Guia NICE sobre anafilaxia. implementacion
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Guia NICE sobre anafilaxia. implementacion

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Presentación de ayuda a la implementación de las recomendaciones de la GPC NICE sobre anafilaxia

Presentación de ayuda a la implementación de las recomendaciones de la GPC NICE sobre anafilaxia

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  • ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline “Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode”. This guideline has been written for staff in primary, secondary and tertiary settings who care for people with suspected anaphylaxis. This guideline is also available as part of the NICE anaphylaxis pathway. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
  • NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then present the recommendations. The NICE guideline contains 12 recommendations. Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Links to the NICE Pathway and NHS Evidence are provided. Finally, we will end the presentation with further information about the support provided by NICE. Image showing child following anaphylactic episode reproduced with kind permission of Dr Pete Smith, Medicalpix.com.
  • NOTES FOR PRESENTERS: Key points to raise: Anaphylaxis may be an allergic response that is immunologically mediated, a non-immunological mediated response, or idiopathic. Certain foods, insect venoms, some drugs and latex are common precipitants of immunoglobulin E (IgE)‑mediated allergic anaphylaxis. Many drugs can also act through non‑allergic mechanisms. A significant proportion of anaphylaxis is classified as idiopathic Food is a particularly common trigger in children, while medicinal products are much more common triggers in older people. The approximate incidence of anaphylaxis is based upon what is recorded in GP records, and is likely to be an underestimation. There are no accurate data on actual incidence of anaphylaxis. There are approximately 20 deaths from anaphylaxis reported each year in the UK, with around half the deaths being iatrogenic, although this may be an underestimate. 1 References Pumphrey RS (2000) Lessons for management of anaphylaxis from a study of fatal reactions. Clinical and Experimental Allergy 30(8): 1144–50
  • NOTES FOR PRESENTERS: Key points to raise: Some groups may be at higher risk of anaphylaxis, such as those with an existing comorbidity (e.g. asthma) or because they are more likely to be exposed to the same allergy again (such as those with venom allergies, or reactions to suspected food triggers). Prevention of anaphylaxis among these groups is not covered within the scope of this guideline, which is specific to those who have received emergency treatment for suspected anaphylaxis.
  • NOTES FOR PRESENTERS: Anaphylaxis is characterised by rapidly developing, life-threatening problems involving: the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes Biphasic anaphylaxis is managed in the same way as anaphylaxis. All known causes of anaphylaxis must be excluded before a reaction can be diagnosed as idiopathic In emergency departments a person who presents with the signs and symptoms of anaphylaxis may be classified as having a ‘severe allergic’ reaction rather than an ‘anaphylactic’ reaction. Throughout the guideline, anyone who presents with such signs and symptoms is classed as experiencing a ‘suspected anaphylactic reaction’, and should be diagnosed as having ‘suspected anaphylaxis’.
  • NOTES FOR PRESENTERS: The NICE guideline contains twelve recommendations about how care can be improved. For this presentation we have divided the recommendations into six areas.
  • NOTES FOR PRESENTERS: Key points to raise: The signs and symptoms include rapidly developing, life-threatening problems involving the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases there will be associated skin and mucosal changes. Recommendations in full: Document the acute clinical features of the suspected anaphylactic reaction (rapidly developing, life-threatening problems involving the airway [pharyngeal or laryngeal oedema] and/or breathing [bronchospasm with tachypnoea] and/or circulation [hypotension and/or tachycardia] and, in most cases, associated skin and mucosal changes). [1.1.1] Record the time of onset of the reaction. [1.1.2] Record the circumstances immediately before the onset of symptoms to help to identify the possible trigger. [1.1.3]
  • NOTES FOR PRESENTERS: Key points to raise: A correct diagnosis of anaphylaxis will mean that the patient will receive the correct treatment, minimising the risk of future reactions. The guideline development group feel that it is important to take two blood samples in order to better understand the pattern of tryptase release and breakdown , and aid clinical interpretation of the results of the first sample. False negative results are seen more commonly in samples from children, whose reactions are often related to food allergy. For this reason, the guideline recommends that measurement is most likely to be useful in children presenting with idiopathic, or suspect venom- or drug-induced anaphylaxis. Recommendations in full: After a suspected anaphylactic reaction in adults or young people aged 16 years or older, take timed blood samples for mast cell tryptase testing as follows: a sample as soon as possible after emergency treatment has started a second sample ideally within 1–2 hours (but no later than 4 hours) from the onset of symptoms. [1.1.4] After a suspected anaphylactic reaction in children younger than 16 years, consider taking blood samples for mast cell tryptase testing as follows if the cause is thought to be venom-related, drug-related or idiopathic: a sample as soon as possible after emergency treatment has started a second sample ideally within 1–2 hours (but no later than 4 hours) from the onset of symptoms. [1.1.5] Inform the person (or, as appropriate, their parent and/or carer) that a blood sample may be required at specialist follow-up to measure baseline mast cell tryptase. [1.1.6]
  • NOTES FOR PRESENTERS: Key points to raise: There is a risk of biphasic reaction (a second reaction with the same trigger as the initial anaphylactic episode) in those treated for suspected anaphylaxis, which necessitates a period of observation, as stated in the guideline. Biphasic reactions are less likely in those who respond quickly to initial treatment following an anaphylactic episode, so shorter observation times may be considered. For children and their parents or carers, an anaphylactic episode can be a traumatic experience. The additional care needed may include paediatric assessment, counselling and education, hence the guideline recommends that children younger than 16 years are admitted to hospital following an anaphylactic episode. Recommendations in full: Adults and young people aged 16 years or older who have had emergency treatment for suspected anaphylaxis should be observed for 6–12 hours from the onset of symptoms, depending on their response to emergency treatment. In people with reactions that are controlled promptly and easily, a shorter observation period may be considered provided that they receive appropriate post-reaction care prior to discharge. [1.1.7] Children younger than 16 years who have had emergency treatment for suspected anaphylaxis should be admitted to hospital under the care of a paediatric medical team. [1.1.8]
  • NOTES FOR PRESENTERS: Key points to raise: Under standard care, people whose initial anaphylactic reaction was due to drugs, venom or food are expected to have 5-6 further reactions in their lives. Under specialist allergy service care, these figures are substantially reduced, with only 1-2 people with a food-related anaphylaxis experiencing a further reaction. Drug related recurrences are almost eradicated once a patient is under the care of a specialist service. Having an adrenaline injector does not prevent occurrence of reactions, but may mitigate their consequences. Risk of death from recurrence is 10% to 30% lower in people with injectors than in those without. Recommendations in full: After emergency treatment for suspected anaphylaxis, offer people a referral to a specialist allergy service (age-appropriate where possible) consisting of healthcare professionals with the skills and competencies necessary to accurately investigate, diagnose, monitor and provide ongoing management of, and patient education about, suspected anaphylaxis. [1.1.9] After emergency treatment for suspected anaphylaxis, offer people (or, as appropriate, their parent and/or carer) an appropriate adrenaline injector as an interim measure before the specialist allergy service appointment. [1.1.10]
  • NOTES FOR PRESENTERS: Key points to raise: Providing information to patients can help to reduce the risks of recurrence of reaction, and prepare them to act promptly and appropriately should a further reaction occur. Awareness of the importance of correct follow-up may also lead to reduced anxiety amongst patients. The guideline development group felt that the person providing this information to patients (or their parent/carer) should have clinical expertise of anaphylactic reactions, particularly when training people in the use of adrenaline injectors. Recommendation in full: Before discharge a healthcare professional with the appropriate skills and competencies should offer people (or, as appropriate, their parent and/or carer) the following: information about anaphylaxis, including the signs and symptoms of an anaphylactic reaction information about the risk of a biphasic reaction information on what to do if an anaphylactic reaction occurs (use the adrenaline injector and call emergency services) a demonstration of the correct use of the adrenaline injector and when to use it advice about how to avoid the suspected trigger (if known) information about the need for referral to a specialist allergy service and the referral process information about patient support groups. [1.1.11] Additional information: As patients are likely to be very ill when the blood sample is initially taken, it may also be beneficial to refer to recommendation 1.1.6 again. Inform the person (or, as appropriate, their parent and/or carer) that a blood sample may be required at specialist follow-up to measure baseline mast cell tryptase. [1.1.6]
  • NOTES FOR PRESENTERS: Key points to raise: Adults and young people have different needs than children younger than 16 years, so separate referral pathways should be in place. Individuals should be referred to age-appropriate services where possible. Recommendation in full: Each hospital trust providing emergency treatment for suspected anaphylaxis should have separate referral pathways for suspected anaphylaxis in adults (and young people) and children. [1.1.12]
  • NOTES FOR PRESENTERS: NICE has found that implementing this guideline is unlikely to result in any significant changes in resource use, based on national assumptions. However, different areas may vary from the national average and it is important to look at the recommendations most likely to have a resource impact to make sure that local practice matches the national average. Potential areas for additional costs are: Additional referrals to specialist allergy services. Potential areas for savings are: Reduced emergency treatments required for anaphylactic reactions following an appointment with the specialist allergy service. Avoiding unnecessary appointments with non-specialists due to an established referral pathway. Full details are provided in the costing statement that accompanies this guideline.
  • NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. Additional questions How is anaphylaxis currently diagnosed and managed?
  • NOTES FOR PRESENTERS: Key points to raise If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered. NICE Pathways: guidance at your fingertips Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended. The NICE pathway can be found at http://pathways.nice.org.uk/pathways/anaphylaxis
  • NOTES FOR PRESENTERS: If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website. For the home page go to www.evidence.nhs.uk
  • NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. ‘ Understanding NICE guidance’ – information for patients and carers. NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant. Audit support – for monitoring local practice.
  • This slide is aimed at those using this slide set for awareness raising or teaching. It is not part of the presentation. In order to access the link please ensure that the presentation is in ‘normal view’

Transcript

  • 1. Anaphylaxis: assessment and referral Implementing NICE guidance December 2011 NICE clinical guideline 134
  • 2. What this presentation covers
    • Background
    • Scope
    • Recommendations
    • Costs and savings Discussion
    • NICE Pathway
    • NHS Evidence
    • Find out more
    Image reproduced with kind permission of Dr Pete Smith, Medicalpix.com
  • 3. Background
    • There are four common triggers – drug, food, latex and insect venom – plus an idiopathic group where the trigger is not known
    • Approximately 1 in 1333 of the population of England has experienced anaphylaxis at some point in their lives
    • There are approximately 20 deaths from anaphylaxis reported each year in the UK
  • 4. Scope
    • This guideline covers adults, young people and children who receive emergency treatment for suspected anaphylaxis.
    • It covers
    • clinical assessment following emergency treatment
    • provision of adrenaline auto-injectors
    • referral
    • information needs and provision
  • 5. Definitions
    • Anaphylaxis – a severe, life-threatening, generalised or systemic hypersensitivity reaction
    • Biphasic anaphylaxis – after complete recovery of anaphylaxis, a recurrence of symptoms within 72 hours with no further exposure to the allergen
    • Idiopathic anaphylaxis – a form of anaphylaxis where no identifiable trigger can be found
    • Recurrence – a return of symptoms as part of the natural progress of a disease
    • Suspected anaphylaxis – the diagnosis prior to assessment by a specialist allergist for people who present with symptoms of anaphylaxis
  • 6. Recommendations
      • Clinical assessment after emergency treatment
      • Mast cell tryptase testing
      • Observation or admittance to hospital (for children)
      • Referral
      • Discharge
      • Referral pathways
  • 7.
      • Document the acute clinical features of the suspected anaphylactic reaction
      • Record the time of onset of the reaction
      • Record the circumstances immediately before the onset of symptoms to help to identify the possible trigger
    Clinical assessment after emergency treatment
  • 8.
      • In adults or young people 16 years or older take timed blood samples for mast cell tryptase
      • In children younger than 16 years consider taking blood samples for mast cell tryptase if the cause is thought to be venom-related, drug-related or idiopathic
      • Take
          • a sample as soon as possible after emergency treatment has started
          • a second sample ideally within 1–2 hours (but no later than 4 hours) from the onset of symptoms
    Mast cell tryptase testing
  • 9.
      • Adults and young people aged 16 and over should be observed for 6–12 hours from the onset of symptoms
      • With appropriate post-reaction care, those whose reactions were controlled promptly and easily, may be observed for a shorter period
      • Children under 16 years should be admitted to hospital under the care of a paediatric medical team
    Observation
  • 10.
      • After emergency treatment for suspected anaphylaxis
      • Offer a referral to a specialist allergy service (age-appropriate where possible)
      • Offer an appropriate adrenaline injector as an interim measure before the specialist allergy service appointment
    Referral
  • 11. Discharge
    • Before discharge offer
    • information about anaphylaxis, including signs and symptoms of an anaphylactic reaction
    • information about the risk of biphasic reaction
    • information on what to do if an anaphylactic reaction occurs
    • a demonstration of use of the adrenalin injector and when to use it
    • advice regarding avoidance of the suspected trigger (if known)
    • information about the need for referral to the specialist allergy service and the referral process
    • information about patient support groups
  • 12. Referral pathways
    • Each hospital providing emergency treatment for suspected anaphylaxis should have separate referral pathways for suspected anaphylaxis in adults (and young people) and children
  • 13. Costs and savings
    • This guideline is unlikely to result in a significant change in resource use in the NHS
      • However, recommendations 1.1.9 and 1.1.12, which concern referral to a specialist allergy service following a suspected anaphylactic reaction, may result in additional costs/savings depending on local circumstances
  • 14. Discussion
    • What are the training needs of staff with regards to provision of adrenaline injectors and information for patients?
    • What specialist services are available locally for referral, and are referral pathways in place?
    • What information do we currently provide to patients who have had an anaphylactic reaction? How does this need to be changed to meet the recommendations in the guideline?
  • 15. NICE Pathway
    • The NICE anaphylaxis pathway covers assessment to confirm an anaphylactic reaction and the decision to refer after emergency treatment for a suspected anaphylactic reaction.
    Click here to go to NICE Pathways website
  • 16. NHS Evidence
      • Visit NHS Evidence for the best available evidence on all aspects of health and social care.
    Click here to go to the NHS Evidence website
  • 17. Find out more
    • Visit www.nice.org.uk/guidance/CG134 for:
      • the guideline
      • ‘ Understanding NICE guidance’
      • costing statement
      • audit support
  • 18. What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete a short evaluation form by clicking here . If you are experiencing problems accessing or using this tool, please email [email_address] To open the links in this slide – right click over the link and choose ‘open hyperlink’. NB. Not part of presentation