Education and training to anaphylaxis patients

Education

NICE (2011) recommends that patients experiencing anaphylaxis receive education and training from emergency care staff in recognition of signs and symptoms, appropriate action to take and when to call the emergency services. This recommendation is reinforced by the World Allergy Organization (Simons et al 2011) and the Australasian Society for Clinical Immunology and Allergy (Kemp 2010) who, along with Fitzsimons et al (2012), recommend a written action plan be made, particularly for children with anaphylaxis who are too young to be taught to auto-inject. It is also recommended that patients be referred to an allergy specialist where the aetiology of the reaction is unknown or where symptoms are severe (Younker and Soar 2010, NICE 2011).

Information on the management of anaphylaxis may be required by:

• Patients.
• Parents or carers of a child with anaphylaxis.
• Extended family of a patient with anaphylaxis.
• Teaching and nursery staff.
• Prison and custodial staff.
• Pre-hospital nursing and ambulance staff.

NICE’s recommendation:

• NICE (2011) recommends that emergency department staff are familiar with the mechanisms of adrenaline injectors and are able to demonstrate these to patients.
• Emergency departments should stock adrenaline injectors to give to patients being discharged after an anaphylactic episode.
• While NICE (2011) recommends that all patients under 16 years are admitted to hospital after an anaphylactic episode, emergency department staff may find themselves required to provide advice to patients older than this who, having undergone a period of observation, are being discharged home (Brown 2006).
• Initial education should focus on avoidance or removal of the allergen, recognition of signs and symptoms of anaphylaxis, and emergency treatment.

Avoidance or removal of the allergen

The avoidance of the allergen is more readily achieved when it is apparent what the allergen is.

• While waiting for investigations to identify the allergen, patients with anaphylaxis should wear some sort of alert necklace or bracelet to inform the public and clinicians of their vulnerability, in addition to making extended family and friends aware of the signs and symptoms of anaphylaxis (Brown 2006, Bryant 2007, Arnold and Williams 2011, Mustafa 2012).
• For those with food-induced anaphylaxis, the involvement of a dietitian is sometimes a necessary precaution (Dunbar and Luyt 2011).
• Particular risk factors include (Bryant 2007, Arnold and Williams 2011, Anaphylaxis.org 2012):
  • Eating out where food ingredients may not always be apparent.
  • Taking new courses of medication.
  • Travelling abroad with potential exposure to new allergens.
• Disinhibiting factors such as alcohol, drugs and peer pressure may make the individual more prone to an anaphylactic reaction (Bryant 2007), and patients should be made aware of this.
• If the patient remains exposed to the allergen and if the personal safety of the rescuer is not compromised, the exposure should be terminated. For example, if a patient experiences an anaphylactic reaction to a bee or wasp sting, where the sting barb remains within the epidermis, it should be gently removed if possible (RCUK 2008, Allergy UK 2012).

Despite recommendations that patients are given discharge advice and education in addition to referral to an allergy specialist where appropriate (Younker and Soar 2010, Arnold and Williams 2011, NICE 2011), a UK-based study found more than half of patients were discharged with no education or specific arrangement made for follow up, and none was referred to specialist allergy services (Caton and Flynn 2013).

Research undertaken in Australia recommended that administration by emergency care staff of injectable adrenaline to patients be deferred until after assessment by specialist allergy services. In reality, this presented a clinical risk to the patient because of the paucity of specialist services and the length of time patients would spend waiting for specialist assessment (Brown 2006). Therefore, it is appropriate for emergency care staff to provide information.

Learning points

1. NICE recommends that patients experiencing anaphylaxis receive education and training from emergency care staff in recognition of signs and symptoms, appropriate action to take and when to call the emergency services.
2. While waiting for investigations to identify the allergen, patients with anaphylaxis should wear some sort of alert necklace or bracelet to inform the public and clinicians of their vulnerability, in addition to making extended family and friends aware of the signs and symptoms of anaphylaxis.
3. Risk factors include eating out where food ingredients may not always be apparent, taking new courses of medication and travelling abroad with potential exposure to new allergens. Alcohol, drugs and peer pressure may also make the individual more prone to an anaphylactic reaction.
4. If the patient remains exposed to the allergen and if the personal safety of the rescuer is not compromised, the exposure should be terminated.