Allergies/Intolerances, and Scope of practice.

[HamsterRN, ADN, RN]

This is similar to a current thread (I'm allergic to....(laundry list)!), but I didn't want to hijack the thread.

There seemed to be some agreement with separating allergies and intolerances in that thread but when we tried this where we work we hit some resistance from nursing staff so I'm wondering what the views are on this outside of my organization.

The EMR we use currently groups allergies and intolerances together. This same system automatically D/C's any medications that are entered for a patient if they are listed in their allergies/intolerances. The problem with this is that when a patient says they have an allergy to Morphine because it makes them drowsy (not even an intolerance) then the standing MI protocol order for morphine gets blocked and we can't get it out of pyxis for that patient when are being treated for ACS, getting it straightened out can take a good 15 minutes.

The proposed fix is to separate allergies and intolerances in the EMR. The issue is that the allergy/intolerance list is maintained solely by nursing and pharmacy, with nursing making the majority of changes to the list when needed. Some nurses have vetoed the plan claiming that nurses can't diagnose. Aside from the myth that nurses can't diagnose in any way (which is a whole different thread), at least understanding the difference between the two should be in our scope since a nurse's scope of practice is supposedly made up of the skills that we have been taught, and that are validated and maintained. While it's true we can't diagnose for the purpose of billing reimbursements, we diagnose and act on those diagnoses (even medical ones) all the time.

I've tried to make the point that we should know the difference between the two since the nursing response to symptoms that correspond with an allergy should be different than with an intolerance or side effects. Although the nurses opposed to separating the two argue even that point, saying all we do is assess and report those findings. We offered to have a review class for those who didn't feel that this was within their scope, but the vetoing nurses claimed it wasn't about needing to review, it was about potential scope. Other organizations who use our EMR have nursing separate the two when entering them, so it would seem that it is possible.

[Altra, BSN, RN]

The EMR we use currently groups allergies and intolerances together. This same system automatically D/C's any medications that are entered for a patient if they are listed in their allergies/intolerances. The problem with this is that when a patient says they have an allergy to Morphine because it makes them drowsy (not even an intolerance) then the standing MI protocol order for morphine gets blocked and we can't get it out of pyxis for that patient when are being treated for ACS, getting it straightened out can take a good 15 minutes.

Agree - this is unacceptable.

But the system can only block things based on someone, a health professional, having entered an allergy and apparently people are doing that without asking the appropriate questions when a patient indicates an "allergy."

Patient: "I'm allergic to Drug X."

Nurse: "What happens when you take Drug X?"

Patient:

"I get a rash" (allergy)

"My throat gets scratchy" (allergy)

"I get diarrhea" (possibly an intolerance -- more likely a common, not unexpected side effect of antibiotics, etc. that can potentially be managed if there isn't a good alternative to this particular med)

"I get a headache" (again - this symptom can probably be managed)

"My heart rate slows down" (intolerance)

etc.

Your EMR can probably be tweaked, but the process of entering "allergies" into the system should also be tweaked, IMO.

[cherrybreeze, ADN, RN]

I can see how the "diagnosing" may come in to play. Perhaps you can solve this issue by having a protocol on the books, listing specifically what would be considered an allergy (rash, anaphylaxis, etc), and EXAMPLES ONLY of intolerances (since an inclusive list would be impossible to put together....I had a patient recently with epinephrine listed as an allergy...reaction? "Heart races"). This protocol could be approved by, say, your facility's medical director, or a physician board. That would be a one-time thing they would have to do, as opposed to separating allergies from intolerances for every patient, so they may be more agreeable to doing it. I would think that would cover the nurses legally from being accused of "diagnosing?"

[HamsterRN, ADN, RN]

I can see how the "diagnosing" may come in to play. Perhaps you can solve this issue by having a protocol on the books, listing specifically what would be considered an allergy (rash, anaphylaxis, etc), and EXAMPLES ONLY of intolerances (since an inclusive list would be impossible to put together....I had a patient recently with epinephrine listed as an allergy...reaction? "Heart races"). This protocol could be approved by, say, your facility's medical director, or a physician board. That would be a one-time thing they would have to do, as opposed to separating allergies from intolerances for every patient, so they may be more agreeable to doing it. I would think that would cover the nurses legally from being accused of "diagnosing?"

When the proposal first came out, a 'help screen' with an algorithm to help differentiate allergies and intolerances was part of the plan. Unfortunately it didn't seem to help.

[HamsterRN, ADN, RN]

Agree - this is unacceptable.

But the system can only block things based on someone, a health professional, having entered an allergy and apparently people are doing that without asking the appropriate questions when a patient indicates an "allergy."

Patient: "I'm allergic to Drug X."

Nurse: "What happens when you take Drug X?"

Patient:

"I get a rash" (allergy)

"My throat gets scratchy" (allergy)

"I get diarrhea" (possibly an intolerance -- more likely a common, not unexpected side effect of antibiotics, etc. that can potentially be managed if there isn't a good alternative to this particular med)

"I get a headache" (again - this symptom can probably be managed)

"My heart rate slows down" (intolerance)

etc.

Your EMR can probably be tweaked, but the process of entering "allergies" into the system should also be tweaked, IMO.

Tweaking how the allergies and intolerances are entered is what we are trying to do, the problem we are running into is that there are nurses who don't feel comfortable entering reactions as either allergies or intolerances, but instead want to continue entering medications as a general "allergy/intolerance" single group, which often also includes expected minor side effects.

[Altra, BSN, RN]

Tweaking how the allergies and intolerances are entered is what we are trying to do, the problem we are running into is that there are nurses who don't feel comfortable entering reactions as either allergies or intolerances, but instead want to continue entering medications as a general "allergy/intolerance" single group, which often also includes expected minor side effects.

This is, well ... unfortunate.

It isn't "diagnosing" to indicate that a patient has indeed experienced one of the multiple expected side effects listed in the medication's package insert or any drug guide.

I would guess that your system is equally cumbersome for physicians -- get them on board with the redesign.