I give infusions of a biologic agent, often referred to as an TNF inhibitor to patients with immune mediated inflammatory disorders such as rheumatoid arthritis, psoriatis arthritis, ankylosing spondylitis, crohn’s disease, ulcerative colitis and plaque psoriasis. This biologic agent works by inhibiting the actions of a particular cytokine produced by the immune system called Tumor Necrosis Factor (TNF) Alpha. TNF alpha is produced by the cells of the immune system and plays an important role in fighting infections. Unfortunately, in patients with these types of disorders, TNF alpha is also responsible for attacking its own cells because the immune system lost the ability to determine what is part of the body and what isn’t. As a result, we see the inflammatory symptoms manifested by our patients. Since TNF inhibitors blocks the actions of TNF alpha, it is effective in treating these disorders and unfortunately, also inhibiting its role in fighting infections.
The Scenario: One day I worked at the infusion center, I was assigned a patient on REMICADE. As I escorted the patient to the infusion area, I began my assessment and asked the patient, “how are you doing?” He replied, “I’m fine and I am so ready for this infusion”. Then my next question was “are you having problems? He replied “no”. Continuing on with my assessment, I asked “do you have any infections?” to which he replied “no”. So I proclaimed…“good, let me get my IV supplies and get your IV started.” When I returned with my IV supplies, the patient pulled his shirt sleeve and graciously offered his arm. He said, “oh, can you use this?” pointing to the object sticking out of his antecubital fossa. I yelled…“that’s a PICC line!!” The patient said, “yes it is. Can you use it for today’s infusion?” The patient stated that he is receiving a medication at home for his kidney infection given by a visiting nurse. By this time, I felt like a total idiot. Didn’t I just ask this patient if he had any infections? To which he replied..NO??
The “AH-HA!” moment: Though the patient outcome is a positive one, the lesson learned from this experience is the failure of our assessment process. We began to realize that patients may not fully understand what we are really asking when we state, do you have any infections? We also began to think about the possibility that we may have missed some patients in the past who may have had infections but were never identified through our assessment. Assessing infections in patients receiving infusions of biologic agents is a key component in the infusion process. It is recommended that detailed questions should be asked such as but not limited to:
- In the past 2 weeks, have you felt very tired or experienced fever, night sweats, sore throat, runny nose, flu-like symptoms, warm, red, or painful skin, face pain, earache, tooth pain, cough, breathing problems, painful urination, urine with blood, antibiotic use, headache, an open cut or sore, or an infection that won’t go away or an infection that keeps coming back?
- Have you had surgery in the past two weeks? If so, did you have any complications from your surgery? Did you experience any drainage from your incision?