Managing anaphylaxis

Associate Professor Amanda Walker, Clinical Director at the Australian Commission on Safety and Quality in Health Care, explains why clinicians and health services need to be consistent in managing this potentially fatal condition.

To observe someone experience anaphylaxis can be confronting. As clinicians know, it is a condition that demands immediate action and a prompt response could save someone’s life. Recognising anaphylaxis as early as possible is crucial, as reactions can escalate quickly from the initial signs.

Each year more than 11,500 Australians present to public hospital emergency departments with anaphylaxis, and this figure is rising. It increased 51% in the five years to 2019–20.¹ It is a sobering fact that up to 20 Australians die from anaphylaxis every year, and we have one of the highest documented rates of hospital anaphylaxis admissions in the developed world.² While fatalities are not common, they are often preventable.

Given this context, it is no surprise the release of the first national standard of care for patients with anaphylaxis has been welcomed across the healthcare sector. The Australian Commission on Safety and Quality in Health Care (the Commission) released the Acute Anaphylaxis Clinical Care Standard in November following extensive public consultation.

Anaphylaxis occurs when the immune system overreacts to an allergy trigger, or allergen. Common triggers are foods such as nuts, milk, fish, shellfish and eggs, insect venoms such as wasp and bee stings, and some medicines. Up to 10% of infants and 2% of adults have food allergies.³

The impact of managing allergies to prevent anaphylaxis affects many in our community. Currently around one in five Australians, or four million people, live with allergies⁴, including many that could trigger an anaphylactic reaction. The condition can be indiscriminate and affect children and young people in the prime of their lives.

Anaphylaxis is a condition that requires management throughout the patient journey — from emergency care and acute settings to the community with general practice and specialist care. The standard describes the care that people can expect when they experience anaphylaxis and recommends priority areas for clinicians who are managing treatment across this spectrum.

Addressing gaps in patient care

Actions in the Acute Anaphylaxis Clinical Care Standard address particular gaps that have been identified in patient care, to help ensure consistent, safe care for all patients presenting with anaphylaxis. These include ensuring timely treatment with adrenaline and strengthening the process for handover of care along the patient journey.

Based on guidelines from the Australasian Society of Clinical Immunology and Allergy (ASCIA), the standard comprises six evidence-based quality statements covering:

• Prompt recognition of anaphylaxis
• Immediate injection of intramuscular adrenaline
• Correct patient positioning
• Access to a personal adrenaline injector in all healthcare settings
• Observation time following anaphylaxis
• Discharge management and documentation.
   

The standard supports healthcare workers to know how to manage patients who have signs and symptoms of anaphylaxis, which can be difficult to recognise in the early stages. If someone has a known allergy or has been exposed to a potential allergen and has signs or symptoms of a multisystem response, clinicians should consider the possibility of anaphylaxis and act appropriately.

As the standard highlights, adrenaline is the first-line treatment for anaphylaxis. Intramuscular adrenaline into the outer mid-thigh carries very few risks and can quickly reduce the allergic response. Yet unfortunately, a study in eight Australian EDs found one quarter of reactions consistent with anaphylaxis were not given adrenaline.⁵

Noteworthy in the standard is the importance of safe practices, such as ensuring a person with anaphylaxis does not stand up or walk during their treatment and early recovery after adrenaline, in order to keep their blood pressure stable. This is a critical issue that is often overlooked when managing anaphylaxis.

There is a new recommendation in the national standard for patients at risk of anaphylaxis who have been prescribed an adrenaline injector to have access to it at all times. In most hospital and healthcare settings, patients do not usually have access to their own medicines — largely for their own safety. This is now one important exception, with the Commission calling on healthcare providers to ensure the adrenaline injector can be kept with the patient wherever they are, so they can use it if they need to.

How anaphylaxis is managed throughout the patient experience is also a key focus — from when symptoms first appear, to treatment and discharge from hospital. Communication is vital to patient safety at these key transitions of care.

Safe discharge and handover of care

When someone has experienced anaphylaxis and is leaving hospital, we are sending a vulnerable person out into the community. There needs to be a safe discharge and clear handover of care to the patient’s GP and immunologist. The clinical care standard sets out how to discharge patients safely, to ensure they are well prepared to manage future anaphylaxis events that may occur after they leave the hospital’s care.

The Anaphylaxis Discharge Checklist and Discussion Tool released with the new standard is a practical tool that will help to ensure patients receive the necessary education, medicines and referrals they need after being treated for anaphylaxis.

For people at risk of anaphylaxis, it is vital that they are educated about how to manage their allergy and have an ASCIA Action Plan. This includes knowing how best to avoid their allergen, how to recognise anaphylaxis symptoms and how to correctly use a personal adrenaline injector, if this is needed. If an adrenaline injector is required, the hospital should ensure the patient has one when they leave hospital, or can get one immediately afterwards.

As well as health professionals, family members and carers of those people at risk, their teachers and childminders need information so they can help treat someone experiencing a severe allergic reaction. Health services and clinicians are an essential conduit for sharing this information with the wider community. The Commission has also developed a consumer guide to the standard, which clinicians can use to have conversations with their patients.

Strong support for new standard

It is pleasing that the new clinical care standard has been endorsed by 16 medical and nursing colleges, including the Australasian Society of Clinical Immunology and Allergy, the Australasian College for Emergency Medicine, the Australian College of Nursing, the Australian College of Rural and Remote Medicine, the Australian and New Zealand College of Anaesthetists and the Royal Australasian College of Physicians.

In the development of the standard, the Commission has worked closely with the National Allergy Strategy, a partnership between the Australasian Society of Clinical Immunology and Allergy (ASCIA) and consumer peak body Allergy & Anaphylaxis Australia (A&AA).

Learn more about the standard, download our resources or view our expert panel discussion at: safetyandquality.gov.au/anaphylaxis-ccs.

Associate Professor Amanda Walker is Clinical Director at the Australian Commission on Safety and Quality in Health Care and led the development of the Acute Anaphylaxis Clinical Care Standard.

At the Commission, she is focused on the development of clinical care standards, resources to address Hospital Acquired Complications and support for clinicians to provide Comprehensive Care. She is a Specialist in Palliative Medicine in the Southern Highlands of NSW and has led state-wide work in end-of-life care at the Clinical Excellence Commission in NSW.

^References

^{[1] Australian Commission on Safety and Quality in Health Care. Analysis of the Non-Admitted Patient Emergency Department National Minimum Data Set (NAPED NMDS), 2015–16 to 2019–20. Sydney: ACSQHC; 2021.}

^{[2] Mullins RJ, Wainstein BK, Barnes EH, Liew WK, Campbell DE. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016 Aug;46(8):1099–110.}

^{[3] Australasian Society of Clinical Immunology and Allergy. Food allergy [Internet]. Sydney: ASCIA; 2021 [cited 2021 Aug 3] Available from: www.allergy.org.au/patients/food-allergy/food-allergy}

^{[4] House of Representatives Standing Committee on Health, Aged Care and Sport. Walking the allergy tightrope. Canberra: Commonwealth of Australia; 2020.}

^{[5] Brown SGA, Stone SF, Fatovich DM, Burrows SA, Holdgate A, Celenza A, et al. Anaphylaxis: clinical patterns, mediator release, and severity. J Allergy Clin Immunol 2013 Nov;132(5):1141–9.}

Top image caption: Adrenaline is the first-line treatment for anaphylaxis and can be given using an auto-injector.