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Oncology Nursing Society 43nd Annual CongressMay 17–20, 2018 • Washington, DC 1Clinical Practice
1. Evaluation of a Standardized Titration Schedule to Be Utilized for the Administration of All Paclitaxel InfusionsCarrie Patton, BSN, RN, OCNMemorialCareTodd Cancer Institute Long Beach, CA
2. Improving Communication in the Transfer of Care in Nursing Handoff: Perfecting a Culture of Nursing Collaboration and Patient Safety in the Outpatient Infusion SettingStacy Farrell, MSN, RN, OCNMemorial Sloan Kettering Cancer CenterBasking Ridge, NJ
3. Combating Chemotherapy Verification Fatigue: Nurse-Led Quality Improvement Interventions in Pre-Treatment Lab EvaluationAya Sato-DiLorenzo, RN, BSN, OCN, BMTCNBeth Israel Deaconess Medical Center Boston, MA
4. Wake Up: A Prescription for Increasing Patient Safety in the Ambulatory Infusion RoomJennifer Foster, BSN, RN, OCN, ONN-CGBaylor Scott and White Hospital Temple, TX
Nurse-Led Improvements and Collaborations in Outpatient SettingsFriday, May 18 • 2:45–4 pm
Note one action you’ll take after attending this session: ____________________________________________________
________________________________________________________________________________
ONS 43rd Annual Congress
Clinical Practice (Patton) 1
Formation of a Paclitaxel Titration Schedule to Reduce
Hypersensitivity ReactionsCarrie Patton, BSN, RN, OCN
Registered NurseMemorial Care, Long Beach Medical Center
Todd Cancer Institute
Disclosures
• None
ONS 43rd Annual Congress
Clinical Practice (Patton) 2
Background
• Paclitaxel (Taxol)– A popular chemotherapy agent used in the treatment of a
number of cancers including:• Ovarian, breast, lung, cervical, pancreatic, and many others
– Classified as a: • Taxane• Plant alkaloid
– Natural derivative
Background • Paclitaxel is often associated with hypersensitivity reactions ranging
from mild to severe– Including:
• Generalized uticaria, facial flushing, shortness of breath, angioedema, and anaphylaxis
– Most reactions occur during the first or second infusions
78% within the first 10‐15 minutes
of initiation of the drug
Literature Review
A thorough literature review conducted revealed:
• Although limited, data was available for patients who had experienced a hypersensitivity reaction in regards to re‐challenge and desensitizing protocols.
• Scarcity of data existing regarding guidelines for administering Paclitaxel during initial infusions.
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Clinical Practice (Patton) 3
Administration Guidelines• Manufacturer provided administration
guidelines include:– Pre-medications
• Corticosteroids, Diphenhydramine, H2 antagonists
– Subjective recommendation • “Administer slowly”
Strategy Review current
nursing practices
•Individual one‐on‐one interviews conducted with each AIC RN
Identify variations in administration
practices
•Attempt to correlate infusion practices with reaction rates
Standardize infusions
•Establish a titration schedule for all Paclitaxel administrations
Retrospective chart review was conducted
on all patients who received Paclitaxel in
the Ambulatory Infusion Center over a
14 month period
Retrospective Study Results
>10% reaction ratein patients receiving 3-hr
infusions
Significantly more reactions occurred when
tubing unprimed
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Clinical Practice (Patton) 4
PlanStaff Education
• New titration schedules to be followed regardless of infusion time, patient reaction history, or volume.
– 999 mL/hour (20 mL) Initial priming step over 1 minute
– 10mL/hour for 5 minutes (0.83 mL)– 25mL/hour for 5 minutes (2.08 mL)– 50mL/hour for 5 minutes (4.17 mL) – 100mL/hour for 5 minutes (8.33 mL) THEN
– 182 mL/hour for 2 hours and 40 minutes (3-hour Paclitaxel)
– 350 mL/hour for 40 minutes (1-hour Paclitaxel)
Pharmacy Labeling
Total volume infused is 15.41mL
in initial 20minutes
Study 3 month period of data collection
on EVERY Taxol infusion including: RN administering medication Date Pt Initials Cycle/Dose(mg) Pre-meds given Reaction Re-challenge with specific re-
challenge protocol Subsequent reaction w/re-challenge
Study Results
99%
1%
Total number of Taxol administrations
NO
YES
3 month data revealed a decrease in reaction rate to <1%
<1% reaction rateobserved in
(combined 1-hr and 3-hr infusions)
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Clinical Practice (Patton) 5
Project Takeaways
• Prime the line…EVERYTIME– Initial step of your titration schedule should always be to clear the priming volume from
the tubing– This ensures your titration schedule begins with the administration of the drug and not
saline or other priming solution.
• Slow and Steady– Titrating Taxol introduces the drug slowly to the body and allows for early recognition and
intervention in the event of a hypersensitivity reaction.
• Consistency is key– Standardizing administration practices not only decreases reactions but increases nursing
and patient confidence with infusion.
Special Thanks• Todd Cancer Institute
Memorial Care, Long Beach Medical Center• Project Co-Authors
– Nicolann Hedgpeth, DNP, RN, AOCNP– Kresta Grabau, BSN, RN, OCN– David Lu, PharmD-Student Intern
References• Huddleston, R., Berkheimer, C., Landis, S., Houck, D., Proctor, A., &
Whiteford, J. (2005, May/June). Improving Patient Outcomes in an Ambulatory Infusion Setting. Journal of Infusion Nursing, 28(3), 170-172. doi:10.1097/00129804-200505000-00004
• Weiss, R. B., Donehower, R. C., Wiernik, P. H., Ohnuma, T., Gralla, R. J., Trump, D. L., . . . Leyland-Jones, B. (1990, July 8). Hypersensitivity reactions from taxol. Hypersensitivity Reactions from Taxol, 8(7), 1263-1268
ONS 43rd Annual Congress
Clinical Practice (Farrell) 1
Nurse-Led Improvements and Collaborations in Outpatient
SettingsStacy Farrell MSN, RN, OCN
Chemotherapy Infusion Nurse Memorial Sloan Kettering Cancer Center
Basking Ridge, NJ Regional Center
Disclosures
• The authors of this presentation have no actual or potential conflict of interest in relation to this program/presentation
• There is no underwriting or funding for this presentation
• All of the authors are clinical nursing staff members at Memorial Sloan Kettering Cancer Center, Basking Ridge, NJ Regional Infusion Unit
ONS 43rd Annual Congress
Clinical Practice (Farrell) 2
Improving Communication in the
Transfer of Care in Nursing Handoff
Perfecting a Culture of Nursing Collaboration and Patient Safety
in the Outpatient Infusion Setting
Mary Wilson-Carnes BSN, RN, OCNTara Cheney BSN, RN
Rodwell Manalo BSN, RNHeidi Foss BSN, RN, OCN
SignificanceApproximately 300 million handoffs occur each year in the U.S.
• Joint Commission Center for Transforming Healthcare reported miscommunication as “the leading root cause of sentinel events.”
(Joint Commission Perspectives, 2012)
• The World Health Organization (WHO) includes improved communication in handoff in its top five patient safety solutions
• Consequences of inadequate handoff:– Inappropriate, delayed or omitted treatment– Adverse events– Inefficiency – Patient harm and dissatisfaction– “Nurses may be found legally liable for failure to report necessary information
during handoff.” (Riesenberg, Leitzsch & Cunningham, 2010)
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Clinical Practice (Farrell) 3
Extended Operating Hours from 10-12 hours Need for end of day transfer of patient care at shift change
Background/Purpose
HuddleBrief Group Meeting
General
HandoffOne to OneSpecific
Question, Clarify, Confirm
Goals: Improve communication, patient safety and nursing satisfaction with the handoff process.
https://www.uptodate.com/contents/patienthandoffs/print?source=search_result&search+h
Methods• Pre and post surveys were conducted to evaluate nursing perceptions, safety,
information retention and efficacy of tools.
• A new systematic handoff tool and procedure were developed and implemented
Transfer of Care Handoff Form•Developed and implemented •Chairside report•Standardized and systems focused
• Transfer of Care Process • Changed from a huddle style report to a
one to one nurse handoff• In the presence of the patient• Interactive verbal and written
JCAHO Targeted Solutions for Hand Off
• http://www.jointcommission.org/assets/1/6/tst_hoc_persp_08_12.pdf• SHARE
– Standardize critical content – Hardwire within your system
• Hand off tool • Expectations set about conducting successful handoff
– Allow opportunity to ask questions – Reinforce quality and measurement
• Use the forms • Consider looking at safety measures (i.e. NSI like falls)
– Educate and coach • Make successful hand off a priority at organizational level
Joint Commission Perspectives August 2012 Volume 32 Issue 8
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Clinical Practice (Farrell) 4
AFFIX PATIENT STICKER POD#:CODE STATUS: FULL DNR
HIGH RISK FOR FALLS: YES NO
ALLERGIES:
PRECAUTIONS:
DIAGNOSIS / TREATMENT C#___
Hx of REACTION IRB#__________
VITALS ht:______cm / wt:______kg
VS: _________________ ABNORMAL
OBTAIN POST VITALS PERFORM ORTHOSTATICS
ACCESS
PIV:_____ PICC HAI IP
MEDIPORT OTHER: ____________
LABS
ABNL POST
RE‐DRAW
________
PRE‐MEDICATIONS
CHEMO / BIO / PLAN / IMPLEMENTATION / EVALUATE
ASSISTIVE DEVICES
CANE WHEELCHAIR WALKER
OTHER: _____________________
NEURO
ORIENTED: PERSON PLACE TIME
MOTOR SENSORY DEFICIT: YES NO
PAIN
#____ / 10 REASSESS
GU / GI
I&O COMMENTS:
SKIN / MUSCULOSKELETAL
CARDIOVASCULAR
EKG ECHO/MUGA COMMENTS:
RESPIRATORY
O2 _____ OTHER:______________ PFTs
COMMENTS:
DISCHARGE / END TIME
CHAP EMAR Follow Up Task
Hand OffTool
Handoff Process Work FlowSending RN prepares for
Handoff:Completes Written
Handoff Form
Sending RN Verbally Reviews Written Handoff Form with
Receiving RN Questions Clarification
team?
Are there any more issues to
clarify with treatment
team?
Sending RN contacts treatment team for plan and contact information
Yes
No
Sending and Receiving Sending and Receiving RNs meet Patient in Treatment POD and
complete Verbal, Written and
Technologic Handoff
Barriers to Effective Handoffs• Communication barriers• Lack of standardization• Equipment issues• Environmental issues• Inadequate or misuse of time• Complex cases and high work loads• Inadequate training or education• Human factors
(Riesenberg, Leitzsch & Cunningham, 2010)
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Clinical Practice (Farrell) 5
Models used in Handoff• SBAR• S- Situation• B- Background• A- Assessment• R- Recommendation
• I PASS THE BATON• I- Introduction• P- Patient (identify the patient)• A-Assessment (V/S, symptoms etc)• S- Situation (current status)• S- Safety Concerns (falls precautions, allergies)• THE• B- Background (history, meds)• A-Action (action taken or required)• T- Timing• O- Ownership• N- Next Sandlin, 2007
Results
65%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Huddle Handoff
Does the Transfer of Care Tool Provide Adequate Information?
Does the Transfer of Care Tool Provide Adequate Information?Huddle n=20Handoff n=16
Huddle Handoff
RN Perception of Safety 55% 93%
RN Ability to Ask Questions 55% 93%
RN Retention of Information 41% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Huddle versus Handoff RN Survey
Pre n = 20Post n= 16
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Clinical Practice (Farrell) 6
Nursing Implications• Improved patient safety and outcomes
• Enhanced nursing collaboration and satisfaction
• Improved the quality of communication in the TOC in nursing handoff
Effective handoff
Meet the Team• Tara Cheney BSN, RN (cheneyt@mskcc.org)• Stacy Farrell MSN,RN,OCN (farrells@mskcc.org)• Heidi Foss BSN, RN,OCN (fossh@mskcc.org)• Rodwell Manalo BSN,RN (manalor@mskcc.org)• Mary Wilson-Carnes BSN, RN, OCN (wilsoncm@mskcc.org)
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Clinical Practice (Farrell) 7
References• Arora, V., & Farnan, J. (2017). Patient Handoffs, from https://www.uptodate.com/contents/patient-handoffs#!• Eggins, S., & Slade, D. (2015). Communication in clinical handover: improving the safety and quality of the
patient experience. Journal of Public Health Research,4(3). doi:10.4081/jphr.2015.666• Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and
situation awareness. BMJ Quality & Safety, 22(11), 899-906. doi:10.1136/bmjqs-2012-001467• Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-off
Communications, Joint Commission Perspectives®, August 2012,32(8). Joint Commission on Accreditation of Healthcare Organizations, from http://www.jointcommission.org/assets/1/6/tst_hoc_persp_08_12.pdf
• Koenig, C. J., Maguen, S., Daley, A., Cohen, G., & Seal, K. H. (2012). Passing the Baton: A Grounded Practical Theory of Handoff Communication Between Multidisciplinary Providers in Two Department of Veterans Affairs Outpatient Settings. Journal of General Internal Medicine, 28(1), 41-50. doi:10.1007/s11606-012-2167-5, from https://www.ncbi.nlm.gov/pubmed/22868947
References• Riesenberg, L. A., Leisch, J., & Cunningham, J. M. (2010). Nursing Handoffs: A Systematic Review of
the Literature. AJN, American Journal of Nursing, 110(4), 24-34. doi:10.1097/01.naj.0000370154.79857.09, from https://www.ncbi.nlm.nih.gov/pubmed/20335686
• Sandlin, D. (2007). Improving Patient Safety by Implementing a Standardized and Consistent Approach to Hand-Off Communication. Journal of PeriAnesthesia Nursing, 22(4), 289-292. doi:10.1016/j.jopan.2007.05.010, from http://www.jopan.org/article/S1089-9472(07)00169-4/fulltext
• Søndergaard, E., Grøne, B., Wulff, C., Larsen, P., & Søndergaard, J. (2013). A survey of cancer patients’ unmet information and coordination needs in handovers – a cross-sectional study. BMC Research Notes, 6(1), 378. doi:10.1186/1756-0500-6-378, from http://www.biomedicalcentral.com/1756-0500/6/378
• Streeter, A. R., Harrington, N. G., & Lane, D. R. (2016, December 08). Communication Behaviors for an Effective Patient Handoff. Communication Currents, National Communication Association, from https://www.natcom.org/communication-currents/communication-behaviors-effective-patient-handoff
• Ulrich, B., & Kear, T. (2014). Patient safety culture in nephrology nurse practice settings: Initial findings. Nephrology Nursing Journal, 41(5), 459-475, from http://www.prolibraries.com/anna/?select=session&sessionID=3102
ONS 43rd Annual Congress
Clinical Practice (Sato‐DiLorenzo) 1
Combating Chemotherapy Verification Fatigue: Nurse-led Quality Improvement Interventions in
Pre-treatment Lab Evaluation
Aya Sato-DiLorenzo, RN, BSN, OCN, BMTCNUnit Based Educator
Ambulatory Hematology/Oncology & Bone Marrow Transplant Beth Israel Deaconess Medical Center
Disclosures
• I have nothing to disclose.
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Clinical Practice (Sato‐DiLorenzo) 2
Our QI WarriorsCombating Chemotherapy Verification Fatigue
Team Hematology‐Oncology Team Hematology/Bone Marrow Transplant
Planning
“orders approved by nurses but halted by pharmacy”Define near-misses
Reduce the number of near-misses by fifty percent over three months
Aim statement
Tools Used to Analyze Baseline Processes and Barriers
Process Map
Cause-and-Effect Diagram
Staff Survey
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Clinical Practice (Sato‐DiLorenzo) 3
Process MapTo understand baseline nursing processes
Unit-Based Nursing SurveyTo understand existing barriers as identified by staff nurses
The survey was created and analyzed in Survey Monkey
Cause and Effect DiagramTo categorize each existing barrier and visually present its influence on the system.
ONS 43rd Annual Congress
Clinical Practice (Sato‐DiLorenzo) 4
Brainstorming Sessions by Nurses
Ideas on post-it notesGroup discussions
Selecting InterventionsEach idea on a post-it notewas placed in one of the coordinates within a priority/pay-off matrix according to its potential effectiveness (low to high impact) and perceived ease (difficult to easy).
Ideas organized in priority/pay-off matrix
easy & high Impact interventions are encouraged.
Chosen Interventions
Two-RN lab check during verification.
Utilization of "display the last day lab results" function in EMR to limit lab display to the most recent results only.
Practice champions from each treatment area initiated these interventions and encourage their peers to follow their lead.
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Clinical Practice (Sato‐DiLorenzo) 5
Study the Results
Interven
tions
Study Sustainability
Post‐intervention Follow up surveillance
Unit-Based Follow Up Survey
Barriers to full success identified by nurses• Returning to past habits.• Primary nurse telling the second verifying nurse that pre-
treatment labs have been verified.
The survey was created and analyzed in Survey Monkey
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Clinical Practice (Sato‐DiLorenzo) 6
Key Conclusions
Our nurse-identified-and-led interventions were successful in reducing the number of near-misses.
Identification of latent failures and interventions to correct them may be necessary to engender sustainable changes.
Further interventions are needed to sustain a low occurrence over time.
What’s Next?
A project by clinical nurses with the aim to improve provider-nurse communication.
Clinical guidelines by pharmacy addressing toxicity monitoring for treatment regimens frequently used at our institution.
A project by nursing leadership to improve the clarity of chemotherapy orders.
Three TakeawaysChoose your interventions wisely. Do not jump into conclusions without careful analysis of contributing factors.
Not gaining the result you were looking for does not mean a failure. It is your opportunity to dig in deeper.
Engage your colleagues and find solutions that are supported by many.
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Clinical Practice (Sato‐DiLorenzo) 7
How to Reach Us:Project Leader:Aya Sato-DiLorenzo, RN, BSN, OCN, BMTCNUnit Based Educator
Ambulatory Hematology/Oncology & Bone Marrow TransplantBeth Israel Deaconess Medical Center
asato@bidmc.harvard.edu
Project Coach:
Meghan Shea, MDAttending Medical Oncologist, Beth Israel Deaconess Medical Center &
Instructor in Medicine, Harvard Medical School
mshea4@bidmc.harvard.edu
References• Spath, P. L. (2011). Error reduction in health care: a systems
approach to improving patient safety. Jossey-Bass.• Zerillo, J. (2017). Oncology quality process improvement project
training. Lecture presented at Oncology Quality Process Improvement Project (PIP) in Beth Israel Deaconess Medical Center, Boston.
ONS 43rd Annual Congress
Clinical Practice (Foster) 1
Wake Up: A Prescription for Increasing Patient Safety in the
Ambulatory Infusion RoomJennifer Foster, BSN, RN, OCN, ONN-CGGenitourinary Cancer Nurse Navigator
Jennifer Havens, BSN, RN, OCN, ONN-CGLung Cancer Nurse Navigator
Baylor Scott & White Vasicek Cancer Treatment Center
Disclosures
• The presenter has no financial relationships to disclose
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Clinical Practice (Foster) 2
Preventing Allergic Reactions• A large number of cancer therapy infusions have the potential to cause
hypersensitivity reactions• Prevention of hypersensitivity reactions traditionally includes the use of H₁
antihistamines, i.e. diphenhydramine• Diphenhydramine is a first generation H₁ antihistamine that was introduced
in1945 (₁)– Traditionally has been the medication of choice for acute allergic
reaction/anaphylaxis– In studies utilizing chemotherapy/biotherapy, diphenhydramine is frequently
used in the prevention of infusion reactions– First generation H₁ antihistamines readily cross the blood brain barrier and
occupy approximately 75% of the H₁-receptor sites in the brain which correlateswith increased CNS related symptoms (₃)
Elderly Population and Antihistamine Effect
• Age is the greatest risk factor for developing cancer. In fact, 60% of people who have cancer are 65 or older (₂)
• People 65 and older often have multiple comorbities resulting in polypharmacy
• Impaired drug metabolism in this population leads to increased CNS symptoms
• Diphenhydramine is included on the Beer’s list
Patient Safety Concerns• Falls• Incontinence• Confusion (altered mental status)• Restless legs• Sedation, inability to report adverse reactions • Impaired driving (₁) • Hypotension• Urinary retention• IV dislodgement
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Clinical Practice (Foster) 3
But Why???
• Patients complained of and nurses noted increased adverse side effects from diphenhydramine during the first two cycles of treatment (traditionally paclitaxel) and the physicians would often switch the patient to cetirizine at the nurses’ request
• Nurses questioned, “Why use diphenhydramine?” –because that is how the drugs causing hypersensitivity were studied, and that is “always how it has been done”
Second Generation H₁Antihistamines
• Emerged in the 1980s• Examples: terfenadine, astemizole, loratadine,
cetirizine, and levocetirizine• Developed to decrease the side effect profile of
antihistamines (₃)• Second generation H₁ antihistamines occupy
approximately 20% of H₁-receptors in the brain which correlates with less cognitive dysfunction (₃)
Comparison of First and Second Generation H₁ Antihistamines
First Generation AntihistamineSide Effects
Second Generation AntihistamineSide Effects
CNS depression (somnolence, impairedcognitive and psychomotor performance)
Minimal or no CNS depression
Anticholinergic effects (dry mouth, blurred vision, urine retention)
Minimal or no anticholinergic effects
Other CNS effects (seizures, dyskinesia, dystonia, hallucinations)
Diphenhydramine Onset of Action Cetirizine Onset of Action
15‐60 minutes 15‐30 minutes
(₄)
(₁)
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Clinical Practice (Foster) 4
Implementation• RNs requested review of current practice by
pharmacy/physician group• Pharmacist completed literature review comparing efficacy of
various premedications (antihistamines)– Limited data available– Cetirizine thought to be acceptable option
• Physician buy-in• Order sets were updated to reflect the change from IV
diphenhyradmine to oral cetirizine as a premedication for: paclitaxel, cetuximab, and rituximab
ResultsSwitch from diphenhydramine to cetirizine in the ambulatory infusion setting demonstrated:• No rise in the number of hypersensitivity reactions• No increase in the required wait time after premedication
(does not effect time for scheduling infusion chair)• Decreased incidence of CNS-related effects, reduced
patient reports of adverse side effects, diminished need for one-on-one nursing care, and overall improved patient safety
Key Takeaways• No increased frequency/severity of reactions with use of
cetirizine vs. diphenhydramine and no effects on the length of infusion chair time (premedication wait time)
• Nurses noted decreased safety concerns and that patients verbalized fewer antihistamine related complaints with the switch to cetirizine
• Nurses can impact safety by being patient advocates by speaking up and questioning the “status quo”
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Clinical Practice (Foster) 5
References1. Banerji, A., Long, A. A., & Camargo, C. A. (2007). Diphenhydramine
versus nonsedating antihistamines for acute allergic reactions: A literature review. Allergy and Asthma Proceedings, 28(4), 418-426. doi:10.2500/aap.2007.28.3015
2. For Older Adults. (2016, April 20). Retrieved from https://www.cancer.net/navigating-cancer-care/older-adults
3. Kay, G. (2000). The effects of antihistamines on cognition and performance. Journal of Allergy and Clinical Immunology, 105(6),
622-627. doi:10.1016/s0091-6749(00)79554-64. Mahdy, A. M., & Webster, N. R. (2008). Histamine and antihistamines.
Anaesthesia & Intensive Care Medicine, 9(7), 324-328. doi:10.1016/j.mpaic.2008.04.016
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