1. Anaphylaxis: The Empty Box Audit
Dr Karim Amer (FY1)
Dr Kristian Turnbull (FY2)
Co-author and supervisor: Dr Geoffrey Warwick (GEM Consultant)
Audit Lead: Dr Caroline Elston
(GEM Consultant)
November 26th 2013

2. Presentation Structure
Idea & Planning
Setting the clinical scenario – originality.
Identifying our aims.
Anaphylaxis
Reminder of Resuscitation Council guidelines
Reviewing the literature for best practice.
Implementation
Methods
Data Collection
Analysis
Suggestions
Cost benefit analysis
Clinical Significance
Trust-wide changes to clinical practice
Importance to good clinical practice
Setting the structure for what will be talked about during the presentation, with time for questions afforded at the end.

3. Setting the Clinical Scene
Describe Kristian’s experience of events leading to the idea for the audit…
I had heard of one episode of anaphylaxis that had occurred on one of the surgical wards. It was brought up by one of the FY1s over lunch and described the anaesthetist having to squirt the 1:10,000 (IV) adrenaline into a nebuliser mask and give it as inhaled rather than IM, I am not sure whether it progressed to shock. This was due to 1:1000 not being found in the resus trolley and only 1:10,00 being available. The anecdote was received with laughter by the group and I was silently appalled that poor clinical care was perceived as hilarity and that no one had even voiced the suggestion that anything should be done about this. Within a month or two of this story, I was presented with a patient on Mary Ray ward who had developed a rash and dyspnoea after receiving her first dose of co-amoxiclav. It transpired that it was just an exacerbation of COPD with a drug rash and not anaphylaxis, however, no one was able to produce any adrenaline at the time. This is what lead me to believe that wards did not stock it and thus I wished to investigate.
Aims of Audit:
1. Reviewing the literature to identify ‘best practice’.
2. Audit the King’s College Hospital (KCH) protocol.
3. Improving current standards via re-audit and setting recommendations to achieve ‘best practice’.

4. Reviewing the Literature
Journal of Clinical & Experimental Allergy
“50 % of IV drug induced anaphylactic arrests occur by 4.6 – 9.9 minutes (study in 164 patients)1.”
Empahising the point that anaphylaxis is an ACUTE EMERGENCY requiring IMMEDIATE action

5. Reviewing the Literature
Resuscitation Council UK guidelines state “Resuscitation equipment and drugs to help with the rapid resuscitation of a patient with an anaphylactic reaction must be immediately available in all clinical settings. Clinical staff should be familiar with the equipment and drugs they have available and should check them regularly2.”
Quoting Resus Council guidance that treatment must be immediately available and that

6. Reviewing the Literature
Resuscitation Council UK guidelines state
“Adrenaline is the mainstay of treatment for an anaphylactic reaction. Hydrocortisone and chlorphenamine are not first line drugs for the treatment of an anaphylactic reaction3.”
Quoting Resus Council guidance that adrenaline/epinephrine is the mainstay of treatment for anaphylaxis

7. Anaphylaxis Algorithm
On recognising anaphylactic shock, immediate administration of IM 1:1000 adrenaline is indicated within the Resuscitation Council guidelines2.
“Highly likely to be anaphylaxis if the 4 criteria are met:
1. Sudden onset
2. Life-threatening airway or circulatory problem
3. Skin changes
4. Anxiety or sense of impending doom2”  Resusitation council (UK)

8. Resuscitation Council UK guidelines state
Reviewing the Literature
Resuscitation Council UK guidelines state
“2 ampoules of epinephrine 1 in 1000 is listed in the Minimum Equipment hospital resuscitation4.”
Quoting Resus Council guidance indicating the ‘MINIMUM’ equiptment required for in hospital resuscitation.

9. The Department of Health
Reviewing the Literature
The Department of Health
““An anaphylaxis pack normally contains two ampoules of adrenaline (epinephrine) 1:1000, four 23G needles and four graduated 1 ml syringes, and Laerdal or equivalent masks suitable for children and adults. Packs should be checked regularly to ensure the contents are within their expiry dates. Chlorphenamine (chlorpheniramine) and hydrocortisone are not first-line treatments and do not need to be included in the pack5.”
The department of health guidance

10. Implementation; The Audit
Clinical areas to assessed consisted of acute medical wards, acute surgical wards, Accident & Emergency, radiology and theatres (a total of 18 wards)
Audit criteria consisted of the following:
1. Does the crash trolley have an anaphylaxis box?
2. Does the crash trolley contain treatments for anaphylaxis?
3. Can the senior sister find an anaphylaxis box?
4. Does the drug cabinet contain the treatment of anaphylaxis?
Clinical areas assessed consisted of acute medical wards, acute surgical wards, Accident & Emergency, radiology and theatres (a total of 18 wards). Audit criteria consisted of; the presence of an anaphylaxis box of each ward crash trolley, supplementary anaphylaxis treatment present of each ward crash trolley, knowledge of where the anaphylaxis box was by the ward senior sister and if anaphylaxis treatment was present in the drug cabinet on each ward. Anaphylaxis boxes were supplied to all 18 wards, multidisciplinary education was stringently adhered to and a re-audit completed 3 months later.
Proforma was used to collect the data – Kristian doing the 1st audit cycle and myself completing the re-audit.

11. Results; Pre-Intervention Audit
Area
Does the crash trolley have a box?
Does the crash trolley contain treatment?
Can the senior sister find a box?
Does the drug cabinet contain treatment?
A and E No
Yes
CDU
Mary Ray
Oliver
Lonsdale
Twining
Annie Zunz
FSU
MITU
SITU
Day Surgery
Theatres
ASU
M. Whiting
Lister
Cotton
Brunel
Radiology - 11

12. Results; Pre-Intervention Audit
Area
Does the crash trolley have a box?
Does the crash trolley contain treatment?
Can the senior sister find a box?
Does the drug cabinet contain treatment?
A and E No
Yes
CDU
Mary Ray
Oliver
Lonsdale
Twining
Annie Zunz
FSU
MITU
SITU
Day Surgery
Theatres
ASU
M. Whiting
Lister
Cotton
Brunel
Radiology - 12

13. Intervention and Re-Audit
Trust-wide teaching
Medical director and clinical governance group
Multidisciplinary team education
Shock Packs containing epinephrine
All FY1 doctors at KCH have ILS training and simulation training in their shadowing week or soon thereafter which deals with the treatment of anaphylaxis. Anaphylaxis is also covered in ALS which all doctors have to do every five years or so. Therefore we thought education was sufficient and that it was mainly the supply of TREATMENT that were deficient rather than KNOWLEDGE. Our main aim was therefore to ensure that there was a provision of treatment. The implementation of this involved contacting both the medical director and the clinical governance group at King's and constantly pestering them once I had the evidence demonstrating the lack of treatment provisions.

14. Results; Post-Intervention Audit
Area
Does the crash trolley have a box?
Does the crash trolley contain treatment?
Can the senior sister find a box?
Does the drug cabinet contain treatment?
A and E
Yes
CDU No
Mary Ray
Oliver
Lonsdale
Twining
Annie Zunz
FSU
MITU
SITU
Day Surgery
Theatres
ASU
M. Whiting
Lister
Cotton
Brunel
Radiology 14

15. Results; Post-Intervention Audit
Area
Does the crash trolley have a box?
Does the crash trolley contain treatment?
Can the senior sister find a box?
Does the drug cabinet contain treatment?
A and E
Yes
CDU No
Mary Ray
Oliver
Lonsdale
Twining
Annie Zunz
FSU
MITU
SITU
Day Surgery
Theatres
ASU
M. Whiting
Lister
Cotton
Brunel
Radiology 15

16. Comparing Audit with Re-Audit Results
As you can see, the comparison is vastly improved with regards to accessibility, availability and knowledge of where the anaphylaxistreatment box is.
*p value achieved using the Fisher’s Exact Test for analysisng small quantities of categorical data.

17. Interpretation of results
Audit
Re-Audit
None of the 18 wards audited was found to have an anaphylaxis box located on the crash trolley.
Only 2 senior sisters on said wards knew where the anaphylaxis treatment box was located.
There were 4 wards found to have the anaphylaxis medications within the drugs cabinet, all of which did not stock epinephrine.
Post-intervention; 18 wards stocked anaphylaxis treatment boxes, 17 senior sisters knew where to find such anaphylaxis boxes, 14 wards had fully stocked anaphylaxis treatment available in drug cabinets.
p value = indicating statistical significance, alongside our clinical significance. 17

18. Limitations
Not all clinical areas (such as; outpatient clinics, Obstetrics & Gynaecology wards and Paediatrics wards) were included in this audit.
Shift patterns and rotation of ward doctors/nursing staff may have introduced variability with regards to results. There may be a difference in levels of staff education regarding the location of anaphylaxis boxes.
Not all ward staff were audited with regards to where the anaphylaxis boxes were kept. For truly good clinical practice to be achieved, all members of clinical staff must be audited and informed. 18

19. Future Recommendations
An anaphylaxis box should be present and clearly labelled on all clinical areas at King’s College Hospital.
Said anaphylaxis boxes should be located in the crash trolley to ease its retrieval.
The location of these anaphylaxis boxes should be known to all clinical ward staff trained in immediate or advance life support, and to all members of the ‘crash team’. Inclusion of this information should be emphasised at formal simulation and resuscitation training.
The minimum content of the box should include two ampoules of epinephrine 1 in 1000, four graduated 1 ml syringes, four 23G needles5 and a Resuscitation Council Algorithm for reference.
A further re-audit of all hospital clinical areas (including outpatients departments) should be undertaken. 19

20. Cost benefit Analysis
Epipen and Anapens available: £40 each, 24 month shelf life.
Anaphylaxis boxes (box, ampoules, syringes, needles and protocol): £25
“Auto injectors should only be used by rescuers if it is the only adrenaline available3”
Resuscitation council (UK)
Financially viable. 20

21. Perspective
In a time were the NHS is directly in the public eye, and when so many changes are being made to what is essentially an imperfect system, it is important to remember that there are junior doctors striving to make a difference to patient care. 21

22. Conclusion Originality Importance
Example of foundation doctors taking the lead and attempting to improve clinical standards.
Importance
Trust-wide implications and alteration of practice.
Striving for best practice.
The merits of this audit are firmly held with its originality and the impact it has had on trust-wide policy. Kristian’s intuitiveness, leadership and desire to improve practice were truly unique attributes of a foundation doctor. His actions on this matter epitomized the ethos that the catalyst for clinical change can come from even the most junior NHS professionals.
With the exception of the CT room, there is no immediately available treatment of anaphylaxis in the clinical areas of King’s
Most clinical areas have the treatment but it is not immediately available
Some clinical areas have no treatment for the rapid resuscitation of anaphylaxis
All King’s junior doctors are trained to look for red anaphylaxis boxes that are not present.

23. References
“Lessons for management of anaphylaxis from a study of fatal reactions” Clinical Exp Allergy 2000; 30 (8): 1144 – 50 Pumphrey RS
Emergency treatment of anaphylactic reactions, Guidelines for healthcare providers; Working group of the Resuscitation Council (UK), January 2008
Frequently asked questions on “Emergency treatment of anaphylaxis reactions Guidelines for healthcare providers” Resuscitation Council (UK) February 2008
Recommended Minimum Equipment for in Hospital Adult resuscitation Resuscitation Council (UK), October 2004
Immunisation against infectious disease. The Green Book 2006, Department of Health

24. ANAPHYLAXIS: THE EMPTY BOX AUDIT
Thank you for your attention.
ANAPHYLAXIS: THE EMPTY BOX AUDIT
Special thanks to:
Dr Kristian Turnbull (FY2)
Co-author and supervisor: Dr Geoffrey Warwick
(GEM Consultant)
Audit Lead: Dr Caroline Elston
All KCH staff involved