CPOL35 Anaphylaxis Policy by Provide Community

Anaphylaxis Policy

Version: V5

Ratified By: Quality & Safety Committee

Date ratified: 27/12/2018

Job Title of Author: Head of Quality and Safety

Reviewed by Sub Group or Expert Group: Clinical Reference Group

Equality Impact Assessed by: Head of Quality and Safety

1. Aim

The aim of this policy is to provide guidance for the primary management of anaphylaxis in a community setting.

2. Background

Anaphylaxis is a rare reaction, the severity of the reaction, should it occur, makes it essential that a practitioner is aware of the necessary steps required to recognise and treat it if necessary.

3. Scope

Any setting where a Provide employee will be expected to deal with an anaphylactic reaction during their usual clinical role.

4. Definitions

Practitioner

A general term used to describe a registered medical practitioner, nurse, pharmacist or other healthcare professional who may perform authorised roles involving medicines.

Anaphylaxis

No universally accepted definition exists because anaphylaxis comprises a variety of features, but a good working definition is “anaphylaxis is a severe, life threatening, generalised or systemic hypersensitivity reaction” (Resuscitation Council UK 2008).

An anaphylactic reaction is an acute, life threatening reaction caused by the body’s reaction to an abnormal antigen/antibody this can include any drugs or other substance including Latex, foods and insect stings. An anaphylactic reaction is characterised by rapidly developing life threatening airway and/or breathing difficulty (which may be due to laryngeal oedema or asthma with shortness of breath, wheeze, tight chest, bronchospasm) and/or circulation problems usually associated with skin and mucosal changes (which can present as fainting, collapse or loss of consciousness).

5. Indications for Use

In the event of any person suffering an anaphylactic reaction, this policy must be followed.

6. Exceptions

Medicines legislation restricts the administration of injectable medicines. Unless selfadministered, they may only be administered by or in accordance with the instructions of an Independent Prescriber (e.g., by a nurse). However, in the case of adrenaline there is an exemption to this restriction which means:

• Any person can administer adrenaline that is prescribed for a specific person

• Any person can administer adrenaline to an unknown person in a lifesaving situation

• If the person administering the adrenaline is a registered practitioner then they must work in accordance with their governing body standards, e.g. NMC and local guidelines, or PGD specific to the work and locality (this must state the competency in the recognition and management of anaphylaxis reactions)

7. Responsibilities of Staff

Every practitioner who comes into direct contact with patients should be able to competently:

• Recognise the signs and symptoms of an anaphylactic reaction

• Instigate early supportive management using the Resuscitation Council Guidelines (UK) and Organisations Resuscitation Policy and in line with training provided by Provide.

• Individual Practitioners need to make themselves aware of any relevant PGDs, e.g. Chlorphenamine and Hydrocortisone, and ensure competency in the application of any use of these in the management of anaphylaxis (see Appendix 1). Practitioners must complete training approved by Provide.

• All clinical staff who administers medication should have initial training and regular updates in dealing with anaphylactic reactions bringing to the attention of their manager any training needs they identify with regard to this policy. Please refer to the organisations training matrix for guidance of training requirements and frequency of training relevant to specific staff groups.

• Each practitioner undertaking anaphylaxis training will be made aware of this policy and where to locate it and must comply with its contents.

8. Availability and Storage of Drugs

A practitioner, where applicable, must ensure that he/she is aware of the location of adrenaline injection to be used in an emergency and that it is readily available. Adrenaline has a limited shelf life. It is the responsibility of all practitioners to ensure that the adrenaline injection available is in-date. Processes should be in place for regular expiry checks and appropriate re-ordering. All practitioners need to be mindful of the MMPOL30 Medicine Management Policy in relation to storage.

9. Guidelines for the

Management of Anaphylaxis

Recognition

Allergic reactions may be local or systemic or both. Local reactions, such as those following an insect bite, are usually swelling, redness and itching. As a local reaction becomes systemic, the patient may initially complain of any of the following:

• A red rash and itching

• Feeling hot

• Anxiety

• Weakness and giddiness

• Breathing difficulties

These signs and symptoms are not entirely specific for an anaphylactic reaction. However, certain combinations of signs and symptoms make the diagnosis of an anaphylactic reaction more likely.

Anaphylaxis is likely when all of the following 3 criteria are met

• Sudden onset and rapid progression of symptoms

• Life-threatening airway and/or breathing and/or circulation problems

• Skin and/or mucosal changes (flushing, urticaria, angioedema)

The following supports the diagnosis:

Exposure to a known allergen for the patient. Remember skin or mucosal changes alone are not a sign of an anaphylactic reaction Skin and mucosal changes can be subtle or absent in up to 20% of reactions (some patients can have only a decrease in blood pressure, i.e. circulation problem) There can also be gastrointestinal symptoms (e.g. vomiting, abdominal pain, incontinence)

(Resuscitation Council UK 2008, annotated 2012)

All practitioners involved in delivering immunisations should be able to distinguish an anaphylactic reaction from fainting (syncope) and panic attacks.

Consent

Refer to QSPOL07 - Consent to Examination or Treatment Policy for guidance around patient consent

NB: a patient or client who becomes temporarily unable to consent due to, for example, being unconscious, may receive treatment necessary to preserve life. In such cases the law allows treatment to be provided without a patient’s or client’s consent as long as it is in the best interests of the patient or client and not purely for the convenience of the clinician

Treatment

The recommendations for treatment of Anaphylaxis by practitioners as advocated by National Guidance are summarised in the algorithm in Appendix 1.

10.Emergency Treatment of Anaphylactic Reactions

Patients having an anaphylactic reaction in any setting should expect the following as a minimum:

• Recognition that they are seriously unwell

• An early call for help

• Initial assessment and treatments based on an ABCDE approach

• Adrenaline therapy if indicated

• Investigation and follow up by an allergy specialist

As the diagnosis of anaphylaxis is not always obvious, all those who treat anaphylaxis must have a systematic approach to the sick patient. In general treatment of anaphylactic reaction should be based on general life support principles; the clinical signs of critical illness are similar whatever the underlying process because they reflect failing respiratory, cardiovascular and neurological systems.

Use an ‘ABCDE’ approach (Appendix 1) to recognise and treat an anaphylactic reaction. Treat life threatening problems as you find them. The principles of treatment are the same for all age groups. Call for immediate assistance – phone 999 for an ambulance stating that an anaphylactic reaction is occurring and request a paramedic crew. NEVER leave the patient alone unless there are specific risks that would endanger yourself and others, i.e. hazardous substances or electrocution risks

Specific Treatment of Anaphylactic Reaction

The specific treatment of an anaphylactic reaction depends on:

• Location

• Training and skills of rescuers

• Number of responders

• Equipment and drugs available

Treatment in a Community Setting

Treating a patient with anaphylaxis in the community (including the community hospital wards) will not be the same as in an acute hospital. Out of an acute setting, an ambulance must be called early and the patient transported to an emergency department.

All clinical staff should be able to call for help and initiate treatment for a patient with an anaphylactic reaction. The single responder must always ensure that help is coming. If there are several rescuers, several actions can be undertaken simultaneously.

Resuscitation equipment and drugs to help with the rapid resuscitation of a patient with an anaphylactic reaction must be immediately available in Community Hospital Wards, ARU, Outpatient departments, and community clinics, if applicable, clinical staff should be

familiar with the equipment and drugs they have available and should check them regularly.

Patient Positioning

All patients should be placed in a comfortable position. The following factors should be considered:

• Patients with airway and breathing problems may prefer to sit up as this will make breathing easier

• Lying flat with or without leg elevation is helpful for patients with a low blood pressure (circulation problems). If the patient feels faint do not sit or stand them up as this can cause cardiac arrest

• Patients who are breathing and unconscious should be placed on their side (recovery position)

• Pregnant patients should lie on their left side to prevent Caval Compression

Removal of Trigger

• Stop any drug suspected of causing an anaphylactic reaction

• Remove the stinger after a bee sting. Early removal is more important than the method of removal

• After food induced anaphylaxis, attempts to make the patient vomit are not recommended

• Removing the trigger for an anaphylactic reaction is not always possible.

Do not delay definitive treatment if removing the trigger is not feasible.

11.Adrenaline IM Doses

Adrenaline is the most important drug for the treatment of an anaphylactic reaction.

The intramuscular (IM) route is the best for most individuals who have to give adrenaline to treat an anaphylactic reaction. The best site for IM injections is the anterolateral aspect of the middle third of the thigh. Avoid using any site that is inflamed or swollen.

Adrenaline IM Dose (Adults)

0.5 mg IM (=500 micrograms = 0.5 mL of 1:1000) adrenaline – repeat after 5 minutes if no better

Adrenaline IM Dose (Children)

IM doses of 1:1000 adrenaline specific to child age (repeat after 5 minutes if no better)

These doses are to be repeated several times if necessary at 5 minute intervals according to blood pressure, pulse and respiratory function

Adrenaline IV to be given only by experienced specialists in a setting where patients can be carefully monitored

Titrate: Adult 50 micrograms (0.5ml of the dilute 1 in 10,000 adrenaline injection. Children 1 microgram/kg (0.01ml/kg of dilute 1 in 10,000 adrenaline by slow intravenous injection

Adrenaline Auto-Injectors

Auto-injectors are often given to patients at risk of anaphylaxis for their own use and where this is the case patients, their families or carers will have been trained to use them

The most appropriate dose for an auto-injector will have been prescribed for individual patients by allergy specialists. If adrenaline auto-injector is the only available adrenaline preparation when treating anaphylaxis healthcare providers should use it.

If practitioners are issued with auto-injectors for management of anaphylactic situations they must ensure they are available and in the required doses, in date and appropriately stored at the beginning of each shift.

12.Cardio-Respiratory Arrest following an Anaphylactic Reaction

Start cardio-pulmonary resuscitation (CPR) immediately and follow current guidelines as detailed in CPOL15 Cardiopulmonary Resuscitation (CPR) Adults and Children V6.

13.Prevention of Anaphylactic Shock

Practitioners have a responsibility to ensure that there is plenty of time available to undertake a proper assessment of the patient, including a comprehensive history of drug reactions and other contraindications:

• The patient should ALWAYS be asked whether he/she has had any previous reactions (drug or otherwise) and the medical notes checked for any relevant information

• The practitioner should identify the following risk factors prior to administering the drug

- Any adverse reactions including convulsions, following previous drug administration

- Any previous allergic condition such as hay fever, asthma, urticaria, eczema

This is to identify possible atopic individuals. If there is any doubt concerning the advisability of any procedure, it should be deferred until a doctor’s advice has been obtained.

• Recipients of any vaccine should be observed for immediate adverse drug reaction

• Document all relevant information in the patient’s notes during assessment

• With any treatment involving the administration of medicine/vaccine there is the potential of adverse side effects. All patients should be informed of these side effects and guided on where to seek further advice if needed. For example from their GP or hospital consultant.

Following any emergency, QSPOL01 - Incident Reporting & Management Policy V8 must be followed and the relevant forms completed.

14.References

The policy and clinical guidelines are based upon recommendations by the Resuscitation Council (UK) Emergency Treatment of Anaphylactic Reactions Guidelines for Health Care Providers. Resuscitation Council (UK) January 2008 updated. www.resus.org.uk

Royal Pharmaceutical Society of Great Britain - https://www.rpharms.com

British National Formulary BNF - https://bnf.nice.org.uk/drug/adrenalineepinephrine

Appendix 1 – Anaphylaxis Algorithm

EQUALITY IMPACT ASSESSMENT

TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Anaphylaxis Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Project/Policy Manager:

Head of Quality & Safety Date: September 2018

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Equality Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Equality Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Equality Neutral

Guidelines: Things to consider

• Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

• The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

• Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

• Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

• Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

• It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

• It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/A

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/A

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/A

Guidelines: Things to consider

• An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

• It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

• The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

• If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.efa.org.uk – Employers forum on age

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’