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Standards › ASF Health Standards v10 › Standard 53

Standard 53

Allergology

Allergology: allergy history recorded before any exposure, anaphylaxis treated at once, allergen testing quality-controlled and interpreted by a clinician, immunotherapy under a written protocol, and results communicated with a written action plan..

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criteria
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documents
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e-learning courses
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references

Criteria on this page

53.153.253.353.453.5

How to read the colours
Red: Must. Required in every setting. Criteria that protect life are always red.
Green: Medium. Required, adapted to what a transition setting can realistically do.
Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.

Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.

Reference, not a requirement. Every policy, SOP, form and course on this page is a draft to help you. Adapt it to your hospital, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
53.1Allergy History Is Taken and RecordedHumanitarian settings: MinimumTransition and fragile: MustStandard: Must

Every patient has an allergy history taken and recorded before any drug, product or allergen is given, and it is checked at each new prescription and each change of condition.

Humanitarian settings
Minimum
Transition and fragile
Must
Standard
Must

Why it matters.

How the surveyor verifies this criterion

Sample. Review the allergy history records of a random sample of patients who received a drug or product in the last 3 months.

1. An allergy history is recorded before the first drug or product is given.

Method. Compare the time of the first administration with the time the allergy history was recorded, for each sampled patient.

Evidence to show. Allergy history record (ALR-FRM-001).

Pass when. Every sampled patient has an allergy history recorded before the first administration.

2. The record covers the agent, the reaction and its severity.

Method. Check each sampled allergy entry for the three elements.

Evidence to show. Allergy history record (ALR-FRM-001).

Pass when. Every sampled allergy entry records the agent, the reaction and the severity.

3. The history is checked at each new prescription.

Method. Check the dates of the checks against the dates of new prescriptions for the sample.

Evidence to show. Allergy history record (ALR-FRM-001).

Pass when. Every sampled new prescription has a recorded check of the allergy history.

Immediate fail (any one means the criterion is not met). A patient with a known penicillin reaction is given amoxicillin because the allergy was never recorded.

Staff responsible

Role Responsibility Level
Nurse (ISCO 2221) Completes the Allergy history taking and recording (ALR-SOP-001); allergy history record Must
Manager (ISCO 1342) Checks the criterion at each review Must

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
ALR-SOP-001 · Allergy history taking and recording Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
ALR-FRM-001 · Allergy history record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Allergy & Immunotherapy Safety Endorsement (AMB-18) Manager; Nurse

References

  1. WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Allergy history and medication safety https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
53.2Anaphylaxis Is Recognised and Treated at OnceHumanitarian settings: MinimumTransition and fragile: MustStandard: Must

Anaphylaxis is recognised from its early signs and treated at once with adrenaline under a written protocol. Adrenaline and the emergency kit are stocked, checked and in date, and each episode is recorded.

Humanitarian settings
Minimum
Transition and fragile
Must
Standard
Must

Why it matters.

How the surveyor verifies this criterion

Sample. Review every anaphylaxis episode in the last 12 months, and the daily kit checks for the same period.

1. Anaphylaxis is treated at once with adrenaline under the written protocol.

Method. Check each recorded episode for the time of recognition and the time of the first adrenaline dose.

Evidence to show. Anaphylaxis recognition and treatment (ALR-SOP-002).

Pass when. Every recorded episode has adrenaline given at once, or a recorded reason.

2. Adrenaline and the emergency kit are stocked, checked and in date.

Method. Check the daily record and the expiry dates for the sample period.

Evidence to show. Anaphylaxis episode and adrenaline check register (ALR-REG-001).

Pass when. Every daily check is recorded, and the adrenaline is in date on every check.

Immediate fail (any one means the criterion is not met). A patient in clinic develops anaphylaxis, and the adrenaline in the kit expired four months earlier.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Anaphylaxis recognition and treatment (ALR-SOP-002); anaphylaxis and emergency response in procedure units Must
Secretary (ISCO 3344) Keeps the Anaphylaxis episode and adrenaline check register (ALR-REG-001); resuscitation area readiness Must

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
ALR-SOP-002 · Anaphylaxis recognition and treatment Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
ALR-REG-001 · Anaphylaxis episode and adrenaline check register Secretary (ISCO 3344) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Allergy & Immunotherapy Safety Endorsement (AMB-18) Manager; Nurse

References

  1. Resuscitation Council UK (n.d.). Emergency treatment of anaphylaxis: guidelines for healthcare providers. Used for: Emergency treatment of anaphylaxis with adrenaline https://news.gmj.ge/guideline/emergency-treatment-of-anaphylaxis-guidelines-for-healthcare-providers/
  2. WHO (2021). Brief overview of anaphylaxis as an adverse event following immunization (AEFI) and practical guidance on its identification, case management and response in a primary care setting. Used for: Anaphylaxis recognition and reporting https://news.gmj.ge/guideline/brief-overview-of-anaphylaxis-as-an-adverse-event-following-immunization-aefi-and-practical-guidance-on-its-identification-case-management-and-response-in-a-primary-care-setting/
53.3Allergen Testing Is Quality-Controlled and Interpreted by a ClinicianHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Skin and blood allergy tests use validated methods with controls checked before results are reported. Results are interpreted by a qualified clinician with the clinical history and reported with their limits.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters.

How the surveyor verifies this criterion

Sample. Review the quality control and result records for the sample period, and the external assessment results.

1. Results are interpreted by a qualified clinician with the clinical history.

Method. Check each sampled result for the interpretation and the signing clinician.

Evidence to show. Allergy test result and interpretation record (ALR-FRM-002).

Pass when. Every sampled result has a clinician interpretation that uses the clinical history.

Immediate fail (any one means the criterion is not met). A skin test run with a failed positive control is reported, and a patient is wrongly told they are not allergic.

Staff responsible

Role Responsibility Level
Nurse (ISCO 2221) Completes the Allergy test result and interpretation record Medium
Manager (ISCO 1342) Checks the criterion at each review Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
ALR-SOP-003 · Allergen testing quality control and interpretation Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
ALR-FRM-002 · Allergy test result and interpretation record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Allergy & Immunotherapy Safety Endorsement (AMB-18) Manager; Nurse

References

53.4Allergen Immunotherapy Follows a Written ProtocolHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Allergen immunotherapy starts only after the written eligibility criteria are met and consent is recorded. Each dose follows the written escalation, with observation after each dose and emergency equipment at hand.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters.

How the surveyor verifies this criterion

Sample. Review all immunotherapy patients in the last 12 months, with their eligibility, consent and dose records.

1. Immunotherapy starts only after the written eligibility criteria are met.

Method. Check each sampled patient for the eligibility record before the first dose.

Evidence to show. Allergen immunotherapy protocol (ALR-POL-001).

Pass when. Every sampled patient met the criteria before the first dose.

2. Each dose follows the escalation with observation time and emergency equipment.

Method. Check the dose and observation records for a sample of doses.

Evidence to show. Immunotherapy dose and observation record (ALR-FRM-003).

Pass when. Every sampled dose follows the schedule, with observation time recorded and equipment available.

Immediate fail (any one means the criterion is not met). A patient receives a dose above the schedule and is discharged after 5 minutes of observation.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Allergen immunotherapy protocol Medium
Nurse (ISCO 2221) Completes the Immunotherapy dose and observation record Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
ALR-FRM-003 · Immunotherapy dose and observation record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)
ALR-POL-001 · Allergen immunotherapy protocol Chief executive (ISCO 1120) Governing body members N/A Chief executive (ISCO 1120) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Allergy & Immunotherapy Safety Endorsement (AMB-18) Manager; Nurse

References

53.5Allergy Results Are Communicated and Acted OnHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Each allergy result and its advice is communicated to the patient and referrer. Each patient has a written action plan, and the allergy alert on the record is updated when a result changes the allergy history.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters.

How the surveyor verifies this criterion

Sample. Review allergy results and action plans for a sample of patients in the last 6 months, and the allergy alerts on their records.

1. Each result and its advice is communicated to the patient and the referrer.

Method. Check each sampled result for the record of communication.

Evidence to show. Allergy results communication and action plan (ALR-SOP-004).

Pass when. Every sampled result has a recorded communication to the patient and the referrer.

2. Each patient has a written action plan.

Method. Check each sampled patient for the action plan.

Evidence to show. Allergy action plan (ALR-FRM-004).

Pass when. Every sampled patient has a written action plan.

3. The allergy alert is updated when a result changes the history.

Method. Check each sampled result that changed the history against the alert on the record.

Evidence to show. Allergy history record (ALR-FRM-001).

Pass when. Every changed history has an updated alert on the record.

Immediate fail (any one means the criterion is not met). A new allergy is confirmed by testing, but the alert on the record is never updated.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Allergy results communication and action plan (ALR-SOP-004); critical result reporting Medium
Nurse (ISCO 2221) Completes the Allergy action plan Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
ALR-SOP-004 · Allergy results communication and action plan Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
ALR-FRM-004 · Allergy action plan Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Allergy & Immunotherapy Safety Endorsement (AMB-18) Manager; Nurse

References

  1. WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Communication of safety information to patients https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Who is responsible for Standard 53

Each criterion names the positions responsible for it. Every position links to its own terms of reference.

Criterion Responsible Supports
53.1 Allergy History Is Taken and Recorded Consultant physician (internal medicine)
Head nurse / ward manager
Emergency nurse
53.2 Anaphylaxis Is Recognised and Treated at Once Emergency nurse
Emergency physician
Anaesthesiologist
53.3 Allergen Testing Is Quality-Controlled and Interpreted by a Clinician Head of laboratory
Medical laboratory scientist
Consultant physician (internal medicine)
53.4 Allergen Immunotherapy Follows a Written Protocol Consultant physician (internal medicine)
Head nurse / ward manager
Emergency nurse
53.5 Allergy Results Are Communicated and Acted On Head of laboratory
Consultant physician (internal medicine)
Medical laboratory scientist

Role details: reporting, supervision and training

Training shown is the general recommendation. Role-specific training is set in the next improvement round.

Role Reports to Supervises Recommended training
Consultant physician (internal medicine) Head of department (per specialty) Resident physician / house officer Facility induction; safeguarding adults (general recommendation)
Emergency physician Head of department (per specialty) None Facility induction; safeguarding adults (general recommendation)
Anaesthesiologist Head of department (per specialty) None Facility induction; safeguarding adults (general recommendation)
Head nurse / ward manager Director of nursing Nurse specialist, Registered nurse, Nursing associate, Health care assistant / nursing aide Facility induction; safeguarding adults (general recommendation)
Emergency nurse Head of department (per specialty) None Facility induction; safeguarding adults (general recommendation)
Head of laboratory Medical director Clinical biochemist, Medical laboratory scientist, Microbiologist, Blood bank technician Facility induction; safeguarding adults (general recommendation)
Medical laboratory scientist Head of department (per specialty) Medical laboratory technician, Phlebotomist / specimen collector Facility induction; safeguarding adults (general recommendation)

Questions and answers

The criterion text is the authority. These answers summarise it.

Who does Standard 60 apply to?

Services that take allergy histories, test for allergies, give allergen immunotherapy or treat allergic reactions, including clinics and hospital wards.

What do the colours mean for this standard?

Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.

Is the allergy history taken before treatment?

Yes. Under 53.1 every patient has an allergy history recorded before any drug, product or allergen is given, and it is checked at each new prescription.

How is anaphylaxis treated?

Under 53.2 anaphylaxis is recognised from its early signs and treated at once with adrenaline under a written protocol, and the emergency kit is stocked and in date.

Are allergy tests checked?

Under 53.3 allergy tests use validated methods with controls checked first, and results are interpreted by a qualified clinician.

Is immunotherapy given under a protocol?

Under 53.4 immunotherapy starts only when eligibility criteria are met and consent is recorded, and each dose follows a written escalation with observation after it.

Are allergy results communicated?

Yes. Under 53.5 each result and its advice reach the patient and referrer, each patient has a written action plan, and the allergy alert on the record is updated.

Guidelines for this standard

8 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.

  1. The skin prick test – European standards (GA2LEN)
  2. EAACI Guidelines on Allergen Immunotherapy: Allergic Rhinoconjunctivitis (EAACI)
  3. Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update (World Allergy Organization)
  4. The Skin Prick Test – European Standards (EAACI) (European Academy of Allergy and Clinical Immunology)
  5. Emergency treatment of anaphylaxis: guidelines for healthcare providers (Resuscitation Council UK)
  6. Brief overview of anaphylaxis as an adverse event following immunization (AEFI) and practical guidance on its identification, case management and response in a primary care setting (World Health Organization)
  7. Guidelines for healthcare workers on the proper interpretation of vaccine vial monitors and their use (Pan American Health Organization)
  8. Protocol for the Use of the Performance Monitoring Tool for the National Expanded Program on Immunization (Pan American Health Organization)