Identifying and Managing Patients’ Allergies

Podcast Transcript

Carol Pehotsky:

One of the earliest things we all learned in nursing school right behind patient identification is review of a patient's allergies. And while it is basic, it is absolutely the cornerstone and the stepping off point for effective patient care across the healthcare continuum.

If we get it wrong, if we don't have a thorough understanding of a patient's allergies and their reactions to those allergens, we risk safety issues everywhere --- from the foods we provide, the medications we administer, all the way through the devices and implants we might use in a surgery. I'm joined today by Jeanette Kubicki, clinical nurse specialist from Allergy and Immunology at Cleveland Clinic to discuss all of this and more.

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing, from patient care to advancing your career, to navigating tough on the job issues. We're so glad you're here. I'm your host, Carol Pehotsky, associate Chief Nursing Officer of Surgical Services Nursing.

Welcome back everyone. I'm so blessed to be surrounded by a team of professionals who help not only put on this podcast but think about interesting topics and who should we have on as guests. I try to make sure my voice is not overly loud in that because our audience is a diverse audience. We want to make sure that we're having episodes that that appeal to a variety of topics.

Today's topic hits very personally for me. Today we're talking about allergies and managing allergies. And as somebody who has managed through her own allergies for as long as I can remember, I was thinking yes, please. Maybe I'll get some good tips. <laugh>.

It is my great pleasure today to welcome my friend and colleague, Jeanette Kubicki. Jeanette is a clinical nurse specialist in allergy and immunology at Cleveland Clinic. Jeanette, welcome. Thank you so much for joining me today.

Jeanette Kubicki:

Oh, thank you for asking me. It's an honor to be here.

Carol Pehotsky:

I'm proud to say we've known each other for a minute, many years. This is not a patient CNS relationship. She's not my allergy provider, but we've known each other throughout other travels in our life. Would you mind sharing with our audience your fascinating nursing journey?  We'll get to all the really good allergy stuff, but I'm hoping you'll share with us first a little bit about your nursing journey.

Jeanette Kubicki:

Sure. Right out of the gate, out of nursing school, I had a special interest in intensive care. So that's where I started my career. And then eventually I moved on to emergency medicine, which I loved. I was young and loved the energy and running around and going home and collapsing.

Then I eventually got to a point where it's time to do something different. And something came up here at Cleveland Clinic in interventional radiology. And I was there for many, many years in all areas of radiology. Eventually I applied for a position as the nurse educator.

Carol Pehotsky:

Mm-hmm <affirmative>.

Jeanette Kubicki:

And I got it. 

Carol Pehotski:                                                                           

That's where we met.

Jeanette Kubicki:

Yes, that's how we met. There was a really big project Carol and I worked on at one point, and  that's how we really got to know each other. And then I decided to go back to school because my career was heading in the direction of education, process improvement, quality improvement.

So I went back to school, got my clinical nurse specialist degree, but then I realized that I really miss the patients. There wasn't a lot of patient interface with me. And that is what drew me to nursing --- taking care of people, teaching people, and going through that journey with them.

So I decided to find another position where I could have that patient care. And I was very purposeful. Like you, I have allergies, so I thought I can do that because I can relate. Another one that I did was pain management because I do suffer with chronic pain. Those were the two that I applied for, and I was offered the one for allergy. So here I am, eight years later.

Carol Pehotsky:

Has it been, wow?

Jeanette Kubicki:

It's been almost eight years. Yes.

Carol Pehotsky:

Oh my gosh. Wow. 

Jeanette Kubicki:

I'm really enjoying it.

Carol Pehotsky:

We have had clinical nurse specialists on this show, and for the most part, they've really lived in the nurse and the organization's sphere of clinical nurse specialists. Talk to us briefly about that transition from a more traditional CNS role to being fully facing patients and any things you needed to do to feel confident in that transition.

Jeanette Kubicki:

To me, it was a very easy decision to make. I'm more cut out for that face-to-face care of patients and really listening, being empathetic and really talking with patients. I think if there was more of a balance in my role that maybe that would've been different. Perhaps if I was in an inpatient role that might've been different, but it just wasn't the case for me. So going into this role is what I had to do to be satisfied.

Carol Pehotsky:

There you go.

Jeanette Kubicki:

And professionally fulfilled. I knew that this was what I had to do for myself.

Carol Pehotsky:

And as far as your education preparation, you felt like between the orientation to the role and your other experiences, it was a natural transition. Any advice you have for people's moving into a more patient facing CNS role?

Jeanette Kubicki:

Right. Well, I made sure to do my homework. I wanted to make sure that I knew what kind of guidelines, protocols, and things were out there. The quad ai, which is the American Academy of Allergy, Asthma and Immunology. They have a plethora of very scientific, very consensus based. So I use that a lot to guide me through my career. It was a very, very steep learning curve. I'll just tell you that right now. It's so much more complex than I think people realize.

Carol Pehotsky:

Yes.

Jeanette Kubicki:

It's a very interesting field of study, and I'm learning every day. I just lean on my peers and my  physician colleagues. That's how I've learned.

Carol Pehotsky:

Awesome.

Jeanette Kubicki:

Yes.

Carol Pehotsky:

Well, now we are fully ready to lean into the allergy fun, <laugh>.  We know nurses throughout the continuum. One of the first questions we need to be reviewing with patients or medical review, et cetera, is looking at their allergies.

A brand new admission patient is new to the hospital system, for example. What are some very basic recommendations you'd make to that nurse to make sure that they're getting at, what are the patient's allergies? What are their reactions? Getting a clear and complete picture of what's going on with that patient in terms of allergies.

Jeanette Kubicki:

Of course you're going to look at them and review them. If there's anything unclear, I think it's really important to get a little bit more specific.

Carol Pehotsky:

Okay.

Jeanette Kubicki:

I think in the real world, we know that's very difficult to do sometimes. Sometimes valuable, and sometimes you don't have the time to do that. But when it comes time where the patient's treatments are being impacted by not being able to receive a certain medication, that's a good time to say, this is what we really want to give you, so tell me exactly what happened, what do you remember, and try to get as much detail as possible.

And then sometimes things are listed on the allergy list and they are side effects. So can we give this, and if the patient has side effects, can we treat those side effects so the patient gets the most appropriate treatment?

Carol Pehotsky:

Okay. Yes. So it's probably that open conversation with the patient about, I'm not looking to take something off your chart. We believe you, but help us understand what it is so that if we get to a point where we need to make some different decisions we know the full scope of our options. 

Jeanette Kubicki:

Absolutely correct.

Carol Pehotsky:

There are plenty of bad side effects out there, so everyone don't worry. We understand that too.  So with all that, obviously we're documenting, but it's also so important as we're reviewing them to make sure that information is accurate. Right?

Jeanette Kubicki:

Correct. Absolutely.

Carol Pehotsky:

I think about it in your former world and in my world, in surgery and procedures, it could be even the implants we're giving to people.

Jeanette Kubicki:

Mm-hmm. That is right. What I've seen happen over the past, I would say 20 years. It's reassuring to see, and, you know, being part of the surgical department, the universal protocols talking about allergies. Talking about what we plan to do as a team is really important to identify those things so nothing slips through the cracks and the patient receives something that could potentially cause them harm.

Or the SBAR. How nurses are communicating these things to the next nurse or what's relevant to the next nurse. Very important. Having the pharmacist in place when the provider orders something and the pharmacist sees some kind of cross reactivity potential, The communication between those two is very important.

Carol Pehotsky:

Yes, because you think about even the way medication's prepared it could have an allergen in it that the prescriber or the nurse who's administering might not know. I was seeing a provider just last week, and we were talking about some of my medication options, and she said, you're not allergic to peanuts, right? I said, oh no, I'm deathly allergic to peanuts. Why do you ask? And she said we’re not going to prescribe that for you. It was a pill --- the way it was prepared had peanut oil in it. So it's a great point about your pharmacy colleagues.

Jeanette Kubicki:

Right. Definitely.

Carol Pehotsky:

We'll lean into an inpatient experience, for example. So, I'm an inpatient nurse. I'm giving a patient a medication. They're, here with a host of things that we're trying to address throughout their stay. How should a nurse handle uncertainty when it's not immediately clear? Is the patient having a different change of function or perhaps it is an allergy, this is something new that they're developing. Any recommendations for that nurse to sort out what's going on?

Jeanette Kubicki:

Assess the patient, of course. Is the patient in distress? Is there multiple system involvement? Is the patient having diffuse hives, as well as you hear them wheezing and now they're vomiting. That would point to anaphylaxis. But if you just gave patient a hefty dose of an antibiotic, and they're just holding their stomach and they're nauseated and vomiting, that's more of a side effect. That's something we can expect from antibiotics, especially those that are a little bit more strong

Carol Pehotsky:

Sure.

Jeanette Kubicki:

Yes. You know?

Carol Pehotsky:

Yes.

Jeanette Kubicki:

Just asking questions and then you know something really bad is happening, It will be very apparent.

Carol Pehotsky:

Either way, it's really stopping that new thing, alerting a provider, getting the team around, calling a rapid to get that help that you need.

Jeanette Kubicki:

That is correct.

Carol Pehotsky:

And then we'll sort out the problem.

Jeanette Kubicki:

Right. Exactly.

Carol Pehotsky:

Any experiences with an unusual delayed allergic reaction that we should be thinking about?

Jeanette Kubicki:

Patients aren't in our clinic long enough to see any kind of delayed reactions. But there are unusual things that happen. 

Carol Pehotsky:

Okay.

Jeanette Kubicki:

For example, a patient may come in having anaphylaxis, oh, I was just on a run and all of a sudden, I can't breathe. I'm wheezing. I have hives everywhere. The patient goes to the emergency room, gets admitted, and they're trying to determine what happened. What did you eat? Well, I ate some peanuts about a two to four hours before, and all of a sudden.  But I've eaten peanuts before and I've never had a problem.

Carol Pehotsky:

Sure.

Jeanette Kubicki :

When you can't really nail it down in that inpatient setting, or in the emergency room, you can call one of your allergy colleagues. Then you find out that the patient has food dependent, exercise induced anaphylaxis.

Carol Pehotsky:

What? Come on.

Jeanette Kubicki :

Yes. The patient can tolerate eating peanuts any other day. But if you combine eating peanuts and within two to four hours you're going on a run, you're going to have anaphylaxis.

Carol Pehotsky:

Really?

Jeanette Kubicki:

Yes. Very, very interesting.

Carol Pehotsky:

Yes. So we don't do a video podcast for a lot of reasons, but what you all missed audience was me just like staring agog at Jeanette. I've never heard of that. That's fascinating.

Jeanette Kubicki:

Yes. There's, there's another one called Alpha Gal.

Carol Pehotsky:

Okay. What's that?

Jeanette Kubicki:

Where a patient gets sensitized or become allergic to the galactose alpha one three galactose protein.

Carol Pehotsky:

Okay, I'm with you.

Jeanette Kubicki:

Right. I had to think about what that was. Subsequently they might have a steak for dinner, and then eight hours later they wake up and they have hives everywhere and they're having anaphylaxis.

Carol Pehotsky:

Hmmm.

Jeanette Kubicki:

And that is one I delayed IgE mediated reaction. IgE mediated means anaphylaxis potentially life threatening.

Carol Pehotsky:

Yes.

Jeanette Kubicki:

That somebody can have.

Carol Pehotsky :

Oh my gosh.

Jeanette Kubicki:

And it's because they've become sensitized, you know, through a lone star tick, typically it's called a Lonestar Tick.

Carol Pehotsky:

Interesting. 

Jeanette Kubicki:

So that's another thing. When things seem unbelievable outside the allergy world, not so much in the allergy world. Because we see a lot of very interesting things like that where you can't put together what happened.

Carol Pehotsky:

Going back to inpatient, we're worrying about a care plan. We've got patient who maybe has medication allergies, they might have food allergies. Right? So you've got incoming stimuli with the food. We bring our patients through the cafeteria and the food service program. How do we make sure that we're avoiding those allergens, that we're communicating that across all the places that patient is going and all the places they could get exposed?

Jeanette Kubicki:

That's really a great question. A very valid concern for patients. Like people like you who have a peanut allergy, is it in any of my food that I'm going to get on my tray?

Carol Pehotsky:

Right.

Jeanette Kubicki:

Was it handled with somebody who made a peanut butter jelly sandwich and they didn't change their gloves and then they prepared my meal? Whatever the case may be. I just say verify allergies at every single step. Document, document, document being very specific about what that allergy was like, what happened?

And then I'm not sure how they would handle it, but I think yes, the people are like handling food, for example.

Carol Pehotsky:

Oh yes. Of course.

Jeanette Kubicki:

That they're properly trained on cross-contamination. And being sure that the patient's tray comes up separately, that from a peanut butter sandwich or whatever, and so it's just a matter of communication.

Carol Pehotsky:

When you think about the supply chain you think about a hamburger bun, for example. I assume most hospitals are not making their own buns anymore. So you're getting a hamburger bun from another supplier you're bringing into your hospital. It's getting into the minutia of knowing the ingredients of every single food product that our food suppliers are bringing into these hospitals to make sure patients are safe.

Jeanette Kubicki:

Right. And every patient knows, or tends to understand what their threshold is.

Carol Pehotsky:

Sure.

Jeanette Kubicki:

For example, I had a young man come in who wanted to join the military, and when you go into the military, they don't want you with a food allergy because they don't want to worry about making a special tray for you.

Carol Pehotsky:

Oh, sure. I'd never thought about that either.

Jeanette Kubicki:

All right. So the young man comes in and says I ate a peanut butter cookie last year, and I did fine. I say let’s test it out in a controlled setting, so if you should eat a handful of peanuts when you were in the army you know you're going to be safe.

Carol Pehotsky:

Yes.

Jeanette Kubicki :

So we started to do this grated dose challenge starting with very small amounts. He went into anaphylaxis. His threshold for maybe a little bit of peanut butter in a cookie was fine, but when he started to increase the dose, it started with gastrointestinal symptoms. We're watching him, watching him, but then all of a sudden diffuse hives and then he is wheezing and epinephrine. Went to the emergency room. 

Carol Pehotsky:

Yes.

Jeanette Kubicki:

Sometimes people can tolerate peanut oil because, it's denatured from the processing or …

Carol Pehotsky:

Yes, I didn't believe it. My first time I had that vendor's chicken was, was three floors above the emergency room, just in case. But yes, <laugh>.

Jeanette Kubicki:

Anyway, I guess it's really important to know, to talk with the patient about, so how do you handle this? You know, maybe we say just get the burger without the bun then if you can't really tell me, and the patient usually knows this. They can usually be a partner in this decision on how to prepare their meals. I think we went on the food train, but you're probably asking about medication as well.

Carol Pehotsky:

I think yes, how do we really make sure that pharmacy really understands the supply chain that comes with those medications, to make sure. Well, I've even had as a patient, we're not going to run into any peanuts with what we're doing here, but there are situations where there might be somebody's medication allergy might be a component of a medication, right? So it's just staying curious, I guess?

Jeanette Kubicki:

Right. Exactly. I just think it's very important to really make those decisions as a team and that patient is part of that team. 

Carol Pehotsky:

We touched on this, but I want to return here and linger a bit longer. Our patients present to us with their own stories and histories, or somebody told me this was an allergy, right. My provider told me this is an allergy. And so we get to a situation where maybe there are limited options for treatment and that allergy might be listed on there.

:

Thinking about how to sensitively meet the patient where they're at, make sure we're not inducing fear and panic, but if we're limited on options, how do we make sure that that as an informational team, the nurses making sure that that patient's needs are being met while we're having that conversation about maybe going into an area an a medication that the patient might be comfortable with.

Jeanette Kubicki:

Right. The first thing I do, I work in allergy, so I have a lot of time to do this <laugh>, I understand the time constraints but ideally you want to confirm is the allergy real and obtain a detailed history about what happened. Then if I determine the patient is low risk, then I might say, okay, let's see how you do by taking it. A good example of this is penicillin.

Carol Pehotsky:

Sure.

Jeanette Kubicki:

Many people have an allergy to penicillin, or at least the allergy is on their list but they're not really allergic. So if the patient is low risk, I'll give it to them in a monitored setting. Reassuring them that this is what you really need. You're getting recurrent sinus infections or you've had multiple pneumonias, and the first choice for that would be a penicillin-based antibiotic.

As long as we've had that conversation, the patient agrees to the risks and the benefits that  align with what they're feeling, then I'll give it to them. And I'm telling you, I've never had anyone react <laugh>.

Carol Pehotsky:

We're not going to knock on wood to screw up the audio recording, but we're all virtually knocking on wood right now, <laugh>.

Jeanette Kubicki:

Right. I do tell them this is limiting as far as if you have a delayed reaction, we can't predict that. And those delayed reactions usually happen after you've been on a medication for several days and all of a sudden you have itchy, diffuse rash. Very annoying, but not typically life threatening.

Carol Pehotsky:

Sure. Okay.

Jeanette Kubicki:

If we had a patient, for instance, they have a very clear history of anaphylaxis to penicillin and the patient has syphilis and they have neurosyphilis and they've failed everything. And they need that penicillin.

Carol Pehotsky:

Yes. Yikes.

Jeanette Kubicki:

Yes. If you're an inpatient, this is a good time to consult allergy. They can come and do penicillin allergy skin testing, and if the patient passes, they can proceed with the penicillin challenge and then they can get the treatment they need. If the patient has positive skin testing, then we're like, what do we do now?

Carol Pehotsky:

Right.

Jeanette Kubicki:

We can do desensitization. Or more accurately we can induce temporary tolerance to the medications.

Carol Pehotsky:

Okay.

Jeanette Kubicki:

This takes hours to do, where you start off with very small doses and you gradually give them greater doses up until the therapeutic dose. Then the patient gets the treatments they need, and then after treatment, about 48 hours later they're allergic again or resensitized. It's temporary tolerance. Just to get them through.

Certainly not without its risks, we could cause them to have anaphylaxis. But those are conversations we have with the patient. You know you need this or this is going to progress. This is the logical next step and if they agree, that's what we do.

Carol Pehotsky:

Well, and, it's a good reminder to our inpatient colleagues that, that although their thriving practices are more of an outpatient basis, allergy is a resource across the continuum.

Jeanette Kubicki:

Yes.

Carol Pehotsky:

It doesn't mean I'm out of choices. It means let's get allergy on board to see what they can do.  Opinions on how they can help, how they can mitigate through this.

Jeanette Kubicki:

Right. Fantastic. Exactly.

Carol Pehotsky:

Let's say I have a patient who's developed a new allergy during their inpatient stay. We want to make sure as we're discharging that patient, all the myriads of other education we're going through, what advice do you have for those inpatient nurses to make sure amidst all those other things that patient needs to think about, they also now need to think about a new allergy?

Jeanette Kubicki:

Right.

Carol Pehotsky:

How do we bridge them to being successful out of the hospital?

Jeanette Kubicki:

First of all, definitely updating the allergy lists. Making sure that you're being as specific as possible. What was the reaction? Educating the patient about it and then making sure the patient has a list of their allergies with them at all times. Or if it was a life-threatening allergy, let's say they had anaphylaxis, penicillin, perhaps getting an allergy bracelet or an alert bracelet, things like that. Just helping them through, educating them so they understand it so that they can be an advocate for themselves when they're outside of that environment. For example, if they go to an urgent care and the urgent care is not connected with the hospital, they typically get treatments and they need to understand.

Carol Pehotsky:

I imagine a lot of patients end up sort of self referring into an allergy practice. I know I did <laugh>.   And so I guess in terms of nurses working all over the spectrum, when might they, when working with their patients, say you might want to reach out to allergy or get them in touch with those finer resources when it comes to outpatient allergy?

Jeanette Kubicki:

It is definitely when they have multiple allergies.

Carol Pehotsky:

Okay.

Jeanette Kubicki:

And that's interfering with good care where they're the first choice for many things they have going on is not being directly targeted.

Carol Pehotsky:

Mm. Okay.

Jeanette Kubicki:

You know, with the therapy that is the first line of therapy. That's when they should. And just multiple in general, because even if they just came in for one simple thing, their post-op and everything went fine, maybe just a gallbladder was removed and they're otherwise healthy, down the line, they may need this. And so I try to have that conversation. It might not mean anything to you right now as a 30-something-year-old, but when you get into your fifties, sixties, seventy, eighties, this is going to make a difference.

Carol Pehotsky:

Sure.

Jeanette Kubicki:

You know?

Carol Pehotsky:

Yes.

Jeanette Kubicki:

So maybe go to them, see what they can tease out. And how they can help you either prove or disprove you have these allergies.

Carol Pehotsky:

Sure.

Jeanette Kubicki:

So yes. Something along the line of that.

Carol Pehotsky:

That's nice and really getting a finer line on is this a really seemingly intolerable side effect that I want to avoid versus this could be life threatening and getting ahead of it.

Jeanette Kubicki:

Right. Patients certainly have the option to totally avoid a medication if they want to. I don't force them into anything, but I make sure that they have all the information. They think of it in many different ways and they come to an educated decision about what they're going to do. 

Carol Pehotsky:

Jeanette, I can't thank you enough. This has been fascinating and educational, and I might have have to revisit the allergy clinic <laugh> personally. Aside from all that, as we're wrapping up, I hope you'll indulge me with a few fun questions to help our audience get to know you as an amazing human being, as well as a subject matter expert.  So you're an amazing nurse, amazing clinical nurse specialist. If you weren't a nurse, what would your passion career be?

Jeanette Kubicki:

I've always wanted to take care of people or if there was a stray animal in my neighborhood, and their little paw was twisted up on something, I was always just very purposeful about making sure everyone or everything was safe. So I think I might've been a veterinarian.

Carol Pehotsky:

As I know, you know, as an organization Cleveland Clinic has spent a lot of great time this year talking about the power of purpose. And all of us as caregivers thinking about what our why is what keeps us coming back for more. I'm hoping you're willing to share with our audience what's your why?

Jeanette Kubicki:

Yes. At the risk of sounding cliche, it truly, truly, truly is the patients. It's truly them that they keep me coming back. I have my days where I'm just like, you know what I mean? But then I have those days where the patients are so appreciative and that we've worked together to accomplish something or whatever the case may be. That's makes me so happy, that keeps me coming back day after day after day.

Carol Pehotsky:

Wonderful. Thank you so much for joining us today.

Jeanette Kubicki:

Oh, thank you so much for having me. It's been a pleasure.

Carol Pehotsky:

As always, thanks so much for joining us for today's discussion. Don't miss out, subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurse essentials@ccf.org.

To learn more about nursing at Cleveland Clinic, please check us out @clevelandclinic.org/nursing. Until next time, take care of yourselves and take care of each other.

The information in this podcast is for educational and entertainment purposes only, and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.