Section III: Nursing Roles

Nurses and pharmacists play a key role in reviewing each biologic to check for recent updates on administration, potential risks, and black box warnings. Nurses will also need to become familiar with the new biologics as they are released into the market. Most patients taking these medications are given education on the benefits, risks and administration before consenting to treatment – usually at the MD office or clinic. We are all aware that some patients are poor historians regarding their medications, but they usually are aware they are getting an injection or infusion for their arthritis or bowel problems (though some biologics are now available in oral form). Remember that these therapies are usually initiated when disease symptoms are moderate to severe and other measures have failed. So most patients or their caregivers are aware of their medical condition and the treatments they receive for it.

Commonly, patients are tested for latent TB and HBV prior to starting biologic treatment, but a careful review of the labs and prior history is advised. It goes without saying that any patient with cold or flu symptoms should be evaluated and cleared before giving the therapy. Ongoing monitoring of the patient on biologics is usually performed by the MD or clinic.


Assessment

A thorough nursing assessment, whether in the ED, hospital, or home setting is the key factor in evaluating patients’ response to biologic treatment and identifying early signs of adverse reactions and infections. It does not take a rocket scientist to know that immunocompromised patients are at an increased risk for infection compared to non-immunocompromised patients. Unfortunately, published data on the frequency of HAI’s in the immunocompromised patient is lacking. The CDC’s most recent data from 2014 does not separate the normal population from those with an impaired immune system. In a study from 2003, the incidence of hospital acquired pneumococcal infections were significantly higher for immunocompromised patients (34.7%) versus non-immunocompromised patients (6.88%) (Fernandez Guerrero, 2003). Nurses are truly the assessment rock stars in any health care setting. In terms of patients on biologic therapy, there are three elements to a successful assessment. This includes the admission, medical history/review of systems, and the patient caregiver evaluation.

Point of Entry/Admission

Biologic MAB Therapy

The initial assessment upon entry into the healthcare setting will establish whether or not staff is aware of the patient’s potential risk due to immunosuppression. It also sets the tone for whether or not appropriate measures are put into place to protect the patient from infection and other adverse effects. For example, if the patient on biologics is admitted through the ED with a hip fracture, will the admitting diagnoses include immunosuppression due to use of biologic medications? Probably not. Will the physician order protective isolation? Doubtful. Nurses should always think about immunosuppression-related complications once it is known that the patient is on biologic therapy. What about the secondary diagnoses and comorbidities? Factors such as diabetes, asthma, malnutrition, age, and cardiac problems could be related to the biologic therapy or add to the patient’s immunosuppression risks. If the patient is admitted, bed placement is critical for the immunocompromised patient. What about the patient on home care? Home care nurses may be the first to identify symptoms of HAI’s. Assessing the home setting, caregivers, and their knowledge of infection symptoms and prevention is just as important.

Medical History and Assessing Current Status

All nurses are aware of the need (and tedium) in obtaining a thorough medical history and list of current problems. It is also tedious for the patient to be asked the same questions that the triage nurse, physicians, and consultants just did. Communication between healthcare providers is important in case the patient has given conflicting information. You may be the first person to recognize a patient at risk from biologic medications. Nursing assessments are usually part of a screen that must be completed in the assessment module of the EMR. Most are related to the admitting diagnosis and secondary problems. Here is the opportunity for nurses to enter the critical information that could prevent complications and added hospital days. Thinking in terms of the condition that required the use of biologic therapy, here are a few questions to help you determine a patient’s risk for immunosuppression related problems:

1. How long with the condition and treatments given? This gives you an idea of how long they may have been or are currently taking immunosuppressants.

2. What is the current status of the condition? If the patient states that his symptoms are getting worse, does that treating MD know?

3. History of current and recurrent infections, cancers, cardiac, GI or respiratory issues related to the drug? If it happened once, it can happen again.

4. Current infections, CHF, swollen lymph nodes or cancers? Does the admitting physician know? This may be related to the biologic rather than an isolated incident.

5. Previous reactions to infusions or injections?

6. Accurate medication reconciliation? Yes, we all know that this can be like pulling teeth! With regard to biologics, even more difficult since many of the patients are not taking this at home, but rather in an office or clinic.

7. Are they on more than one immunosuppressant medication? Many of these patients are also on prednisone, steroid inhalers, etc.).

8. Where are they getting the biologics? It is helpful to know if they are receiving injections or infusions in a clinic, MD office or is self-injecting.

9. Is the patient adherent? When was the last dose given?

10. Who is the prescribing physician? This information may be needed if the patient is unable to answer questions accurately or at all.

This list is intended to increase your assessment tools, not add to an already burdensome task. You may find other questions more appropriate for a particular situation. However, knowing if patients are taking more than one immunosuppressant, length of time on them, and previous adverse effects are essential in order to ensure accurate communication between care providers that will meet patient safety goals.

Patient and Caregiver Assessment in Hospital or Home Settings

Nurses know how difficult it can be to obtain an accurate medical history, let alone a current list of medications. So it makes sense to first identify who the caregiver or responsible party is. Once the historian is identified, the nurse must try to get a sense of their familiarity of their disease, medications, and medical history. Assessing factors such as the level of education, healthcare literacy, and language barriers are usually a part of the admission process. However, does the patient or caregiver have an accurate understanding of biologic medications, potential risks, and reportable symptoms?

When patients arrive in the ED, time is of the essence and this information may not be obtainable or readily available. So what do you do? As mentioned earlier, the good news is that biologics are usually prescribed to patients who have had the condition for a while and previous treatments are no longer managing their symptoms effectively. Also, remember that most patients receive some sort of informed consent prior to starting on these biologics. So patients and caregivers are often able to tell the nurse that they receive a shot or IV that helps their arthritis or colon problems. Do not forget to get the name of the prescribing doctor, such as a rheumatologist or gastroenterologist so further information may be obtained if needed.

Some patients may be treated with these biologics by home health nurses upon an order from the physician’s office. Homecare nurses usually have the hospital discharge summary or physician orders to guide them in their assessment. Patients on biologics that are discharged to home from the hospital are at a high risk for bringing home a hospital acquired infection (HAI). Regulatory standards are based on reducing hospital readmissions, so nurses must be vigilant in performing ongoing assessments for infections related to not only the biologics, but hospitalization-related issues as well.



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