Transcript This is the title of the presentation

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
Presentation Structure
Idea &
Planning
• Setting the
clinical
scenario –
originality.
• Identifying
our aims.
Anaphylaxis
Implementation
• Reminder of
Resuscitation
Council
guidelines
• Reviewing
the literature
for best
practice.
•
•
•
•
•
Methods
Data Collection
Analysis
Suggestions
Cost benefit
analysis
Clinical
Significance
• Trust-wide
changes to
clinical
practice
• Importance
to good
clinical
practice
Setting the Clinical Scene
• 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’.
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.”
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.”
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.”
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)
Reviewing the Literature
Resuscitation Council UK guidelines state
“2 ampoules of epinephrine 1 in 1000 is listed in the Minimum
Equipment hospital resuscitation4.”
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.”
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?
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
No
No
Yes
CDU
No
No
No
No
Mary Ray
No
No
Yes
Yes
Oliver
No
No
No
Yes
Lonsdale
No
No
No
Yes
Twining
No
No
No
Yes
Annie
Zunz
No
No
No
Yes
FSU
No
No
No
No
MITU
No
No
No
Yes
SITU
No
No
No
Yes
Day
Surgery
No
No
No
Yes
Theatres
No
No
No
Yes
ASU
No
No
No
Yes
M. Whiting
No
No
No
No
Lister
No
No
No
Yes
Cotton
No
No
No
Yes
Brunel
No
No
No
No
Radiology
No
No
Yes
-
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
No
No
Yes
CDU
No
No
No
No
Mary Ray
No
No
Yes
Yes
Oliver
No
No
No
Yes
Lonsdale
No
No
No
Yes
Twining
No
No
No
Yes
Annie
Zunz
No
No
No
Yes
FSU
No
No
No
No
MITU
No
No
No
Yes
SITU
No
No
No
Yes
Day
Surgery
No
No
No
Yes
Theatres
No
No
No
Yes
ASU
No
No
No
Yes
M. Whiting
No
No
No
No
Lister
No
No
No
Yes
Cotton
No
No
No
Yes
Brunel
No
No
No
No
Radiology
No
No
Yes
-
Intervention and Re-Audit
Trust-wide
teaching
Shock Packs
containing
epinephrine
Intervention
Multidisciplinary
team education
Medical director
and clinical
governance
group
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
Yes
Yes
Yes
CDU
Yes
Yes
Yes
No
Mary Ray
Yes
Yes
Yes
Yes
Oliver
Yes
Yes
Yes
Yes
Lonsdale
Yes
Yes
Yes
No
Twining
Yes
Yes
Yes
Yes
Annie Zunz
Yes
Yes
Yes
Yes
FSU
Yes
Yes
Yes
Yes
MITU
Yes
Yes
Yes
Yes
SITU
Yes
Yes
Yes
Yes
Day Surgery
Yes
Yes
Yes
No
Theatres
Yes
Yes
No
Yes
ASU
Yes
Yes
Yes
Yes
M. Whiting
Yes
Yes
Yes
Yes
Lister
Yes
Yes
Yes
Yes
Cotton
Yes
Yes
Yes
No
Brunel
Yes
Yes
Yes
Yes
Radiology
Yes
Yes
Yes
Yes
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
Yes
Yes
Yes
CDU
Yes
Yes
Yes
No
Mary Ray
Yes
Yes
Yes
Yes
Oliver
Yes
Yes
Yes
Yes
Lonsdale
Yes
Yes
Yes
No
Twining
Yes
Yes
Yes
Yes
Annie Zunz
Yes
Yes
Yes
Yes
FSU
Yes
Yes
Yes
Yes
MITU
Yes
Yes
Yes
Yes
SITU
Yes
Yes
Yes
Yes
Day Surgery
Yes
Yes
Yes
No
Theatres
Yes
Yes
No
Yes
ASU
Yes
Yes
Yes
Yes
M. Whiting
Yes
Yes
Yes
Yes
Lister
Yes
Yes
Yes
Yes
Cotton
Yes
Yes
Yes
No
Brunel
Yes
Yes
Yes
Yes
Radiology
Yes
Yes
Yes
Yes
Comparing Audit with Re-Audit Results
p = 0.02607*
Does the drug cabinet
contain treatment?
Can the senior sister
find a box?
Does the crash trolley
contain treatment?
NO
NO
YES
YES
Does the crash trolley
have a box?
0
10
20
0
5
10
15
20
*p value achieved using the Fisher’s Exact Test for analysisng small quantities of categorical data.
Interpretation of results
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.
Re-Audit
• 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 = 0.02607 indicating statistical significance, alongside
our clinical significance.
Limitations
1. Not all clinical areas (such as; outpatient clinics, Obstetrics & Gynaecology
wards and Paediatrics wards) were included in this audit.
2. 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.
3. 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.
Future Recommendations
1. An anaphylaxis box should be present and clearly labelled
on all clinical areas at King’s College Hospital.
2. Said anaphylaxis boxes should be located in the crash
trolley to ease its retrieval.
3. 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.
4. 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.
5. A further re-audit of all hospital clinical areas (including
outpatients departments) should be undertaken.
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.
Perspective
Conclusion
Originality
Importance
• Example of foundation doctors
taking the lead and attempting to
improve clinical standards.
• Trust-wide implications and
alteration of practice.
• Striving for best practice.
References
1.
2.
3.
4.
5.
“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
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
(GEM Consultant)
All KCH staff involved
[email protected]