ALR-POL-001: Allergen immunotherapy protocol

Policy · ALR-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 53.4

At a glance

Allergen immunotherapy starts only when the patient meets the written eligibility criteria, with consent (CON-SOP-001).
Each dose follows the written dose escalation, and the observation time after each dose is set in the protocol.
Emergency equipment and adrenaline are available for every dose (ALR-REG-001).
Each dose and each reaction is recorded (ALR-FRM-003).
Stop and get help straight away if: immunotherapy is given outside the eligibility criteria, or without observation time or emergency equipment.

1. Purpose

To make sure allergen immunotherapy is given safely, with eligibility, dose escalation, observation and emergency equipment (53.4).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

To make sure allergen immunotherapy is given safely, with eligibility, dose escalation, observation and emergency equipment (53.4).

5. Responsibilities

Role	Responsibility	Competence
Allergologist	Decides eligibility and sets the dose schedule	Clinical lead
Nurse	Gives each dose, observes for the set time and records it	Allergologist

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Eligibility and consent.

Check the eligibility criteria and record informed consent before the first dose.

Key point: Eligible.

Step 2. Dose.

Give each dose on the written escalation schedule, with emergency equipment at hand.

Key point: Dosed.

Step 3. Observe and record.

Observe for the set time after each dose and record it (ALR-FRM-003).

Key point: Observed.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Patients started only after eligibility and consent	100%	Monthly	Allergologist	Stop the programme for that patient
Doses given with the observation time recorded	100%	Monthly	Allergologist	Review the dose and the process

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
ALR-FRM-003	Immunotherapy dose and observation record	Record
CON-SOP-001	Informed consent before significant care (existing, reused)	SOP

17. Evidence

Reference	Note
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Allergy & Immunotherapy Safety Endorsement (AMB-18)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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