Life saved…What now? Lessons learned about Anaphylaxis Discharge Management from an Emergency Department (ED)

BATCHELOR Melanie 1, HUDSON Pam 2,

1 Allergy Clinical Nurse Flinders Medical Centre, Bedford Park, Southern Adelaide Local Health Network (SALHN).South Australia 5048. melanie.batchelor@sa.gov.au
2 Allergy Clinical Practice Consultant Nurse Flinders Medical Centre, Bedford Park, Southern Adelaide Local Health Network (SALHN). South Australia 5048. pam.hudson@sa.gov.au

Background: Acute, life-threatening systemic allergic reactions (anaphylaxis) are increasing with 1.6% of the population having a history of anaphylaxis1.

For patients and their carers the threat of further episodes can lead to significant lifestyle restrictions and psychological consequences.

Death from anaphylaxis is thought to be rare, however there is evidence that anaphylaxis fatality rates in Australia have increased over the last 16 years. This is in contrast with UK and USA – based studies that describe overall lower and static anaphylaxis fatality rates 2

Despite increased awareness of the risks associated with anaphylaxis, up to 50% of patients are discharged from Southern Adelaide Local Health Network (SALHN) ED’s without best practice anaphylaxis discharge management. Anecdotal evidence suggests this is not isolated to SALHN ED’s.

Since 2008, the SALHN Allergy/Clinical Immunology Service nurses have undertaken multiple clinical practice improvement (CPI) projects to understand and ultimately improve compliance with SALHN Anaphylaxis Management Guidelines.

Method: Anaphylaxis (grade 2 and 3) 3 presentations between 2008-2014 were identified using ICD- 10 coding for anaphylaxis and patient referral software (RFL).

Mixed methodology was applied to obtain information about the standard of care being delivered and included:

  • Facilitated incident monitoring
  • ED nurse questionnaire prior to “anaphylaxis blitz” education sessions
  • Patient/carer phone interview
  • Ad hoc clinical audits
  • Retrospective medical record review

Results: Clinical auditing of anaphylaxis discharge management identified:

  • 40% of patients received an Anaphylaxis Action Plan and EpiPen prior to discharge with appropriate instruction and education.
  • 40% of patients have their allergies recorded on case note alert systems.
  • 50% of patients are not referred for Allergy Specialist follow up

The content of anaphylaxis education in existing ED Nurses Clinical Development Pathway was explored in conjunction with senior ED nurses.

ED Nurses knowledge of anaphylaxis was accessed through a questionnaire (n= 40)

  • 75% could list the clinical features of anaphylaxis.
  • 33% could list the first-line treatment for anaphylaxis.
  • 73% recognised the need to observe patients for a biphasic reaction.
  • 17% could list the patient discharge management requirements.

To assist in addressing these gaps, additional clinical resources and tools were developed to assist staff to comply with anaphylaxis management guidelines.

These include:

  • Specific Allergy Specialty referral form inclusive of Anaphylaxis Discharge Checklist sticker to enable direct ED referral
  • Anaphylaxis Discharge Checklist poster and patient instruction aids
  • Consumer follow-up after anaphylaxis information
  • Facilitation of an ED nurses “Anaphylaxis Blitz”
  • Identifying and up skilling of Anaphylaxis Nurse Champions and Pharmacy staff.
  • Developing SALHN Intranet- based anaphylaxis clinical resource page to assist  medical, nursing and pharmacy staff with acute and discharge anaphylaxis management

Conclusion: Embedding anaphylaxis discharge education as a competency amongst ED nursing staff will assist in reducing the omission of care to this vulnerable patient cohort.  ED medical, nursing and pharmacy staff require easy access to clinical resources to provide evidenced base care and appropriate discharge planning to patients presenting with anaphylaxis.

  1. Pumphries RS. Lessons for management of anaphylaxis from study of fatal reactions Clin Exp Allergy 2000;30 1144-50.
  2. Mullins R et al. Increase in anaphylaxis fatalities in Australia 1997-2013. In press
  3. Brown SGA Clinical features and severity grading of anaphylaxis J Allergy Clin Immunol 2004 Aug; 114(2): 37: 1-6

Biography

Background: Registered Nurse.  Bachelor of Nursing, Certificate in Neonatal Nursing and Allergy Nursing Professional Associations:Associate member of Australasian Society of Clinical Immunology and Allergy (ASCIA)  Clinical Nurse in Allergy/ Clinical Immunology at Flinders Medical Centre, providing specialist care to paediatric & adult patients with particular focus on improving patient outcomes through education and applying current research to nursing practice within a multidisciplinary team. Building network opportunities with emergency care providers and community to  enhance patient- focused care to individuals and their carers.