Clinical Audit on: The Clinical Guidelines for Prescription of Epinephrine Auto Injectors (Epipen, Anapen) for Food Allergy in The Paediatric Allergy Clinic

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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
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Introduction

• There has been a doubling of admissions for
  anaphylaxis in UK (1991-1995)
• 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

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Main Aim of guidelines

• To prevent deaths from food allergy induced
  anaphylaxis
• To prevent over-prescription of an epinephrine
  auto injectors

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Brief aspects of guidelines- Grading of Worst
Reaction
Severity 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)
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Criteria for prescription of epinephrine
auto-injector

• The following patients should be prescribed an
  epinephrine auto-injector
• Those with grade 4-5 reactions (moderate to
  severe)
• Those with ongoing asthma of any cause
• 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

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Objectives

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

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Methodology

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

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Results Grading according to guidelines (50
cases less 4 DNA)
(n46)

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Results Treated according to guidelines (n
25)
Antihistamines all patients received
antihistamines 100
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Results Out of Non-graded patients (n21)
Not on Preferred Treatment 6/7 Asthma 1/7
Anaphylaxis on admission
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Results Overall management of
patients (n46)
Not on Preferred Treatment 4/11 (36) Graded
7/11 (64) Not graded
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Results summary

• Only 54 of patients were graded
• The number of patients receiving Proper Treatment
  was 76
• All patients with grade 4 and 5 were given
  epinephrine auto-injectors
• Those not receiving epinephrine majority of
  patients were asthmatic
• 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

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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 asthmatic patients should be given Epipen
  according to guidelines to prevent serious
  reaction

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Take Home Message

• 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)