Clinical Audit on: The Clinical Guidelines for Prescription of Epinephrine Auto Injectors (Epipen, Anapen) for Food Allergy in The Paediatric Allergy Clinic Dr J Chapman and Dr R Parikh Facilitated by Clinical Audit Office JPH

Introduction: There has been a doubling of admissions for anaphylaxis in UK ( ) There has been a doubling of admissions for anaphylaxis in UK ( ) Food is the commonest cause with nuts being commonest to cause fatal reaction Food is the commonest cause with nuts being commonest to cause fatal reaction The guidelines were prepared with the intention for proper use in diagnosis and management of Paediatric Food Allergy Patients attending our hospital The guidelines were prepared with the intention for proper use in diagnosis and management of Paediatric Food Allergy Patients attending our hospital

Main Aim of guidelines: To prevent deaths from food allergy induced anaphylaxis To prevent deaths from food allergy induced anaphylaxis To prevent over-prescription of an epinephrine auto injectors To prevent over-prescription of an epinephrine auto injectors

Brief aspects of guidelines- Grading of Worst Reaction: Severity grading of worst reaction Reaction grade Clinical features (/=and/or) 1 Mild Localised cutaneous erythemal/urticaria/angioedema/oral pruritus 2 Mild Generalised erythema/urticaria/angioedema 3 Mild At least 1 or 2 plus gastrointestinal symptoms/rhinoconjunctivitis 4 Moderate Mild laryngeal oedema (voice change/tightening of throat)/mild asthma 5 Severe Marked dyspnoea/hypotensive symptoms (collapse/loss of consciousness)

Criteria for prescription of epinephrine auto-injector: The following patients should be prescribed an epinephrine auto-injector The following patients should be prescribed an epinephrine auto-injector Those with grade 4-5 reactions (moderate to severe) Those with grade 4-5 reactions (moderate to severe) Those with ongoing asthma of any cause Those with ongoing asthma of any cause Those with a grade 1-3 reaction caused by trace exposure only Those with a grade 1-3 reaction caused by trace exposure only All patients, including those prescribed an epinephrine auto-injector, should be prescribed oral antihistamines (usually Piriton) for emergency use All patients, including those prescribed an epinephrine auto-injector, should be prescribed oral antihistamines (usually Piriton) for emergency use

Objectives: To ensure that allergic reactions to food are appropriately graded To ensure that allergic reactions to food are appropriately graded To ensure that epinephrine auto-injectors are prescribed in accordance with current guidelines To ensure that epinephrine auto-injectors are prescribed in accordance with current guidelines

Methodology: Retrospective study of 50 cases attending Paediatric Allergy Clinics Retrospective study of 50 cases attending Paediatric Allergy Clinics Time period between 1 st July and 31 st October 2003 Time period between 1 st July and 31 st October 2003 Specific data collection form to establish whether patients were graded and treated according to guidelines Specific data collection form to establish whether patients were graded and treated according to guidelines

Results – Grading according to guidelines: (50 cases less 4 DNA) (n=46) %

Results – Treated according to guidelines: (n=25) Antihistamines – all patients received antihistamines 100%

Results – Out of Non-graded patients: (n=21) Not on Preferred Treatment – 6/7 Asthma : 1/7 Anaphylaxis on admission

Results – Overall management of patients: (n=46) Not on Preferred Treatment – 4/11 (36%) Graded : 7/11 (64%) Not graded

Results – summary: Only 54% of patients were graded Only 54% of patients were graded The number of patients receiving Proper Treatment was 76% The number of patients receiving Proper Treatment was 76% All patients with grade 4 and 5 were given epinephrine auto-injectors All patients with grade 4 and 5 were given epinephrine auto-injectors Those not receiving epinephrine majority of patients were asthmatic Those not receiving epinephrine majority of patients were asthmatic All patients attending Allergy Clinics received antihistamines All patients attending Allergy Clinics received antihistamines The patients who were not graded and not on proper treatment were almost double those who were graded and not treated The patients who were not graded and not on proper treatment were almost double those who were graded and not treated

Scope of improvement: All the patients should be graded according to severity which will give clear-cut picture of management due to excellent guidelines All the patients should be graded according to severity which will give clear-cut picture of management due to excellent guidelines All asthmatic patients should be given Epipen according to guidelines to prevent serious reaction All asthmatic patients should be given Epipen according to guidelines to prevent serious reaction

Take Home Message: All Professionals involved with Allergy Clinic should grade the patients and give treatment following it to ensure proper management of patients All Professionals involved with Allergy Clinic should grade the patients and give treatment following it to ensure proper management of patients If done it is not far to complete cycle of audit (needs a single tick on stickers) If done it is not far to complete cycle of audit (needs a single tick on stickers)