NOTE: Permission was granted to share this hospital protocol.  It is in a small font
 so that you can print it.  

MERCY MEDICAL CENTER
PROCESS STANDARDS

Page 1 of 3

Mu

 MULTIPLE CHEMICAL SENSITIVITY PROTOCOL

 APPROVED FOR All Patients with Multiple Chemical Sensitivities

 DISTRIBUTED TO All Patient Care Areas, Admitting, Environmental Services, Nutritional Services

 ........................................... and Governance/Administrative Policy/Procedure Manual


PURPOSE           To outline the management of patients with multiple chemical sensitivities.

LEVEL             Independent (requires nursing order only)

SUPPORTIVE DATA    Patients with a history of allergy to chemicals found in perfume, pesticides, detergents,
                    household cleaners, etc. may have multiple chemical sensitivities.
                  -  All supplies used to clean patient room (where the patient is to be housed) and
                     in the care of the patient should be chemical free.
                  -  Staff caring for the patient should not wear scented products.
                  -  Do not use air fresheners or furniture polish in patient room.
                  -  Use only non-toxic cleaning products: Vinegar, Bon AMI, Borax, baking soda,
                     Ultra-Safe Plus+# cleaning solution.
                  -  Use only I 00% cotton blankets, towels, sheets.
                  -  Patient allergy is marked in demographics on patient's permanent record; this comes up on re-
                     admission.
                  -  Patient may have multiple food allergies.
                  -  Rinse all equipment before taking into patient room.

  KIT CONTENTS -  FOR PATIENT CARE AREA'S USE AND EMERGENCY ROOM

 •  Yellow arm band                                           .  Butterfly cotton batting
 •  Suction kit (without gloves)                              .  Stopcock
 •  Non-latex surgical gloves                                 .  Paper Tape
 •  Non-latex powder-free exam gloves                         .  Butterfly for IV access
 •  Planet Solution cleaning solution                         .  Velcro Tourniquet/ BP cuff
    (Planet Solution catalogue included in kit)               .  Ivory liquid soap for staff
 •  IV solution 5% Dextrose in water 1000 cc                  .  3M Mask R-95 Dust Mist mask
 •  Porcelain oxygen mask, tygon tubing                       .  Normal Saline 0.9% 1000 (glass
 •  5% Electrolyte Travert Solution 1000 cc (glass bottle)
 •  2 Yellow Multiple Chemical Sensitivity allergy signs
 •  Soda Bicarbonate solution 500 cc (IV solutions are order from Baxter)
 •  Codan IV administration kit (ordered from Codan Pharmaceuticals 1-800-332-6326)
 •  Sterile cotton sheets, towels, blankets, wash cloths, cotton pillows, gowns washed with non-
    perfumed detergent and no fabric softener.

Supplies for MCS patients may be ordered from this foundation: (catalog included in MCS kit.)
               American Environmental Health Foundation      1-800-428-2343

KIT CONTENTS - FOR OBOR, OR, OPSC, NICU
 Each unit has a latex-free cart specific to their area to which this protocol is added (refer to Unit Specific
 ManuaL).


SPECIAL
PROCEDURES.
30 MIN TO 1 HR/DAY

    LSU:
    -  Listen to the patient. Reassure the patient that you understand they are chemically sensitive
       and that you will work with them in providing care.
    -  Use all methods to minimize exposure of the patient to exhaust fumes.  Avoid idling the
       ambulance.  Turn off the motor when loading and unloading the patient.
    -  Refrain from wearing perfumes, cologne, or smoking while on duty.
    -  Remove the patient from hostile environment.  If they are having a reaction, move them out into
       fresh air.
    -  Use the patient's own medical equipment whenever possible.
    -  Wear non-latex gloves.
    -  Avoid the use of IV and medications, if at all possible, until patient is transported to their
      destination, unless in a life-threatening situation.
11/5/99 3:25 PM

Mu

MERCY MEDICAL CENTER
PROCESS STANDARDS

Page 2 of 3

 MULTIPLE CHEMICAL SENSITIVITY PROTOCOL

 APPROVED FOR All Patients with Multiple Chemical Sensitivities
 DISTRIBUTED TO All Patient Care Areas, Admitting, Environmental Services, Nutritional Services
 .......................................... and Governance/Administrative Policy/Procedure Manual

   EMERGENCY ROOM:
 -  Immediately contact MCS patient's physician for special instructions and review any medical
    alert identification the patient may be wearing or carrying, as well as any existing hospital
    computer records on the patient.  No treatments, IVs, tests, or medications should be administered
    to a MCS patient without prior approval of patient's private physician, unless a life-threatening
    emergency exists.
 -  Immediately isolate MCS patient from all other patients and visitors.
 -  Patient should not be wait in the waiting room.
 -  Patient should be placed in Prompt Care Room One ASAP (remove latex products from the room
    and request Environmental Services to clean with approved cleaner for that purpose prior to
    placing patient in the room, if at all possible).
 -  Obtain MCS kit from Central Supply for caring for this patient.

PRIOR TO
ADMISSION OF
PATIENT TO ROOM

PATIENT SERVICES SUPERVISOR:
 -  Notify Environmental Services and Pharmacy of MCS and place the patient in private room.
ENVIRONMENTAL SERVICES:
 -  Remove all latex products and cubicle and window curtains from the patient room.
 -  Clean the patient room with Planet Solutions cleaning solution. Do not use products with
    chemicals or wear latex gloves to clean the room.  Hang cotton cubicle curtains.  Make bed with
    cotton bed linen that is washed in non-perfumed detergent and no fabric softener.
 -  Install new sharps container in room.
 -  Place air filter (HEPA Plus activated carbon liner) in patient room and turn on. (Obtain filter from
    Central Supply with the MCS kit).
PHARMACY:
 -  Use glass bottles for IV solutions.
 -  Do not use any substitutions or generic drugs for the MCS patient without checking with the
    physician.
 -  Patients with MCS may react to dyes, preservatives, and artificial sweeteners and flavorings,
    cornstarch, or any other excipient.
 -  Capsules may be safer than tablet form.
 -  Monitor MCS patient medications by listing MCS patient under heading "Highly Allergic Code"

ADMISSION
ASSESSMENT

 -  Assess all patients on admission to the hospital for allergies, and have Epinephrine available.
 -  Patient who has MCS should be in a private room; follow procedure for preparing room
 -  Obtain MCS kit from Central Supply.
 -  Place yellow arm band on patient; mark with Multiple Chemical Sensitivity
 -  Place Multiple Chemical Sensitivity sign on patient's bed and outside door.
 -  Place Multiple Chemical Sensitivity under "isolation" on the Patient Profile OC (prompt F4); this
    will print on the order sheet on receiving department.
 -  Patient should be provided distilled drinking water in a glass container.
 -  Notify Nutritional Services of the patient's special needs. Patient needs to be interviewed by
    Nutritional Services as soon as possible.
 -  Ask the patient to describe all beneficial procedures that have helped reduce the severity of
    reactions in the past.  List this information in the medical record.  Patient suggestions may include
    items such as administering oxygen, drinking water, eating fresh fruit, and other tolerated foods.
    Drinking a solution of baking soda and water (one teaspoon to 1/2 cup water).  Showering or
    shampooing.

RD:
DIET MODIFICATION

NUTRITIONAL SERVICES:
 -  Patient with MCS will require a special diet. The diet should include no processed foods of
    any kind, including instant oatmeal, instant mashed potatoes, and other prepackaged mixes (such
    as gravies, sauces and flavor packets).  Use no dyes, preservatives, artificial flavorings, artificial
    sweeteners, or MSG.  Provide patient with chlorine-free distilled water, decaffeinated
    coffees (which have not been processed with chemicals), and lactose-free milk.  Food and drink
    should be provided in glass containers.  Allow patient to select plain, non-processed foods from
    meats, vegetables, fruit, and grain list.


11/5/99 3:25 PM


MERCY MEDICAL CENTER
PROCESS STANDARDS

 Page 3 of 3

Mu

 MULTIPLE CHEMICAL SENSITIVITY PROTOCOL

 APPROVED FOR All Patients with Multiple Chemical Sensitivities
 DISTRIBUTED TO All Patient Care Areas, Admitting, Environmental Services, Nutritional Services
 ........................................ and Governance/Administrative Policy/Procedure Manual

-  On physician orders, permit patient to supply his/her own tolerated food products and dietary
   supplements.
-  Retain patient's dietary requirements in the patient's medical record for future reference.

ROUTINE SAFETY

-  All hospital employees and visitors are to check with the patient's nurse prior to entering patient's
   room.
-  Patient should be isolated from other patients and their visitors at all times.  In the event that the
   patient must be transported elsewhere in the hospital, the patient should wear a R-95 mask.
-  Staff caring for the patient should not wear perfumed products, hair spray, or perfume.
-  Hospital personnel are to wash their hands with unscented or ivory soap and apply non-latex
   gloves prior to touching the patient.
-  No live plants and flowers are permitted in the patient's room.
-  No latex balloons
-  Alcohol swabs should not be used on the patient.  Food grade alcohol is OK.
-  Remove tops of vials before drawing up medications.
-  Do not inject through any latex ports.
-  Patient should bathe using products they are familiar with that do not cause a reaction.
-  Petroleum products, i.e. K-Y jelly should not be used.
-  Patients with MCS going to surgery alert Anesthesia well ahead of time in order for the physician
   to discuss what anesthesia and pain control will be used.

TEACHING:
DISEASE PROCESS

-  If patient has not been aware of Multiple Chemical Sensitivities prior to admit, alert them to the
   fact that they may be allergic to many things.
-  If patient would like more information about Multiple Chemical Sensitivities, they may contact the
   following:

 Environmental Health Network of California
 P.O. Box 1155,
 Larkspur, California 94977-0074
 Support and information line (SAIL) 415-541-5075

 Chemical Injury Information Network
 P.O. Box 301
 White Sulphur Springs, MT 59645
 (406) 547-2255
 (406) 547-2455 Fax

 American Environmental Health Foundation
 1-800-428-2343
 (Supplies for MCS patients may be ordered from this foundation).  Catalog included in MCS kit.

DOCUMENTATION

-  Document Multiple Chemical Sensitivity in the patient's medical record, in the front of the chart,
   PCP, PCS, MAR, and computer profile.
-  Record implementation/modification/discontinuation of protocol in PCP/PFS.
-  Record evaluation of effectiveness of care in the EOSS on the NPR as related to the nursing
   diagnosis/patient outcome.

REFERENCES*  Healthier Hospitals, Toni Temple, Ohio Network for the Chemically Injured, 1996.
          *  The Environmental Illness Syndrome, Sherry A. Rogers, M.D., Syracuse, N.Y. 1997.
          *  Human Ecology Research Foundation, 8345 Walnut Hill Lane, Dallas, TX 7523 1.
          #  4/24/02: Upgraded by website owner due to available improved formulas
APPROVAL Clinical Standards Development Committee ..................... 10/99
                              Hospital Standards of Clinical Practice Committee ...........

AUTHOR               Cathy Carl, RN, BS, CIC

REVIEWED

REVISED

CONSULTING PHYSICIAN:. Jo Tillman.M.D. DATE: 9/99

11/5/99 3:25 PM