Enter your text here...
Clinical Safety
Clinical Safety
Basic
Infection
CNT Principles
Acupuncture
Precautions
Risk Management
Patients and Their Records
Herbal Safety
Date | Topic | ||
1 | Jan. 2 | Guidelines and Clean Needle Technique | |
2 | Jan. 9 | CNT Basic Principles | |
3 | Jan. 16 | Preventing Acupuncture Needling Adverse Events | |
4 | Jan. 23 | Contraindications and Precautions for Acupuncture | |
5 | Jan. 30 | Risk Management | |
6 | Feb. 6 | Management: Patients and Their Records | |
7 | Feb. 13 | Herbal Safety Procedures | |
8 | Feb. 20 | Midterm (50% Marks) | |
| Feb. 27 | Reading Break | |
9 | March. 5 | Preventing Moxibustion Adverse Events | |
10 | March.12 | Preventing Cupping Adverse Events | |
11 | March. 19 | Preventing EA Adverse Events | |
12 | March. 26 | Preventing Acupuncture Bleeding Therapy Adverse Effects | |
13 | Apr. 2 | Preventing Gua Sha Adverse Events | |
14 | Apr. 9 | Preventing Tui Na Adverse Events | |
15 | Apr.16 | ||
|
Why clinic safety is important and what will be in it?
What is Patient Safety?
•Patient Safety aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
•Patient safety is fundamental to delivering quality essential health services.
Acupuncture: basic safety principles
•Ensure that acupuncture is the most appropriate treatment for your patient
•Check for significant underlying diseases and ‘red flag’ symptoms and signs and inform the patient’s general practitioner or specialist immediately if signs or symptoms of a serious condition are evident.
•Minimize the risk of trauma or injury
•Pneumothorax is a serious adverse event. When needling over the thoracic region use superficial oblique insertion. The depth of needle insertion must be within safe limits for each patient and each location related to the underlying anatomy.
•Always note the number of needles retained during treatment and ensure that the same number are removed and disposed of safely.
•Reduce the risk of infection
•Wash your hands before patient contact, before inserting and removing needles and whenever there is a risk of cross infection from practitioner or patient to patient.
•Maintain a clean field for any equipment you use in your practice.
•Skin surface should be clean and free from emollients.
•Check your equipment.
•Needles must be sterile, disposable and single use only.
•Maintain your practice in line with current laws
•Dispose of sharps containers and clinical waste in line with current hazardous waste legislation.
•Practitioners must be legally registered or licensed with the local authority.
•Scope of practice
•Work only within your limits of competence and professional training, and within the scope of your professional practice.
•Joining an appropriate professional body that can keep you abreast of current best practice in acupuncture.
•Report serious adverse events or notifiable diseases immediately to:
•your professional body
•your professional insurers
•the Health and Safety Executive
•your local authority or local health protection team (in the case of notifiable diseases).
Infection Prevention and Control
•Infection prevention and control is an essential consideration for TCM practitioners when providing patients with safe health care services.
•Infections can occur with or without direct skin penetration.
•Sharps (e.g., acupuncture needles, dermal needles) are intended to penetrate the skin thereby becoming easily and regularly contaminated by blood or body fluids. The contaminated sharp can infect the practitioner through inadvertent penetration caused by unsafe disposal or handling of the sharps.
•Infections may be the result of the use of contaminated equipment or utensils coming in contact with open cuts or contaminated hands inadvertently touching mucous membranes at the eye, nose, or mouth.
Infectious Agent
•A pathogenic micro-organism causing the infection or disease.
•The four types of infectious agents that cause most infectious disease are viruses, bacteria, fungi and parasites.
Reservoir
•The reservoir is where the organism lives and grows between outbreaks. This can be food, water source, feces, in the environment, or in a living organism.
Portal of Exit
•Portal of exit identifies how the infectious agent is able to leave the reservoir (e.g., blood, mucus, secretions, and open wounds).
Transmission
•Transmission identifies how the agent is able to move from one host to another host (e.g., human-to-human through blood contact, respiratory droplets or other secretions, on the hands of a health care worker, through the air in an unfiltered ventilation system, attached to a living organism like a mosquito).
•Knowing how the infection is transmitted is essential for deciding the infection control measures that will be the most effective.
•In a TCM practice setting, the four main transmission routes that are important to understand are direct contact, indirect contact, droplet, and airborne.
Portal of Entry
•This describes how the agent enters the vulnerable host (e.g., insect bite, inhaling, break in the skin, mouth when eating).
•The portal of entry (nose, mouth, skin) informs the practitioner on the personal protective equipment that may be required.
Vulnerable Host
•The vulnerable host is the person infected by the agent. The most vulnerable are often the very young and the very old, or those who have their immune systems suppressed.
•Because of the occupational exposure of health care workers, TCM practitioners and staff have increased opportunities to be exposed to infectious diseases.
Contamination
•Contamination is the spread of infectious micro-organisms to an object (such as an acupuncture needle or herb storage container).
Sterilization & Disinfection
Infections
•Infectious micro-organisms in human blood (blood borne pathogens) can cause disease in humans.
•Use of sharps can expose TCM practitioners to blood borne pathogens. Sharps include objects such as needles, broken glass, and razor blades.
•the following diseases and conditions are highlighted for special attention for TCM practitioners.
•Hepatitis A – contact Food or drink
•Hepatitis B -- blood and other body fluids
•Hepatitis C -- contaminated blood
•Tuberculosis-- breathing in droplets
•AIDS-- blood and other body fluids
•Influenza-- breathing in droplets
•Skin Infections-- broken skin
Hepatitis
•Hepatitis A is common source of Hepatitis A virus (HAV).
•Hepatitis A is more frequently evidenced in locations with poor sanitation. Eating food and drinking water that is contaminated by fecal matter containing Hepatitis A is common source of Hepatitis A virus (HAV).
•Hepatitis A is less severe than Hepatitis B or C.
•Hepatitis A infected blood presents a smaller risk to practitioners.
• There is a vaccine that can be administered for Hepatitis A.
• An effective means of prevention against HAV infection is regular hand washing.
•Hepatitis B is an irritation and swelling of the liver caused by infection with the Hepatitis B virus (HBV).
•Hepatitis B can cause acute illness but can become chronic (lifelong).
•Vaccination is an effective means to prevent HBV infection.
•Health care workers who regularly come in contact with blood and other body fluids are particularly at risk and should be immunized against Hepatitis B.
•The use of the clean needle technique greatly reduces the risks of infection.
•Hepatitis C is caused by the Hepatitis C virus (HCV).
•HCv transmit by contaminated blood
•Hepatitis C has an acute and chronic form.
•There are some treatments, but there is no vaccine.
•The use of the clean needle technique greatly reduces the risks of infection.
Tuberculosis
•Tuberculosis is contagious bacterial infection that mainly involves the lungs.
•it can also spread to bone, skin, gastrointestinal tract.
•Tuberculosis can be transmitted by breathing in droplets from a cough or sneeze of an infected person.
Acquired Immune Deficiency Syndrome (AIDS).
•AIDS caused by infection with Human Immunodeficiency Virus (HIV)
•HIV is spread through direct blood-to-blood contact and through direct contact with certain body fluids, including blood.
HIV can lead to Acquired Immune Deficiency Syndrome (AIDS), which is a collection of diseases that a person can contract when their immune system is weakened.
HIV can be diagnosed with a blood test.
•Health care workers who regularly come in contact with blood and other body fluids should take appropriate precautions.
Influenza
•Influenza or the flu affects primarily the respiratory tract and is caused by the influenza virus.
•Influenza is spread through droplets when someone coughs or sneezes, through the air in enclosed spaces, through direct contact with contaminated hands, and indirect contact with contaminated objects (e.g., door knobs).
•Influenza often has seasonal strains. The elderly or weak are at greater risk of worsening complications.
Pneumonia
•Pneumonia is a respiratory condition caused by an infection of the lungs.
•Pneumonia may be caused by bacteria, viruses, or fungi.
•In adults, bacterial infection is the most common cause (e.g., bacteria from the sinuses or mouth may spread to the lungs). In infants and children, viruses can commonly cause pneumonia.
Skin Infections
• Skin infections can range in cause (bacterial, fungal), visibility (from small spot to covering large portions of the body) and in seriousness (from harmless to life threatening).
•The most common types of bacterial skin infections are caused by Staphylococcus and Streptococcus. Bacteria can invade through broken skin causing a range of discomfort and ulcerations. The nature of TCM practice requires practitioners to be vigilant of skin disorders on themselves and on their patients.
CNT Basic Principles
Clean Needle Technique (CNT) includes the following basic principles
•1. Always wash hands between patients, and before and after needling.
•2. Always establish a clean field before performing acupuncture.
•3. Always use sterile single-use needles and other instruments that may break the skin, such as seven-star hammers, press intradermal needles, and lancets.
•4. Always immediately isolate used needles and other sharps.
•5. Follow Standard Precautions.
1. Hand Hygiene
•Hand washing should be done:
· before and after patient contact or acupuncture treatment;
· when hands are contaminated during the treatment;
· immediately after inadvertent exposure to blood or body fluids;
· after contact with environmental surfaces or equipment;
· after removing gloves;•Remove any hand or wrist jewelers and avoid use of artificial nails. Follow these 6 steps when hand washing.
•1. Wet your hands in warm running water.
•2. Apply sufficient liquid soap to achieve lather.
•3. Wash all surfaces of your hands including backs of hands, fingertips, between fingers, wrists, base of thumbs, and around and under finger nails. Scrubbing should last approximately 15 seconds.
•4. Rinse well and leave water running.
•5. Dry thoroughly with a disposable paper towel or electric hand dryer.
•6. Turn off the water with the towel, and not with your bare hands.
2. Establish a Clean Field
•Use a metal tray or clean paper towel:
• Ensure area for supplies is clean, lay out the clean field without contaminating it.
• Place only clean supplies in field, set out needles, cotton balls. lay out an appropriate number of needles for the procedure without contaminating the site or the needles. Sterile needles must not be placed on a non-sterile environment (e.g., tray, cotton).
• Touch clean supplies only with clean hands
• The waste bag and sharps container must be established in an area away from the clean field.
3. use sterile single-use needles
•Prior to use, acupuncture practitioners need to inspect the packaging of any single-use sterile needles (and other sterile sharps) to ensure that the protective barrier has not been breached or damaged by exposure to water.
•The expiration date of all needles in a clinic should be checked regularly (i.e., monthly) and all expired needles be discarded.
•Discard any package of needles that has been punctured, torn or damaged, or past the expiration date of sterilization.
•When using acupuncture needles from packages that contain more than one needle, all needles left over at the end of a treatment must also be treated as non-sterile sharps and must therefore be discarded in an appropriate sharps container. Any unused but unsterile needles.
4. Safe Handling and Disposal of isolate used needles and other sharps.
•Sharp Container must be:
• Puncture resistant, • Leak proof
• Designed to allow sharps to be easily deposited, but difficult to remove
• Designed with a secure lid and handle for carrying
• Clearly marked “Biohazard” with easily identifiable symbol
• Large enough to hold all sizes of sharps
• Disposed of in a suitable manner when 3/4 full
5. Follow Standard Precautions
Skin Preparation
Acupuncture needles should be used only where the skin is clean and free of disease.
Acupuncture needles should never be inserted through inflamed, irritated, diseased, or broken skin. Otherwise, infections can be carried directly into the body past the broken skin barrier.
The areas to be needled should be clean prior to treatment. Alcohol swabbing is recommended but not essential before acupuncture needle insertion as long as an area is clean.
If swabbing an area, 70% alcohol is required.
Palpating the Point
It is acceptable clean technique to palpate the acupuncture point after cleaning the skin, as long as the hands are clean and have not been contaminated.
However, it is strongly recommended that before picking up the needle or palpating the point, the hands should be washed with soap and water or an alcohol-based hand sanitizer if they have been contaminated since the last handwashing by some activity such as arranging clothing or taking notes.
After this second cleaning of the hands, nothing should be touched but the needle handle, guide tube, and the skin over the point.
If anything else is touched, the fingers should be cleaned again as described above before proceeding.
Can I touch the needle during needle insertion?
If you need to support the shaft of the needle during needle insertion, either because you are using a thin needle (e.g., 0.15 mm width) or a long needle (e.g., more than 25 mm length) or both, you must use a sterile barrier between your fingers and the shaft of the needle.
While washing your hands removes most of the transient bacteria from the skin of the hands and fingers, it does not dislodge the resident bacteria. Some people carry resident bacteria on their skin that is pathogenic to other people.
Any object that pierces the skin must be sterile. To support the shaft of the needle, when necessary, use sterile gauze or sterile cotton between the fingers and the needle shaft.
Managing Used Needles
Used instruments that have penetrated the skin must be isolated immediately in an appropriate sharps container. Used needles, lancets and the head of a seven star/plum blossom should not be reused.
Used needles present risk for practitioners, staff, and children waiting for their parents.
When using needles from packages that contain more than one needle, all needles left over at the end of a treatment.
A sharps container for the used needles should be right beside the treatment table, on a flat, stable surface (not directly on the treatment table)
Sharps containers should be replaced regularly and not be filled over 75%.
Preventing Acupuncture Needling Adverse Events
•Adverse reactions are unexpected and undesirable effects that were not predicted or foreseen. The reasons for adverse reaction vary greatly based on the current mental, emotional, and physical status of the patient.
Acupuncture is a safe procedure when conducted by trained and skilled practitioners. Practitioners are expected to identify symptoms, causes and management strategies related to the adverse reactions and accidents such as:
•fainting
•bent needle
•stuck needle
•broken needle
•Hematoma
Needle stick injury
Fainting:
Cause:
This is often due to nervous tension, delicate constitution, hunger, fatigue, improper position or to the too forceful manipulation.
Manifestations:
During acupuncture treatment. there may appear dizziness, vertigo, palpitation, short breath, nausea, pallor, cold sweating, weak pulse. In severe cases, there may be cold extremities, drop of blood pressure, and loss of consciousness.
Management:
When fainting aurae such as dizziness, vertigo and nausea appear, stop needling immediately and withdraw all the needles. Then help the patient to lie down and offer him some warm or sweet water. The symptoms will disappear after a short rest. In severe cases, press hard with the fingernail GV 26, PC 9, PC 6 and ST 36, or apply moxibustion to DU 20, Ren 6 and Ren4.
Generally, the patient will respond, but if not, other emergency measures should be taken.
Prevention:
Avoid needling patient when their hunger or fatigue, not to forceful manipulation the needles.
Stuck needle
Cause:
This may arise from nervousness, strong spasm of the local muscle after the insertion of the needle, twirling the needle with too large amplitude or in one direction only, causing muscle fibers to bind, or from a change of the position of the patient after the insertion of the needles.
Manifestations:
After the needle is inserted, it is found at times difficult or impossible to rotate, lift and thrust the needles.
This situation is known as stuck needle.
Management:
Ask the patient to relax.
If the needle is stuck due to excessive rotation in one direction, the condition will release when the needle is twirled in the opposite direction.
If the stuck needle is caused by the tension of the muscle temporarily, leave the needle in place for a while, and then withdraw it by rotating, or by massaging the skin near the point or by inserting another needle nearby to transfer the patient's attention.
If the stuck needle is caused by the changing of the position of the patient, the original posture should be resumed and then withdraw the needle.
Prevention:
Sensitive patients should be encouraged to release their tensions.
Avoid the muscle tendons during insertion.
Twirling with too large amplitude or in one direction only shall in no case be allowed.
In the process of manipulation, the posture of the patient should remain original.
Bent needle
Manifestations:
It is difficult to lift, thrust, rotate and withdraw the needle. At the same time, the patient feels pain.
Cause:
This may result from unskillful manipulation or too forceful manipulation, or the needle striking the hard tissue, or a sudden change of the patient's posture for different reasons, or from an improper management of the stuck needle.
Management:
When the needle is bent, lifting, thrusting, and rotating shall in no case be applied. The needle may be removed slowly and withdrawn by following the course of bend. In case the bent needle is caused by the change of the patient's posture, move him to his original position, relax the local muscle and then remove the needle. Never try to withdraw the needle with force.
Prevention:
Perfect insertion and gentle manipulation are required. The patient should have a proper and comfortable position. During the retaining period, change of the position is not allowed.
Broken needle
Cause:
This may arise from the poor quality of the needle or from too strong manipulation of the needle, from strong muscle spasm, or a sudden movement of the patient when the needle is in place, or from withdrawing a stuck needle.
Manifestations:
The needle body is broken during manipulation and the broken part is below the skin surface.
Management:
When it happens, the patient should be asked to keep calm to prevent the broken needle from going deeper into the body.
If the broken part protrudes from the skin, remove it with forceps or fingers.
If the broken part is at the same level of the skin, press the tissue around the site until the broken end is exposed, then remove it with forceps.
If it is completely under the skin, surgery should be resorted to.
Prevention:
To prevent accidents, careful inspection of the quality of the needle should be made prior to the treatment.
The needle body should not be inserted into the body completely, and a little part should be exposed outside the skin.
On needle insertion, if it is bent, the needle should be withdrawn immediately. Never try to insert a needle with too much force.
Properly Positioning the Patient
•Practitioners must be aware that the proper positioning of patients can reduce the likelihood of fainting or of causing sudden movements that can result in bent or stuck needles.
•Depending on the area to be needled, the practitioner should carefully consider both the comfort of the patient as well as the requirements for effective and safe insertion and manipulation of the needle. Both the patient and the practitioner should feel comfortable.
Hematoma
Cause:
This may result from injury of the blood vessels during insertion, or from absent pressing of the point after withdrawing the needle.
Manifestations:
Local swelling, distension and pain after withdrawal of the needle.
Management:
If the local swelling and pain are serious, apply local pressing, or light massage, or warming moxibustion to help disperse the hematoma.
Prevention:
Avoid injuring the blood vessels.
Needle stick injury
Needlestick injuries can lead to serious or fatal infections with bloodborne pathogens such as hepatitis B virus, hepatitis C virus, or HIV.
Any worker who may come in contact with needles is at risk. Whenever a needle or other sharp device is exposed, injuries can occur. Studies have shown that needlestick injuries are often associated with:
Not using safety-engineered sharps or using them incorrectly
Failing to dispose of used needles properly in puncture-resistant sharps containers
Prevent needlestick injuries
As a healthcare professional, you can protect yourself from a needlestick injury by:
Using devices with safety features
Planning for safe handling and disposal of needles before using them
Promptly disposing of used needles in conveniently placed and appropriate sharps disposal containers
Participating in training related to infection prevention
Getting a hepatitis B vaccination
If you experienced a needlestick injury or were exposed to the blood or other body fluid of a patient during your work, immediately follow these steps:
Wash needlesticks and cuts with soap and water
Report the incident to your supervisor
Immediately seek medical treatment
NEEDLES STRUCTURE
Size of needles:
Normal reaction of needles/De Qi
•After the insertion of the needles, in order to promote Qi Sensation, certain manipulating techniques are used.
•The basic manipulating techniques include lifting-thrusting techniques and rotating techniques.
1 . Lifting and thrusting techniques
•Method
•The needle pushed from the shallow region to the deep region is called thrusting and from the deep region to the shallow region is called lifting.
Such a repeated manipulation of the needle is known as lifting-thrusting techniques•When inserted into a certain depth, the needle is rotated forward and backward.
•Method
•When inserted into acupoint, the needle is rotation repeatedly forward and backward in the acupoint; This technique is called rotation.
•combined techniques rotating lifting- thrusting technique.
Precautions and Contraindications in Acupuncture Treatment
•1) It is advisable to apply few needles or to delay giving acupuncture treatment to the patients who are either hungry or overeaten, over fatigued or very weak.
•2) It is contraindicated to puncture points on the lower abdomen and lumbosacral region for women pregnant less than three months.
•After three months pregnancy it is contraindicated to needle the points on the upper and Lower abdomen and lumbosacral region.
Those points causing strong sensation such as Hegu (LI4), Quepen(ST12), Sanyinjiao (SP6), Kunlun (BL60), Jianjing (GB21).•4) Needling should avoid the blood vessels to prevent bleeding. Points of the chest and back should be carefully needled to avoid injury of the vital organs.
•Points are located close to the eyeball:
•Jing Ming (UB 1), Chengqi (ST 1)
•Points are deeper are close to spinal canal:
•Yamen(Du15), Fengfu (Du16)
•Caution: the spinal canal lies between 1.5 and 2 cun deep to the skin surface, varying according to body build. Deep perpendicular or superior oblique insertion is therefore strictly contraindicated.
•6) No needle on ST17 and Ren8
Risk Management
Working Environment
•Principles for Maintaining Safe Working Environments
•The premises used for the practice of Traditional Chinese Medicine and Acupuncture must be appropriate and suitable for the safe delivery of professional health care services.
•The premises must have hand-washing facilities.
•The treatment room must allow for ease of movement and efficient cleaning.
•The treatment room and work room procedures must reduce the risk of possible cross-contamination.
•If the practice is in a private home, the treatment room(s) must be entirely separate from any rooms used for living, sleeping, dining or other domestic purposes that are not compatible with the delivery of health services.
Site of Practice
•Acupuncture is practised in a variety of locations and settings including private clinics, hospitals, educational institutions, and multi-disciplinary health care settings.
• Each site must comply with the appropriate regulatory requirements and jurisdictional bylaws.
•The following are guidelines for the building and site of the practice.
•Check city bylaws to ensure the premises are zoned for the practice of TCM. Make sure that building code requirements are met.
Accessibility for disabled patients or employees:
•Wheelchair accessibility to a TCM practice may or may not be a requirement for your jurisdiction.
•Where required, patients and staff may need wheelchair access from the parking area to the office.
•Where required, patients and staff will need access to a restroom with a toilet stall equipped with a transfer bar, and with a sink that is at an accessible height.
Electrical/Heating/Ventilation/Air Conditioning Systems
•The electrical, heating, ventilation and air conditioning systems must be maintained in suitable working condition.
•Install smoke detectors and carbon monoxide detectors in compliance with local requirements. The use of moxa increases the importance of ongoing monitoring and preventative maintenance.
•If you use moxa in your treatment room(s), the ventilation system is of particular importance and must comply with local government requirements.
Air Quality Control:
•Moxa smoke may require the installation of special ventilation systems.
•Moxibustion treatments need to be carefully monitored as a potential fire hazard.
•Ventilation and air filtration systems are important considerations.
•Odors from disinfectants such as bleach and other solvents may cause allergic reactions or illness. Thoughtful selection of a disinfectant is an important risk management consideration.
Emergencies
•Clearly identify and post a list of phone numbers to call in the event of an emergency.
•These telephone numbers may need to include local hospital, local physician and community health centre, and the poison control centre.
Fire Emergency Plans
•Fire emergencies are a potential risk factor in the practice of TCM and acupuncture, especially in the use or moxa or fire-cupping therapies.
•Moxa extinguishers or containers with sand are critical when using moxa in the clinic.
•It is important that clinics and practices have a documented fire prevention plan that includes:
•information on location of fire alarms and fire extinguishers
•instructions on how to use the fire extinguisher
•how and where to evacuate the building
•guidelines to assist the evacuation of patients or staff with disabilities
•guidelines if people become trapped in the building due to the fire
•lists of flammable chemicals used or stored in the practice
Chemical Hazards and Labelling
•Disinfectants, bleach, alcohol are often used and stored in TCM practices. Most of these items can be safely stored and used as long as containers are properly labelled (with common or chemical name and any hazards clearly indicated) and used as directed.
•Precautions do need to be taken with chemicals that are transferred from bulk containers to other generic containers. These generic containers should be labelled with important precautions clearly indicated so that chemicals are not improperly used
First Aid and First Aid Certification
•Every TCM clinic should be equipped with a functional first aid kit.
•It is recommended that:
–registered practitioners hold a current Standard First Aid Certificate (or equivalent), or
–a person is present at the TCM clinic that holds a current Standard First Aid Certificate (or equivalent).
Management Patients and Their Records
Scope of Practice
•Practitioners of TCM offer an important and unique set of diagnostic and treatment skills to their patients.
•Like all health care professionals, TCM practitioners have a defined scope of practice.
•Unless training and applicable legislation allows, TCM practitioners must not make a medical diagnosis based on non-TCM modality/therapy.
Legal Concepts that are Relevant to the Practitioner-Patient Relationship
•Confidentiality: patients have the right to expect that their personal information will remain confidential
•Informed Consent
Consent
•Consent is the voluntary agreement given by a person to allow something to happen to them, and/or to be done to them, and/or to allow their participation in something.
•It is a fundamental right that every adult with capacity has the absolute right to determine what happens to their own body. This right is protected by law.
Valid consent has to meet the following:
•The patient must have the capacity to give their consent
•The consent must be given voluntarily
•The patient must have been given all the information they ask for in order to make their decision
If any one of the requirements outlined are not met then the consent may not be legally valid.
Can a child consent to treatment without guardian permission?
•Yes, according to the BC Infants Act, individuals under 19 years of age may consent to a medical treatment on their own as long as the health care provider is sure that the treatment is in the child’s best interest, and that the child understands the details of the treatment, including risks and benefits. It is up to the health care provider to assess and ensure the child’s understanding of the treatment. (HealthLinkBC)
There is no age in British Columbia when a child is considered capable of giving consent to health care.
•A health care provider can accept consent from a minor provided the health care provider is confident the minor understands the following:
•- the need for treatment
•- what is involved in the treatment
•- and the benefits and risks of having treatment
Treatment records
•TCM practitioners have a legal and ethical responsibility to keep patient information confidential.
•Practitioners must comply with all laws and regulations related to:
•• collection, use, disclosure, disposal and transfer of information;
•• processes that affect the quality and security of the information;
•• procedures that grant access to patient information.
Patient Record Keeping
Practitioners must comply with all laws and regulations related to:
• collection, use, disclosure, disposal and transfer of information;
• processes that affect the quality and security of the information;
• procedures that grant access to patient information.
Purpose of Record Keeping
•The patient ‘record’ includes all written, scanned, digital, photographic, radiological or other forms of documented.
•• patient health records
•• photographs, images, audio or video tapes
•• lab reports, imaging reports
•• e-mails, records of telephone conversations or text messages
The records can include the following:
•date and time of consultation
•patient’s name, address and contact number
•relevant medical and health history (allergies, prescription and non-prescription medications, past illnesses, pregnancies, etc.)
•relevant family and social history
•other treatments/therapies being used
•allergies with any allergy alerts noted.
•document adverse reactions to medications, foods, environmental substances, etc.
TCM consultation
•symptoms and signs (identified by the patient and detected and recognized by the practitioner using the four diagnostic methods of Inspection, Auscultation and Olfaction, Inquiry and Palpation)
•assessment findings including tongue and pulse observation/palpation
•TCM diagnosis (with clear evidence of thorough assessment of the patient's condition)
•treatment principles
•detailed treatment plan
•evidence of informed consent by patient. (e.g. a dated and signed “Consent to Treatment” form.)
•First visits
• chief complaint and other complaints
• health history
• allergy notation
• medications
• other therapies being utilized
• TCM diagnosis
• treatment principles
• treatment plan
• consent to treatment
• treatment performed
advice given
•Follow-up visits :
•progress notes, significant observations during appointment, and clinical findings
•explanations given to the patient
•discussions with the patient
•responses to previous treatment(s)
•documented patient's refusal to follow recommendations
•document missed appointments, cancellations, and late arrivals
•correspondence with the patient and others (e.g., blood tests, e-mail messages)
Records Management
Records must be handled and accessed in compliance with provincial personal information and protection of privacy acts.
• Patient records, or any other patient-related information, should not be sent by email.
• No individual should be permitted to access or use the practice’s computer(s), other than the TCM practitioner and authorised staff.
• If a practitioner leaves a practice, she or he must provide a safe arrangement for the transfer of those records.
What to include in acupuncture treatment records
•A copy of the informed written consent form
•Location of the needles using Name or Numbers
•If trigger point needling, the location of the needles should be described using muscle name and depth of needle. A diagram of needle application may sometimes be useful
•Left, right, or bilateral needle placement
•De Qi present or not present for each needle
•Has the needle been removed following treatment
•How the needle was stimulated and how many times
•Was a timer used and set
•The duration of needles
•Was the patient left alone during the acupuncture treatment,
•Any adverse events or comments
•The following can also be included:
•Depth of needle
•Angle of needle (such as oblique/perpendicular)
•Anything to reduce risk at risky points.
Retention and Storage
• Patient records have a life cycle, and must be retained for a stated number of years after the records are closed. Currently patient records must be retained for ten (10) years (or longer if the patient is under 18 years of age).
• The storage area for current records should prevent or limit damage to records (e.g., fire, water).
• Storage areas should be secure to restrict unlawful or unauthorized access.
• Electronic files are subject to technical failure (power failure, computer break-down). Backup files.
• Paper records may be placed in a secondary storage area (off-site) or scanned and saved electronically if they need to be retained but are no longer required for current use.
Disposal
•Disposal of patient records (following the end of treatment plus the recommended periods of retention) must be conducted in a managed and confidential way.
•Practitioners must comply with all regulations and requirements related to the legal disposal of patient records.
•Records must be destroyed or shredded in a secure environment.
•Keep a register of the records that have been destroyed.
Patient Privacy and Duties to Report
•As a health care provider, practitioners have a legal and professional duty to keep information about their patients private and confidential. However, there is a responsibility and a need to report particular events or conditions to the appropriate government or regulatory agency.
Patient Privacy and Duties to Report
•Requirements for mandatory reporting include, but are not limited to, the following:
•suspected child abuse and neglect
•suspected elder abuse
•certain communicable and reportable diseases (Health Protection and Promotion Act, report to Health Canada or equivalent provincial offices such as British Columbia Centre for Disease Control)
Relevant Regulations
•British Columbia’s Privacy Acts
•The Office of the Information and Privacy Commissioner (http://www.oipc.bc.ca) is independent from government and monitors and enforces British Columbia's Freedom of Information and Protection of Privacy Act (FIPPA) and Personal Information Protection Act (PIPA).
Safe Procedures and Processes: Herbology
不耐性是指用药者较难耐受一些被视为对中草药的正常反应的情况。虽然这种情况较少见于中草药的使用,有些病人还是会对一些属于适当的剂量调整表现出较少(或较多)的容忍性。
Intolerance means a lowered threshold to what is seen as normal reactions to the herbal medicine. Though not prevalent with herbal medications, some patients may have less (or more) tolerance requiring appropriate adjustments to the dosage.
副作用是在治疗的预期效果之外不希望出现的作用。虽然我们不想见到副作用,但对很多病人来说它们是不能避免的,因为乃是药物的可预期治疗作用(例如一些中草药可用作轻微的兴奋剂,因此或会造成失眠)。执业医师在开中草药处方前应先提醒病人可能有的副作用。
Side Effects are an undesirable effect which occurs in addition to the desired therapeutic effect of the medication. Side effects are unwanted, but are often unavoidable because they are predictable reactions to the therapeutic effects of the medication (e.g., some herbs contain compounds that can act as mild stimulants that may cause incidents of insomnia). Practitioners should advise their patients of any common side effects when prescribing herbal medications.
不良反应是未能预期亦不希望出现的用药后反应。发生不良反应的原因可以是很不同的(例如预料不到的配伍反应,错认中草药,不正确的诊断,不正确使用中草药,以及中草药受到污染)。
Adverse reactions are unexpected and undesirable effects that were not predicted or foreseen. The reasons for adverse reaction vary greatly (e.g., caused by unwanted interactions with pharmaceutical medications, incorrect identification of herb, incorrect diagnosis, incorrect use of herb, and contamination of herb).
过敏反应是免疫系统对一些无害物质(例如过敏原)的「过度反应」。过敏原可包括尘埃、食物、虫咬、动物皮毛等。一些中草药能在某些人身上产生类似食物过敏的反应 (如皮疹、反胃、消化不良)。
Allergic reactions are “overreactions” by a person’s immune system to normally harmless substance (i.e., allergen). Allergens include dust, food, insect bites, animal dander, etc. Some herbs can cause food allergy reactions in select individuals (rash, nausea, indigestion).
中草药治疗的禁忌
Herbal Remedies Contraindications and Precautions
在某些情况下应禁用或慎用中草药。这些情况包括:
Herbal medications are contraindicated or used with great caution in specific situations. These situations include:
• 病人正在服用多种药物
• patient is taking many different drugs
• 在使用中草药后病人的肝功能检查显示不正常
• after using herbs, liver-function test indicates abnormality
• 明显出现肝脏或肾脏功能衰竭的症状,或病人正在用药治疗肝脏或肾脏的问题(宜慎用中药)
• symptoms of liver or renal failure are clearly evident or patients are on medications to treat the condition (cautionary use may be appropriate)
• 病人曾经对中药发生过敏反应
• patient has suffered allergic reaction to herbs in the past
• 怀孕不足三个月的孕妇(慎用中药)
• during the first three months of pregnancy (used with great caution)
• 未满一岁的婴儿(慎用中药)
• babies under one year of age (used with great caution).
用药剂量及持续用药的时间
Dosage and Duration
执业医师都熟识传统的用药剂量,但有很多与用者有关的因素可以影响每个病人的最佳剂量。我们建议开始时使用相对低的剂量,随着治疗所需及病人对治疗的正面反应才逐渐增加。只有当情况是可预料及不复杂,或是要应付严重的症状时,才可在一开始就用到足量。
Traditional dosages are well known to practitioners, but the multitude of client-dependent variables can impact finding the optimum dosage for each individual patient. It is recommended that starting doses should be relatively low, allowing increases to occur as required by the treatment and supported by positive reactions to treatment. Starting with full dosage may be warranted if the situation is predictable and uncomplicated, or may be necessary if treating severe symptoms.
执业医师必须谨慎分析病人应该服用的中药剂量,需要仔细考虑的因素如下:
Dosage for patients must be carefully considered and analyzed by the practitioner, and be given thoughtful consideration to such factors as:
• 体重及体表面积
• body weight or body surface area
• 疾病的特征
• character of the illness condition
• 病人的整体健康
• general health of the patient
• 症状的严重性(急性或严重的情况宜用较大剂量,慢性或轻微的宜用较小剂量)
• severity of the symptoms (for acute or serious conditions, larger dosage may be appropriate, and for chronic or mild conditions, small dosages are preferred)
• 中药的剂型 (汤剂的剂量可较粉剂的剂量为大)
• form of the medication (herbs in the form of decoction may be given in a higher dosage than herbs given in powder form)
• 以前的用药经验
• previous experiences and use of herbs
• 病人的性别 (例如月经期间剂量应较小)
• gender of the patient (e.g., during menstrual period, dosage may be smaller)
• 气候及季节的变化(例如:温度的冷暖会影响皮肤毛孔的大小及出汗的多寡。燥湿的辛苦药较少用于干燥的季节)
• climate and seasonal differences (e.g., cold or hot temperatures can affect the skin pores and the amount of sweating, pungent and bitter herbs that dry damp are less used in dry climates)
• 病人的年龄 (年长或年幼的病人需要的剂量较小)
• age of the patient (older patients and children may require lower doses).
以下的指引有助于根据儿童的年龄决定用药剂量
The following guidelines can be referenced to assist in deciding on dosage for children based on age.:
1-6 个月 成人剂量的 1/18-1/10
• 1-6 months 1/18-1/10 of adult dose •
• 6-12 个月 成人剂量的 1/10-1/8
• 6-12 months 1/10-1/8 of adult dose
• 1-2 岁 成人剂量的 1/8-1/6
• 1-2 years 1/8-1/6 of adult dose
• 2-4 岁 成人剂量的 1/6-1/3
• 2-4 years 1/6-1/3 of adult dose
• 4-6 岁 成人剂量的 1/3-2/5
• 4-6 years 1/3-2/5 of adult dose
• 6-9 岁 成人剂量的 2/5-1/2
• 6-9 years 2/5-1/2 of adult dose
• 9-14 岁 成人剂量的 1/2-2/3
• 9-14 years 1/2-2/3 of adult dose
以下的指引有助于根据儿童、老人及瘦小成人的体重决定用药剂量:
The following guidelines can be referenced to assist in deciding on dosage based on weight for children, the elderly, and small adults.
• 30-40 磅 成人剂量的 20-27% • 30-40 lbs 20-27% of adult dose
• 40-50 磅 成人剂量的 27-33% • 40-50 lbs 27-33% of adult dose
• 50-60 磅 成人剂量的 33-40%• 50-60 lbs 33-40% of adult dose
• 60-70 磅 成人剂量的 40-47%• 60-70 lbs 40-47% of adult dose
• 70-80 磅 成人剂量的 47-53%• 70-80 lbs 47-53% of adult dose
• 80-100 磅 成人剂量的 53-67%• 80-100 lbs 53-67% of adult dose
• 100-120 磅 成人剂量的 67-80%• 100-120 lbs 67-80% of adult dose
• 120-150 磅 成人剂量的 80-100%• 120-150 lbs 80-100%
其他影响剂量的考虑因素包括:
Other considerations effecting dosage include:
• quality (e.g., herbs that are wild may require smaller doses than farmed herbs) •中药的质量(例如:野生中草药所需的剂量可比种植的中草药为少)
•中药的质地(花及叶类会需要较少的剂量;无毒的植物类中草药的用量通常是3-10 克;无毒的矿物类中药的用量通常是 10-30 克)
• texture(flowers and leaves may require smaller doses; non-toxic plant herbs commonly use 3-10 grams; non-toxic mineral herbs commonly use 10-30 grams)
•味道(例如:味道较强的中草药所需剂量会较小)
• flavour (e.g., stronger flavour may require small doses)
•毒性 (例如:具有毒性的中草药剂量要小心斟酌)
• toxicity (e.g., dosage of toxic herbs need cautioned consideration).
用于祛邪的中草药(利尿、通便、发汗)或行气活血的中草药应密切监控使用,并在病情开始改善后减少剂量或停用。
Herbs that eliminate a pathogen (promote urination, promote bowel movement, promote sweating) or increase blood/Qi movement, should be closely monitored and reduced in dosage or stopped when the condition improves.
有些中草药若使用剂量太大或服用太久,可能会引起病人的肾脏、肝脏、心脏、胃或神经系统的损害。以下是一些需要小心留意剂量和毒性的中草药:
Some herbs, if the dosage is too large, or if used for too long a time, may cause harm to the patient’s kidney, liver, heart, stomach, or nervous system. The list that follows includes some of the herbs that require careful attention to dosage and toxicity.
• Ma Huang, Ephedra, (Herba Ephedra) •麻黄
• Tian Hua Fen (Trichosanthes Root) Radix Trichosanthis •天花粉
• Fen Fang Ji (Stephania Root) Radix Stephaniae Tetandrae •汉防己
• Guang Fang Ji (Aristolochia Fanchi Root) Radix Aristolochiae Fangchi •广防己
• Guan Mu Tong (Aristolochia Manshuriensis Stem) Caulis Aristolochiae Manshuriensis•关木通
• Xi Xin, Asarum, (Herba Asari) •细辛
• Chuan Mu Tong (Clematis Armandi Stem)Caulis Clematidis Armandii•川木通
• Fu Zi (Aconitum) Radix Aconiti Lateralis Praeparata•附子
• Zao Jiao (or Zao Jia) (Gleditsia Fruit) Fructus Gleditsiae Sinensis•皂角(或皂荚 )
• Ting Li Zi (Lepidium Seed) Semen Descurainiae Seu Lepidii•葶苈子
• Bai Guo (Ginkgo Seed) Semen Ginko•白果
• Zhu Sha (Cinnabaris),Cinnabaris•朱砂
除了剂量以外,另一个重要考虑因素是处方中所开方剂的天数。
Aside from dosage, another important consideration is the number of days that the herbal medication may be prescribed.
处方的中药开多久会受多个因素影响,包括病人的状况,对使用中草药的经验及了解,症状有多严重等等。只有当执业医师对病人的病史及病情非常了解,并且很清楚了解配方可以长时间使用而没有不良作用,否则不要处方超过一星期的药物。
Duration of the prescription will be influenced by many factors including the patient’s condition, experience and understanding of herbal medications, and severity of symptoms. Prescriptions of longer than 1 week should be limited to situations where the practitioner is very familiar with patient’s history , condition, and is knowledgeable about the formula to know that it can be taken for a longer duration without risk of adverse effects.
中草药处方的一般要求
General Overall Requirement of Prescriptions
开处方的执业医师有责任在处方上提供完整、准确及详尽明了的数据。执业医师的行事准则是要确保处方数据清晰易明。
The prescribing practitioner has responsibility for the completeness, accuracy and comprehensiveness of information that is provided on the prescription. Clarity of prescription information is the guiding principle for practitioners.
在任何情况下,维持中草药处方的准确性和清晰度都是很重要的,尤其是当执业医师把处方交由他人去配制的时候。
The accuracy and clarity of the herbal prescription is important in all situations, but has increased importance when the prescribing practitioner uses an external dispensary to fill the prescription.
中医的中草药处方应该清晰可读,并包含一切所需数据以便处方被准确及安全地配制、使用和追踪。为了公众的安全,处方上的数据必须对其他医务人员(尤其是在急救时)有用且清楚能读。
TCM prescriptions should be legible and should contain all necessary information to allow the prescription to be accurately and safely dispensed, used, and tracked. For the safety of the public, the information in the prescription must be useful to and understandable by other health professionals, especially in emergency situations.
书写处方的语言要求
Language Requirements for Writing Prescriptions
在安省 :
In Ontario:
执业医师可先选择自己所喜欢的语言开处方,但他们必须预备另一份以官方语言(英文或法文)写成,令其他医务人员可以看得懂的记录。
A practitioner may choose their preferred language to initially record the prescription. However, they must include a record that other health professionals who use the official languages (English or French) will understand.
在纽芬兰省 :
执业医师可先选择自己所喜欢的语言开处方; 但是, 如果需要文件副本或报告时,则必须以英语提供。
In Newfoundland and Labrador:
A practitioner may choose their preferred language to initially record the
prescription. However, in the event that a file copy or a report is required, this must be provided in English.
在卑诗省 :
In British Columbia:
执业医师可先选择自己所喜欢的语言开处方; 但是, 如果需要文件副本或报告时,则必须以英语提供。
A practitioner may choose their preferred language to initially record the prescription. However, in the event that a file copy or a report is required, this must be provided in English.
书写处方的指导准则
Guidelines for Writing a Prescription
中药处方需包括以下数据:
The information required on a TCM herbal prescription includes:
• 执业医师的姓名、地址及联络电话
• name, address and contact telephone number of the practitioner
• 病人姓名(如有需要,加上父母或监护人的姓名 )
• name of the patient (and patient's parent or guardian where required)
• 处方内每种草药的名字
• name of each herb included in the prescription
• 草药的入药部分 (需要时宜确切说明避免混淆)
• part of the herb (when relevant to avoid confusion)
• 每种中药的剂量
• quantity of each herb
• 草药煎煮准备方法说明
• preparation instructions
• 药方剂数(包数) 及服用剂量
• number of packets or dosage as applicable
• 如何安全用药之说明
• instructions on how to use the medication as required for safe usage
书写中草药名的要求
Requirements for Naming Herbs
中药的名字通常开始会以中文或汉语拼音写出,但也应该包括其植物学或拉丁文药物名称。指导原则是要以有效及易懂的方法清晰表达,从而确保病人的安全。
In general, the name of the herb may initially be written in Chinese characters or in Chinese using Pinyin but it is expected that the botanical or Latinate medicinal name will also be provided. The guiding principle is that information be communicated in an effective and understandable way so that patient safety is best ensured.
中草药的剂量
Amount of Herb
处方中要清楚写明用药的剂量,单位可以是克或数量。为安全起见,计量单位要写清楚。
The amount of each herb should be specified on the prescription. This amount may be
stated in grams or in numbers as applicable. For safety, the measurement unit should be
specified clearly.
煎煮准备说明
Preparation Instructions
处方中需说明特殊的煎煮准备方法。如果有一种中草药需要区别于其他处方中的药物被处理、加工或使用(例如,何时入药煎煮、或浸泡等特殊要求),这些准备说明需要明确写在相关的中药旁边。
Special preparation instructions should be provided. If a herb is expected to be handled, treated or used differently from other herbs in the prescription (e.g., specific requirements when to add herb, steeping, etc.), these instructions should be provided clearly on the prescription adjacent to the relevant herb or herbs.
药方剂数(包数)
Number of Packets
处方中应该写明需要配制的小包或大包的数量。
The number of packets or bags to be dispensed should be evident on the prescription.
用药说明
处方中必须写明病人服用中药具体及特殊的说明(例如只在饭后服用,不可在服完另一种药物的一小时内服用,用药时不可饮用含咖啡因或酒精的饮品),或者另外将这些说明作为补充数据提供给病人。
Administration Instructions
Specific or special instructions for the patient on how to use the herbal medication (e.g., use only after meals, do not take within 1 hour of other medications, do not consume caffeinated drinks or alcohol while on this medication) should be provided to the patient on the prescription or alternatively on supplementary information provided to the patient.
警告
Warnings
处方上必须写明有关使用或存放中药的警告事项(例如,要放在儿童接触不到的地方)。
Warnings related to the use or storage of the TCM herbal medication should be clearly written on the prescription (e.g., keep out of reach of children)
颗粒状或粉末状中草药的额外要求:
Prescribing Granulated or Powdered Herbs
• 开浓缩单味中药的处方:要写明每种中药的准确重量、处方的总重量及服用剂量。
• Prescribing single herb extracts: specify the weight of each herb, the total
weight of the prescription and the dosage
• 开浓缩方剂的处方:要写明方剂的名称,重量及服用剂量。
• Prescribing a formula extract: specify the name of the formula, weight and dosage
• 开浓缩方剂加单味中药的处方:要写明方剂的重量,每种单味中药的重量,处方的总重量及服用剂量。
• Prescribing a formula with additional single extracts: specify the weight of the formula, the weight of each addition, the total weight of the prescription, and the dosage If relevant to ensure quality and safety, the manufacturer of the granulated or powdered herbs should be specified on the prescription.
向患者提供使用说明
Providing Instructions to Patients
执业医师应向病人(或其父母或监护人)给予清楚的说明(口头及书面),使病人可以安全地:
Clear instructions should be provided to the patient (or the patient's parent or guardian
as required) both verbally and in writing, to allow the patient to safely:
• 按照要求准备煎煮中草药(见下文);
• prepare the herbal medication as required (see below);
• 服用或使用中草药。
• consume or use the herbal medication.
执业医师应书面及口头交代清楚煎煮准备中草药的方法。说明书应该使用病人或代理人看得懂的语言。
The method of preparing an herbal decoction should be explained verbally and in writing. The instruction sheet should be in a language that is understandable to the patient or designate.
口头说明应为病人提供以下数据:
The verbal instructions should provide the patient with information related to:
• 处方的使用次数、时间及持续使用的天数;
• frequency, timing, and duration of the prescription;
• 关于使用中草药的可预期因素或正常反应(例如意想不到的味道、可能的气味、使用后常有的感觉)。
• expected factors or normal reactions related to the medication (e.g., unexpected taste, likely aroma, common sensations that may be experienced after use);
• 可能出现的不良反应,以及当不良反应发生时病人应如何做的具体指导。
• possible adverse reactions, and specific guidance on what the patient is to do if adverse effects are experienced;
• 何时停止使用处方药物(例如恶心,排便的显著变化,月经来临,或怀孕);
• when to stop taking the prescription (e.g., nausea, significant change in bowel movements, having a menstrual period, in the event of pregnancy);
• 在中药全部服完后该怎样做(例如:是否要重复使用,或若继续使用中药是否需要进一步诊治)。
• what to do after completion of the medication (e.g., what repeats may be utilized, or if further consultation may be required to continue medication).
如果病人需要到别处药房取药,应给予的说明需包括到哪里找药房以及告诉配药员怎样做。
If the patient is required to fill a prescription at a separate herbal dispensary, instructions should be given regarding how to find a dispensary and what to tell the dispenser to do.
Others
Moxa
Cupping
E-Stim
Bleeding
Gua Sha
Tui Na
Preventing Moxibustion Adverse Events
Preventing Cupping Adverse Events
Preventing EA (Electroacupuncture) Adverse Events
Preventing Acupuncture Bleeding Therapy Adverse Effects
Preventing Gua Sha Adverse Events
Preventing Tui Na Adverse Events
Preventing Moxibustion Adverse Events
Direct Methods
•Cone or rice grain-size moxa is placed over the area, and then lit with incense. The loose moxa cone is taken off before the embers touch the skin (non-scarring) or left to burn to the skin (scarring moxa), which is thought to stimulate the release of immunological mediators resulting in a prolonged healing reaction.
•Direct methods strongly penetrate the skin, used for deeper pathologies, such as abdominal, visceral, or joint problems.
Indirect Methods
•Moxibustion is commonly applied indirectly, without contacting the skin.
•Stick moxa supplies infrared heat to the skin around acupuncture points.
•Moxa Box, Raised over the skin, and with a built-in heat filter, the Moxa Box provides prolonged gentle heat to a broad area.
•Barriers of salt, garlic, ginger, or other herb that absorbs some of the heat and transports some healing substances from the herbs.
•Needle Moxa (Warming Needles) is put moxa bar on the tail of the needles, the moxa is then ignited from the side closest to the skin.
Burns
•Practitioners performing moxibustion should avoid causing burns (except when performing scarring moxibustion) and be aware that each person has a different tolerance to heat.
•It is important to be especially careful with persons who have conditions where sensitivity of local nerves may be diminished, such as in neural injury, diabetes mellitus, or pathology resulting in paralysis, because such persons are especially susceptible to burns.
•When using indirect moxa on the needle, be sure to protect the patient’s skin from any falling moxa or ashes.
•If using direct moxa or scarring techniques, it is suggested that the practitioner fully explain the technique to the patient and ask the patient to sign an informed, written consent form before using this technique.
Management for burning
•If a patient has been burned, infection is the primary concern. If the burn is a very small first-degree burn, current practice is to run cool water over the burn (never ice), and then apply sterile gauze secured to the skin with medical tape. burn creams may also be used.
•If a burn is severe, or if there is a concern with infection, refer the patient to a physician.
•Burns to the practitioner can also occur when proper precautions are not taken.
Safety Guidelines to Prevent Moxa Burns
• Take a careful patient history to identify neuropathies or other conditions that might limit a patient’s response to pain or the ability to sense heat.
• During moxa therapy the practitioner must remain in the room at all times.
• Avoid direct moxibustion on the face, or in other highly sensitive areas.
• Anticipate and shield a patient from falling ash when utilizing needle-top moxa.
• The practitioner should not attempt to multi-task during the application of moxa therapies.
• The practitioner should monitor the skin temperature and amount of heat generated by moxa, and not rely solely on patient feedback about heat sensations when utilizing any form
of moxibustion.
Rooms in which moxa is to be used should be equipped with water and a fire extinguisher.
Secondary Infection from Moxa Burns
•Infections associated with moxibustion are secondary adverse events related to burns.
•Burn prevention is critical. When more than 1 cm of skin is involved with a burn, practitioners need to assess the amount of skin damage and consider a referral to a medical practitioner for treatment.
Safety Guidelines to Prevent Secondary Infection from Moxa Burns
• Prevent moxa burns.
• Paying close attention to patient comfort and skin reactions during all treatments can prevent second degree burns, which are more likely to become infected due to depth of tissue damage.
• Follow Safety Guidelines for Hand Sanitation before and after treating any burns as potentially infectious material may be present.
• Wash all burns that do occur with cool running water immediately.
Measure and chart the diameter and location of any burns occurring as a result of moxa therapies.
Assess the amount of damage and refer to a western medical practitioner if needed.
Nausea or Other Adverse Reactions to Moxa Smoke
•Both practitioners and patients may have a reaction to inhaling moxa smoke.
•Such reactions are usually temporary and can be minimized by proper ventilation of the treatment room.
Safety Guidelines to Prevent Adverse Reactions to Moxa Smoke
Rooms in which moxibustion is performed must have proper ventilation.
Practitioners should utilize air filter units when performing moxibustion.
Consider other options for treatment instead of burning moxa for patients with a history of significant asthma or other reactions to smoke.
Other Heat Therapies
•Infrared and TDP (Teding Diancibo Pu) lamps are used by practitioners to warm the patient, or specific areas of a patient.
•TDP lamps consist of a heating element on an adjustable arm that may be placed above the patient and is used to warm the patient’s skin.
•The heating element in the lamp may reach a temperature that will burn a patient. It is imperative that a TDP lamp be monitored carefully when in use, and that unexpected movements of the heating element are prevented.
•Some lamps may slowly lower during the course of a treatment, resulting in a burn over the area being warmed.
Safety Guidelines for Heat Therapies
• Heat lamps should not be used on infants, children,
or sleeping or unconscious persons.
• Prevent water, moisture, liquids or metal objects from coming in contact with the lamp. Do NOT use this lamp in wet or moist environments.
• Do not use if any part of the lamp is cracked. Do not allow any part of the lamp to touch accessory equipment.
• When heat lamps are used on patients who have a reduced response to heat, the use of heat must be monitored at all times.
• Do not use heat lamps in close proximity to combustible materials (litter, paper, etc.).
• Take a careful patient history to identify diabetes, neuropathies or other conditions that might limit a patient’s response to pain or the ability to sense heat.
• Do not use oversensitive skin or persons having poor blood circulation.
• The practitioner should monitor the skin temperature and amount of heat generated by a heat lamp and not rely solely on patient feedback about heat sensations.
When patient information is unclear, request an opinion from a physician before using a heat lamp on the limbs of a patient with diabetic or other neuropathies.
Preventing Cupping Adverse Events
•There are three types of cupping, each with different safety profiles:
•fire cupping, suction cupping, and wet cupping (cupping after the use of a lancet for blood withdrawal).
•Cups used in the modern setting are made of glass, plastic, or silicone.
Fire Cupping
•Burns from fire cupping are reported in the literature; they are an avoidable medical error/adverse event.
•In this procedure, a ball of burning cotton or a lit alcohol swab is briefly placed inside a glass cup to heat the air inside, which then creates a partial vacuum as it cools.
•Glass cups are used. Typically, cups are left on the patient’s skin for 2-10 minutes, but may be left in place for up to 20 minutes, and leave a temporary reddish mark that is a result of cutaneous petechiae and ecchymosis.
•Unintentional expression of blood or fluid into cups may occur as a result of fire cupping when the skin is not intact, or from previous needling, or other local skin pathologies
Suction Cupping
•Suction cupping involves the use of plastic or silicone cups with valves at the top that attach to hand pumps; the pumps create suction by removing a quantity of air after the cups have been placed on the skin.
•Typically cups are on for 2-10 minutes, but may be left in place up to 20 minutes and leave a temporary reddish mark that is a result of cutaneous petechiae and ecchymosis. Unintentional expression of blood or fluid into cups may occur as a result of suction cupping when the skin is not intact, or from previous needling, local pimples or other local skin pathologies.
Wet Cupping
•In this procedure, the skin is punctured with a lancet or sterile needles, such as those used for plum blossom tapping, before the cups are applied.
•Wet cupping may be done with either suction cups or fire cups. The technique, which draws out blood, carries obvious risk of exposure to and transfer of bloodborne pathogens.
Cupping Adverse Events
•Skin Reactions
•Some reactions to cupping may be part of the therapeutic process but be interpreted by other practitioners or observers as “harms” or even child abuse.
•These include swelling, petechiae, ecchymosis, and persistent hyperpigmentation. Typically these reactions resolve in a few days to 2 weeks.
Infection
Infection has been reported as an adverse event of cupping.
Preventing Cupping Adverse Events Burns
•Burns are associated with fire cupping only.
Safety Guidelines to Avoid Fire Cupping Burns
Take a careful patient history to identify diabetes, neuropathies, or other conditions that might limit a patient’s response to pain or the ability to sense heat. Assess this patient carefully when utilizing fire cupping.
• Remove the burning material before applying the cup to the patient’s skin.
• Never retain the burning material inside the cup when the cup is placed onto the skin.
Infections
•The same procedures are recommended as in preparation for acupuncture:
•follow Safety Guidelines for Establishing and Maintaining a Clean Field, for Hand Sanitation and Skin Preparation.
•Wear personal protective equipment (PPE) (gloves and protective eyewear) when blood may be present, if performing wet cupping, or cupping after needling.
•Avoid cupping over lesions, rashes, injuries or breaks in skin barrier.
Safety Guidelines to Prevent Cupping-Related Infections
• Follow Standard Precautions.
• Follow Safety Guidelines for Establishing and Maintaining a Clean Field.
• Follow Safety Guidelines for Hand Sanitation.
• Cupping should be applied on clear skin only. Do not apply cups over any active lesions.
• When performing wet cupping, use PPE such as gloves.
• Do not cupping over active herpes zoster lesions.
Cleaning and Disinfecting Cups
•If cupping is performed on intact skin only, cups would be treated as noncritical reusable medical devices that need to be cleaned with soap and water, and then disinfected in an appropriate intermediate-level disinfectant in accordance with label instructions. Cups should be rinsed and dried with clean towels, and placed in a clean, closed container. Whenever cups have been or will be placed over nonintact skin, they need to be treated as semi-critical reusable devices. In these cases, the cups need to be cleaned with soap and water to remove the lubricant (if used) and biological material before disinfecting with a high-level disinfectant in accordance with label instructions. If the cups will be used on nonintact skin, they should rinsed with sterile, distilled or filtered water. After rinsing, dry and store in a manner that prevents recontamination.
Safety Guidelines for Cup Disinfection
• Clean all cups of all lubricants and biological material using soap and water before disinfecting.
• Disinfect all cups using an appropriate FDA-cleared intermediate to high-level disinfecting solution in accordance with label instructions.
• Use appropriate PPE while cleaning and disinfecting cups
Disinfect all cups using a high-level disinfecting solution following package directions for semi-critical devices.
Use disposable cups for wet cupping and dispose of used wet cups in the biohazard trash.
Extensive Bruising & Other Skin Lesions
•While petechiae and ecchymosis are expected after cupping, extensive bruising can result from either applying the cups for too long or with too strong of a vacuum.
•Extensive bruising is a risk with patients who have bleeding disorders.
Safety Guidelines for Preventing Cupping Skin Lesions
Take a careful patient history to: • Screen patients for the potential for reactive skin lesions such as keloid scarring (previous keloids) and Köebner phenomenon (history of psoriasis). • Screen for bleeding disorders including hemophilia and Von Willebrand’s disease.
Limit the retention time of cups to that of the physical tolerance of the patient, and the intended appearance of transitory therapeutic petechiae and ecchymosis. Observe the process of cupping to avoid bullae formation.
Safety Guidelines for Needle Cupping
• Apply over needles that are inserted obliquely in the thoracic region to avoid pneumothorax
Safety Guidelines to Prevent Cupping Adverse Events
• Cupping should not be applied 48 hours before or 24 hours after chemotherapy treatment.
Preventing EA (Electroacupuncture) Adverse Events
Electrical Stimulation
General Principles
•Developed as a way to provide continuous stimulation to acupuncture points without the use of manual manipulation.
•Electrical acupuncture, or “e-stim”, is beneficial for chronic pain, muscle spasm, and paralysis.
Indications
• Chronic pain
• Muscle spasms
• Paralysis
Cautions
• Do not use on patients with pacemakers
• Do not cross directly over the heart or spine (i.e., Ren17-Sp21, or from left UB23 to right UB23)
• Avoid the neck region
• Do not use over known malignancy or tumours
• Adverse effects include: lethargy, dizziness, aggravation of symptoms (esp. pain)
• May induce labour during pregnancy
Attention
•Ensure the machine is turned off prior to attaching the clips to the needles to avoid an inadvertent electric shock.
• Gradually increase the intensity until either heaviness, numbness, or radiating symptoms are reported by the patient or slight muscle twitches can be seen at the surface.
•The standard length of stimulation with electric current is between 10-30 minutes.
•Electroacupuncture (EA) is used by many acupuncturists as an adjunctive therapy for conditions associated with qi, blood, or phlegm stagnation.
•Prior to the advent of modern electrical appliances, hand manipulation of the needles was used to strongly stimulate qi flow.
•EA is used to replace prolonged needle manipulation for conditions in which there is an accumulation of qi, such as in chronic pain syndromes, or in cases where the qi is difficult to stimulate.
Preventing EA Adverse Events
•Certain types of metal should be avoided for use in electroacupuncture such as silver needles, which are softer than stainless steel and may electrolyze in the body very quickly resulting in a toxic reaction.
•Stainless steel needles are safe to use with electrical stimulation.
Safety Guidelines for Preventing EA Adverse Events
• Avoid applying EA near the brainstem.
• Avoid crossing the spine with the electrical stimulus.
• Consult with the primary physician of any patient with a history of a seizure disorder before instituting EA.
• Electrical stimulation should not be applied from one side of the chest across to the other side of the chest (front to back or side to side) in the region of the heart. A circuit should not cross the midsagittal line of the patient.
Injuries Due to Muscle Contraction
•Excessive electrical current can cause significant muscle spasms which may then cause local tissue or bone damage. EA should never be employed in such a manner as to cause continuous, strong muscle spasms.
Safety Guidelines for Preventing Excessive Muscle Contraction During EA
• EA should not be used on infants, children, sleeping or unconscious persons.
• Turn up the amperage of the EA machine slowly and ask for constant feedback from the patient about sensation of pain; electrical stimulation
should be turned off before needles are removed from the body.
• The level of stimulus should never approach the sensation of pain.
• Apply EA in such a manner as to avoid muscle contraction except in those
cases where muscle stimulation is the expected outcome.
Interference with a Cardiac Pacemaker
•Electrical stimulation can interfere with the functioning of pacemakers.
•Patient histories must be specific for ruling out that your patient has a pacemaker.
Safety Guidelines for Preventing Interference with a Cardiac Pacemaker During EA
Avoid use of EA on the trunk of anyone with an implanted cardiac device, including a pacemaker.
EA should not be used on any part of the body of patients with pacemakers or other electronic implants.
Preventing Acupuncture Bleeding Therapy Adverse Effects
The nine ancient acupuncture needles
1. Needles
•The three-edged needle is developed from the lance needle of the Nine Needles created in the ancient times.
•The needle is shaped in a round handle, a triangular head and a sharp tip
2. Indications
•The three-edged needle functions to promote the smooth flow of qi and blood in meridians, dispel blood stasis and eliminate the heat.
•It is advisable to treat blockage of the meridians, blood stasis, excess syndrome and heat syndrome, such as high fever, loss of consciousness, sore throat, local congestion or swelling.
3. Precautions
1) Sterilize the needles and the local area to be treated is applied to prevent infection.
2) Avoid injuring the deep large arteries.
3) Caution with hemorrhagic patients or people taking blood thinner medications.
Acupuncture Bleeding Therapy
•Therapeutic blood withdrawal is referred to in the literature as “bloodletting” ( “Puncture of a vein to draw blood for therapeutic purpose”), “pricking,” “bleeding,” or the “use of the three-edge needle.”
Bleeding Therapy
•Bleeding is an original form of medicine found in every early culture.
•(1) There is evidence, in chronological iterations of the Nei Jing Su Wen, that acupuncture itself evolved from bloodletting.
•(2) Bleeding is done removing drops of blood until its quality and color lightens. It is possible that even minor bleeding or hematomas at an acupuncture needle site might be considered part of the therapy.
•(3) The bleeding of specific points is an acupuncture therapy that continues to be used to treat, for instance, fevers, pain, or itching.
Preventing Acupuncture Bleeding Therapy Adverse Effects
•Once the lancet has been used, discard it in a sharps container immediately. Single-use spring loaded lancets can be used and discarded but they are more difficult to control in terms of specific point location and depth.
•As with acupuncture needling, bleeding carries a risk of infection, local pain, bleeding, and bruising; safety guidelines for preventing these adverse events are listed in the previous acupuncture section. This includes screening patients for medications or supplements that may thin the blood, such as anticoagulant and antiplatelet therapies and pain medications such as NSAIDS.
Safety Guidelines for Acupuncture Bleeding Therapy
• Follow Safety Guidelines for Hand Sanitation.
• Follow Safety Guidelines for Skin Preparation.
• Practitioners must take a thorough history including bleeding disorders, medication, and supplement history before using bleeding techniques.
• Personal protective equipment (PPE) is required. Wear gloves at all times as blood will be present.
• Inspect area to be treated for evidence of inflammation, lesion, infection, or a break in the skin barrier. Do not bleed in these areas.
• Lancing devices must be limited in use to a single patient.
• Lancets cannot be reused after a single insertion; not on another site.
• Lancets should be used only once and then discarded in a sharps container.
• Utilize eye protection, such as goggles, when performing bleeding techniques.
• Utilize lancets engineered to retract after use to significantly reduce the risk of needlestick injuries.
Preventing Gua Sha Adverse Events
What is Gua Sha?
•Skin scraping therapy
•Gua – (to scrape or rub)
•Sha – (the reddish raised petechiae -subcutaneous hemorrhage- that appear under the skin after application).
Gua Sha Tools
Clinical Applications
• Strongly Moves Qi and Reduce Blood stasis --
Musculoskeletal pain
• Alleviates fever due to external pathogenic factors -- Acute respiratory illness (common cold, flu, bronchitis, asthma)
Contraindications
•Avoid local treatment to acute inflammatory injuries.
•Do not scrape over sun burn, rash, lesions, or previous sha that has yet to heal.
•Avoid the sacrum and abdomen of pregnant patients.
Diagnosis of Sha
•The colour of petechiae is useful in diagnosis:
•sha that takes a long time to appear during treatment, or is a pale red indicates Blood deficiency;
•dark red means heat is present; purple indicates blood stasis.
•Sha is also useful in prognosis: the longer it takes for the petechiae to heal, the more chronic the condition and deficient the patient.
Safety Guidelines for Gua Sha
• Follow Safety Guidelines for Establishing a Clean Field.
• Follow Safety Guidelines for Hand Sanitation.
• Take a careful patient history to identify if the patient is taking medications that thin the blood,
• Gua sha should not be applied 48 hours before or 24 hours after chemotherapy treatment.
• When reusing gua sha tools, select only tools that are disposable or that have been properly disinfected.
• Gua sha should be applied on clear skin only. Do not apply gua sha over any active rash, lesion, inflammation, infection, or break in the skin barrier.
• Do not gua sha over swelling or recent trauma, including over burns or sunburns.
Any application of gua sha for children should be done in the presence of a parent or assigned guardian.
Explain the therapeutic intention of gua sha as well as with a handout on gua sha.
Disinfection of Gua Sha Devices
•When used on intact skin only, gua sha devices would qualify as non-critical reusable medical devices.
•As non-critical devices, reusable gua sha spoons and other devices would be cleaned of lubricants and biological material with soap and water, and then disinfected in an appropriate intermediatelevel disinfectant, in accordance with the label instruction. They should be rinsed and dried with clean towels, and placed in a clean, closed container.
•Whenever gua sha has been or will be used over nonintact skin, the tools need to be treated as semi-critical reusable devices.
•In these cases, the gua sha tools need to be cleaned and scrubbed with soap and water to remove the lubricant (if used) and biological material before disinfecting with a high-level disinfectant in accordance with the label instruction.
• If the tools will be used on nonintact skin, they should be rinsed with sterile, distilled, or filtered water. After rinsing, dry and store in a manner that prevents recontamination.
Safety Guidelines for Disinfection of Gua Sha Tools
• Clean all tools of all lubricants and biological material using soap and water before disinfecting.
• Disinfect all tools using an appropriate intermediate- to high-level disinfecting solution, in accordance with label instructions.
• Use appropriate PPE while cleaning and disinfecting gua sha tools.
Disinfect all tools using a high-level disinfecting solution for semi-critical devices, in accordance with label instructions.
Preventing Tui Na Adverse Events
What is Tui Na?
•Tui na is a manual therapy which uses Chinese massage and manipulation techniques.
• Tui na is used in China for a variety of pain and musculoskeletal syndromes.
Contraindications to tui na
• Wounds
• Diseases with hemorrhagic tendencies
• Dematoses
• Acute infectious diseases
• Diseases of the brain, heart, liver, kidney, and other viscera
• Menstruation and pregnancy
• Abscesses, tumors.
Preventing Tui Na Adverse Events
•General clean techniques and vigilance to avoid using tui na where there are active skin infections, open wounds, fractures, or acute trauma, and consultation with other physicians when using the technique after surgery or during treatments for cancer should be sufficient to maintain the safety record of this procedure.
Safety Guidelines for Tui Na
• Follow Safety Guidelines for Hand Sanitation.
• Never apply tui na to areas that have dermatitis, active lesions or
other wounds.
Provide appropriate pressure and adjust tui na treatments according to age, location, body constitution and medical history.