloves, and patients are at as much risk as (and sometimes more risk than) caregivers when they are exposed to latex-containing products.These products are far more numerous than was originally recognized, and health care organizations are challenged to identify latex-containing products and latex-free alternatives. Stethoscopes, catheters, blood pressure cuffs, intravenous (IV) tubing, and vial stoppers for multidose medications can all contain latex.Even medications may contain latex; for example, both diphenhydramine (a front-line drug for the treatment of allergic reactions) and enoxaparin sodium (used to treat clotting problems) can contain latex in their injectable forms. Initial patient assessments should include questions about sensitivity to latex (see Sidebar 1 below). In hospitals or long term care facilities, an allergic patient or resident should only be placed in a room with another latex-allergic individual or one who is willing to abide a latex-free environment.“The protein in latex that causes the allergic reaction can be aerosolized just by pulling off a glove that has latex in it or snapping a balloon,” notes Kathy Stucker,R.N., patient safety officer at OSF Saint Anthony Medical Center in Rockford, Illinois. Allergic patients who are exposed to latex may experience a (sometimes severe) skin rash at the point of contact or anaphylaxis (extremely low blood pressure, difficulty breathing, and even death).

Sidebar 1. Latex Allergy/Sensitivity Questionnaire
This screening tool can be used to assess all patients for latex allergies. When health care workers ask patients the following questions, they should make sure the patient understands what latex is and where it can be found; health care workers may also have to further explain each question.

Have you ever been told that you have an allergy or a sensitivity to latex?
Have you ever had swollen lips or throat after blowing up a balloon or having dental work?
Have you ever had a reaction (that is, rash, swelling, itching of hands or eyes, hives, difficulty breathing) after being in contact with the following (circle all that apply):

Rubber/latex gloves
Ace bandages
Rubber bands
Foam pillows
Elastic in clothing
Condoms or diaphragms
Erasers containing latex

Do you have any congenital condition, such as spinal bifida, myeloma, or myelodysplasia?

If yes, have you had a problem with latex?

Did you have multiple surgeries or procedures involving the spine or use of multiple catheters before you were one year old?

If yes, did you have a problem with latex?

Are you allergic to the following foods: bananas, avocadoes, kiwi fruit, or chestnuts?

If yes, do you have a problem with latex?

For health care staff: Did you provide educational materials on latex to the patient?

Source: Used with permission from OSF Saint Anthony Medical Center, Rockford, Illinois.

Various professional groups,such as the Association of periOperative Registered Nurses,have published guidelines for preventing and treating allergic reactions to latex.Individual organizations are also developing ways to reduce the risk.“Better labeling of medical products has made it easier to identify products that contain latex,”says Stucker.“We got rid of all latex gloves,with the exception of a specific glove that is used in surgery.We worked with local florists to ban all balloons except the Mylar type,and we’ve trained staff to be on the lookout for them.For patients with a known allergy,we have carts with only latex-free products outside the room.Our pharmacy also uses a password-protected Web site to determine,by manufacturer, whether a specific drug contains latex.”A 2005 study based at Johns Hopkins University recommended that staff assume that every pharmaceutical vial may contain a latex closure and follow protocol by which all vials and IV fluid bags/bottles are punctured only once,with unused medications being discarded.1

Minding the Meds
Although fewer than 10% of adverse drug reactions are caused by allergies,2 the reactions patients experience can range from mild to severe. Medications commonly associated with allergic reactions include the following:

Analgesics such as aspirin and nonsteroidal antiinflammatory drugs (patients often report allergic reactions to codeine and morphine, but these are usually side effects and not true allergic reactions)
Antibiotics such as penicillin, tetracycline, and sulfa
Antiseizure medications such as phenytoin and carbamazepine.

An allergic patient may develop a mild to severe rash, fever, muscle/joint aches, kidney inflammation, and/or anaphylaxis. The type and severity of reaction is key in determining whether a medication may be used for a specific patient. “What we often find is that what patients think is an allergy isn’t a true allergy. It may be a known side effect of a drug,” explains Darryl Rich, Pharm.D.,M.B.A., F.A.S.H.P., a Joint Commission surveyor.“For example, a lot of people will complain of an upset stomach with narcotics, which is a known side effect,but that won’t stop a person who’s in severe pain from taking the drug. It depends on the severity of reaction and the need for the drug.”

A thorough history and effective medication reconciliation processes are the best ways to avoid allergic reactions to drugs. In-depth screening (see Sidebar 2 below) can help staff determine whether previous reactions were caused by allergies or other types of adverse events, such as wrong dosage or drug interaction.Double-checks for allergies can also be built into admission, transfer, and discharge processes.“The Joint Commission requires that the list of medications be reconciled whenever a patient’s setting, service, level of care, or practitioner changes as well as when new medications are ordered or the patient’s medication orders must be rewritten; this has been helpful in identifying what drugs the patient comes in on,” says Gina Pugliese,R.N.,M.S., vice president of the Premier Safety Institute at Premier, Inc.“This is especially important for patients with allergies when a brand of drug is changed during the course of care and at discharge.”

Sidebar 2. Medication Allergy Questionnaire
Patients often identify a side effect from a drug as an allergy, so careful screening is needed to determine the type of reaction and whether it precludes the use of a specific medication. The following questions can help determine whether a patient has a medication allergy:

Have you ever had a reaction of any kind after taking a medication? If so, what was the medication? And what was the reaction?
How did you take the medication (orally, intravenously, topically)?
What was the strength or dose?
How long ago did this reaction occur?
Did you take the medication more than once? Did your doctor have you take the drug again to see if you would have a similar reaction?
Describe your reaction in detail.

If you developed a rash, was it in one spot or all over? What did it look like?
How do you know it was the drug that caused the reaction? Did the reaction go away once you stopped taking the drug? Was that the only drug you were taking at the time?
What medical treatment, if any, did you receive for the reaction?

Fighting Food Allergies
Preventing reactions due to food allergies is a joint effort between floor staff and dietary services.The most common food triggers are eggs,cow’s milk,soy,wheat,peanuts,tree nuts,fish,and shellfish.However,many people believe they have an allergy when they simply have an intolerance.For example,a person who has trouble digesting milk products,resulting in gas and nausea,has lactose intolerance;on the other hand,someone who can’t breathe after eating shrimp has a true allergy.“It’s a real challenge to food services,”notes Debby Kasper,R.D.,L.D., manager of Clinical Nutrition at Premier,Inc.“The patient relays an allergy to the nurse,but sometimes it’s just a preference,and sometimes it’s the person’s interpretation of an upset stomach.”

Another point of confusion may result from patients who have undergone skin tests for allergies.“I’ve seen mothers bring in children with a list of 25 things they can’t eat because they had some kind of reaction to a skin test,”says Kasper.“That’s when people need to have a more detailed discussion with their health care provider or physician to find out exactly what their allergies are. Especially in the case of children,you want to restrict the diet as little as possible so they get all their nutrients.”

Transfer of information from the patient care area to dietary services is crucial. Organizations with automated systems may be able to pass information directly from admissions or the floor to the dietitian.Many hospitals have instituted programs through which patients can order their meals from a menu when they want them.With computerized records, aides can double-check for allergies at the same time the patient places the order and alert the dietitian to any discrepancies.However, even these systems are not foolproof.“Sometimes it depends on where in the record the information appears,”says Kasper.“If the nurse types it in as a free-text note [rather than in a prescribed field], it might not pass through to food service.” Another double-check can occur when the food is brought to the patient.Whoever delivers the food can check the patient’s two identifiers and match them to the identifiers assigned to the food to ensure that the right patient is receiving the right food. The person delivering the food can also check the patient’s chart to ensure that the patient is not receiving any food that he or she shouldn’t be eating. Finally, staff should encourage family members or friends of the patient to speak up if they notice that the patient is being given inappropriate foods.

Educating Staff and Patients
No matter what type of system is used,communication among caregivers and patients is requisite to preventing allergic reactions. Health care workers need to know exactly how and where patient records are marked to indicate allergies to any substance, whether there is a specific field in an electronic medical record or a stamp or sticker on the front of a paper chart.They also need to be trained in how to elicit information from patients.“If someone asks you if you’re ‘allergic to anything,’ you might think of a bee sting or wool,” says Pugliese.“You have to ask the question in a way the patient will understand, and you have to be specific and ask in more than one way if necessary.With all the different languages and cultures we deal with today, health literacy is a major issue.Even getting an accurate history is very challenging. It all depends on how you ask the question and the patient’s frame of reference.”

Health literacy also comes into play when patients require education about their allergies.Pertinent information should be presented in a manner that patients can understand.For example,many patients do not read or cannot understand the literature that accompanies medication samples or pharmacy orders; thus, they have no idea that an allergy to one type of drug could indicate a similar reaction to another.This makes clear explanations at discharge even more important. Staff also cannot assume that a patient who knows he or she has an allergy automatically knows all the triggers or what to do in case of a reaction.OSF Saint Anthony Medical Center includes a prompt for staff members to provide patient education.“We tell them about things they might not even realize have latex in them and what might happen if they have a reaction,”says Stucker. Although serious injury and death related to allergies are far less common than other types of adverse events,even mild reactions need to be prevented,if possible.Health care staff members need to work with patients and families to ensure that potential allergens are not overlooked during the course of care.

References

Hamilton R.G., et al.:Administering pharmaceuticals to latex-allergic patients from vials containing natural rubber latex closures. Am J Health Syst Pharm 62:1822–1827, Sep. 1, 2005.
Hanson K.: Drug Allergy Overview. http://www.em edicinehealth.com/drug_allergy/article_em.htm (accessed Sep. 12, 2006).