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Anaphylaxis: assessment and referral after emergency treatment

About

What is covered

This interactive flowchart covers assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode.
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It 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 changesResuscitation Council (UK) 2008. Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers..
In emergency departments a person who presents with the signs and symptoms listed above may be classified as having a 'severe allergic' reaction rather than an 'anaphylactic' reaction. Throughout these recommendations, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'.
After an acute anaphylactic reaction, it is believed that many people do not receive optimal management of their condition. One reason for this is healthcare professionals' lack of understanding when making a diagnosis, for example failing to differentiate anaphylaxis from less severe histamine-releasing reactions or from other conditions that mimic some or all of its clinical features. Another reason is a lack of understanding of when or where to refer patients. This can affect the likelihood of the person receiving a definitive diagnosis, which can lead to anxiety, inappropriate management and recurrent reactions. It can also lead to avoidable costs for the NHS and increase the need for acute care.

Updates

Updates to this interactive flowchart

3 November 2017 Structure revised.
17 May 2016 ImmunoCAP ISAC 112 and Microtest for multiplex allergen testing added to specialist diagnosis and management.
29 March 2016 Anaphylaxis (NICE quality standard 119) added.
29 July 2015 Drug allergy (NICE quality standard 97) added.
22 February 2012 Pharmalgen for the treatment of bee and wasp venom allergy (NICE technology appraisal guidance 246) added to specialist diagnosis and management.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment in an interactive flowchart

What is covered

This interactive flowchart covers assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode.
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It 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 changesResuscitation Council (UK) 2008. Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers..
In emergency departments a person who presents with the signs and symptoms listed above may be classified as having a 'severe allergic' reaction rather than an 'anaphylactic' reaction. Throughout these recommendations, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'.
After an acute anaphylactic reaction, it is believed that many people do not receive optimal management of their condition. One reason for this is healthcare professionals' lack of understanding when making a diagnosis, for example failing to differentiate anaphylaxis from less severe histamine-releasing reactions or from other conditions that mimic some or all of its clinical features. Another reason is a lack of understanding of when or where to refer patients. This can affect the likelihood of the person receiving a definitive diagnosis, which can lead to anxiety, inappropriate management and recurrent reactions. It can also lead to avoidable costs for the NHS and increase the need for acute care.

Updates

Updates to this interactive flowchart

3 November 2017 Structure revised.
17 May 2016 ImmunoCAP ISAC 112 and Microtest for multiplex allergen testing added to specialist diagnosis and management.
29 March 2016 Anaphylaxis (NICE quality standard 119) added.
29 July 2015 Drug allergy (NICE quality standard 97) added.
22 February 2012 Pharmalgen for the treatment of bee and wasp venom allergy (NICE technology appraisal guidance 246) added to specialist diagnosis and management.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Pharmalgen for the treatment of bee and wasp venom allergy (2012) NICE technology appraisal guidance 246
Anaphylaxis (2016) NICE quality standard 119
Drug allergy (2015) NICE quality standard 97

Quality standards

Quality statements

Referral to specialist allergy services after emergency treatment

This quality statement is taken from the anaphylaxis quality standard. The quality standard defines clinical best practice in anaphylaxis and should be read in full.

Quality statement

People who have emergency treatment for suspected anaphylaxis are referred to a specialist allergy service.

Rationale

Specialist allergy services can provide a definitive diagnosis and identify the cause of an anaphylactic reaction. Referral to these services after emergency treatment for suspected anaphylaxis will ensure that people receive the correct advice and treatment. If people are not referred to a specialist allergy service their safety might be compromised and they may receive inappropriate management, have an increased risk of recurrent anaphylactic reactions and feel anxious about possible recurrence.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people who have emergency treatment for suspected anaphylaxis are referred to a specialist allergy service.
Data source: Local data collection.
Process
Proportion of cases of emergency treatment for suspected anaphylaxis that are followed by referral to a specialist allergy service.
Numerator – the number in the denominator that are followed by referral to a specialist allergy service.
Denominator – the number of cases of emergency treatment for suspected anaphylaxis.
Data source: Local data collection.
Outcome
People who are vulnerable to anaphylaxis feel able to manage their condition.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary care providers, emergency departments, paediatric services) ensure that people who have had emergency treatment for suspected anaphylaxis are referred to a specialist allergy service.
Healthcare professionals (such as GPs, emergency department staff, members of paediatric and adult medical teams) refer people who have had emergency treatment for suspected anaphylaxis to a specialist allergy service. The referral can be made by the person’s GP, for example, after initial treatment in an emergency department or by hospital staff.
Commissioners (clinical commissioning groups and NHS England) commission local specialist allergy services and agree pathways for referral to specialist allergy services for people who have had emergency treatment for suspected anaphylaxis.

What the quality statement means for patients, service users and carers

People who have had emergency treatment for suspected anaphylaxis (a severe, life-threatening allergic reaction) are offered an appointment at a specialist allergy service. This is to find out the cause of the reaction and to get advice on what to do in the future.

Source guidance

Definitions of terms used in this quality statement

Suspected anaphylaxis
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. The NICE guideline on anaphylaxis: assessment and referral after emergency treatment and the Royal College of Physicians’ concise guideline on emergency treatment of anaphylaxis in adults give details of clinical features that suggest anaphylactic reaction. Anyone who presents with such signs and symptoms should be diagnosed as having ‘suspected anaphylaxis’.
Specialist allergy service
A service consisting of healthcare professionals with the skills and competencies needed to accurately investigate, diagnose, monitor and provide ongoing management of, and patient education about, suspected anaphylaxis. The service should be age-appropriate if possible.
[Anaphylaxis: assessment and referral after emergency treatment (NICE guideline CG134) recommendation 1.1.9]
Details of local allergy services are available from the British Society for Allergy and Clinical Immunology (BSACI) including information on services with expertise in particular allergies, such as food, drug or venom allergies) or from NHS Choices. The BSACI website can also be used to find allergy services with appropriate expertise to deal with a particular allergy (for example food, drug, venom allergy).
[Expert opinion]

Equality and diversity considerations

When referring people to a specialist allergy service, any potential difficulties in access such as travelling distance, disability or financial barriers should be taken into account.

Education in adrenaline auto-injector use

This quality statement is taken from the anaphylaxis quality standard. The quality standard defines clinical best practice in anaphylaxis and should be read in full.

Quality statement

People who are prescribed an adrenaline auto-injector after emergency treatment for suspected anaphylaxis are given training in how and when to use it before being discharged.

Rationale

Adrenaline auto-injectors should be offered to people after emergency treatment for suspected anaphylaxis, as an interim measure before they have a specialist allergy service appointment. It is important to use an adrenaline auto-injector as soon as possible if an anaphylactic reaction is suspected. Ensuring that people know when and how to use their device will help ensure timely and correct use if they have a further anaphylactic reaction.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that people who are prescribed an adrenaline auto-injector after emergency treatment for suspected anaphylaxis are given training in how and when to use it before being discharged.
Data source: Local data collection.
Process
Proportion of people who are prescribed an adrenaline auto-injector after emergency treatment for suspected anaphylaxis who are given training in how and when to use it before being discharged.
Numerator – the number in the denominator who are given training in how and when to use an adrenaline auto-injector before being discharged.
Denominator – the number of people who are prescribed an adrenaline auto-injector after emergency treatment for suspected anaphylaxis.
Data source: Local data collection.
Outcome
a) People who have had a suspected anaphylactic reaction feel able to manage their condition.
Data source: Local data collection.
b) Cases of emergency treatment for suspected anaphylaxis after an adrenaline auto-injector has been prescribed.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as emergency departments, paediatric and adult medical services) ensure that healthcare professionals can provide training in how and when to use adrenaline auto-injectors for people who are prescribed adrenaline auto-injectors after emergency treatment for suspected anaphylaxis. They also ensure that information on using auto-injectors is available to give to people.
Healthcare professionals (such as emergency department staff, members of paediatric and adult medical services) provide training for people prescribed an adrenaline auto-injector after emergency treatment for suspected anaphylaxis, before they are discharged. They demonstrate correct use, provide an opportunity for the person to practice using a training device, and give people information about how and when to use it.
Commissioners (clinical commissioning groups) ensure that they commission services that can provide training and information on how and when to use adrenaline auto-injectors for people who have been prescribed an adrenaline auto-injector after emergency treatment for suspected anaphylaxis.

What the quality statement means for patients, service users and carers

People who are prescribed an adrenaline auto-injector because they have had emergency treatment for suspected anaphylaxis (a severe, life-threatening allergic reaction) are shown how to use it, can practise using a training injector, and are given information that explains how and when they should use it before they go home from hospital.

Source guidance

Definitions of terms used in this quality statement

Training in how and when to use an adrenaline auto-injector
This includes a demonstration of using an adrenaline auto-injector and practice using a training device. Information should also be given about anaphylaxis, including the signs and symptoms of an anaphylactic reaction and what to do if an anaphylactic reaction happens (use the adrenaline auto-injector and call emergency services).
[Adapted from Anaphylaxis: assessment and referral after emergency treatment (NICE guideline CG134), recommendation 1.1.11 and expert opinion]

Equality and diversity considerations

Information provided about using adrenaline auto-injectors should be accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not read or speak English. People receiving information about adrenaline auto-injectors should have access to an interpreter or advocate if needed.

Specialist assessment for venom immunotherapy

This quality statement is taken from the anaphylaxis quality standard. The quality standard defines clinical best practice in anaphylaxis and should be read in full.

Quality statement

People who have a systemic reaction to wasp or bee stings are referred to a specialist allergy service to assess whether venom immunotherapy would be suitable.

Rationale

Venom allergy from bees and wasps accounts for approximately a quarter of adult cases of anaphylaxis of known cause. Venom immunotherapy can reduce the risk and severity of systemic reactions. Ensuring that people who could benefit from venom immunotherapy are assessed for this treatment will help to improve uptake and reduce the incidence of venom-induced anaphylaxis.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that people who have a systemic reaction to wasp or bee stings are referred to a specialist allergy service to assess whether venom immunotherapy would be suitable.
Data source: Local data collection.
Process
Proportion of people who have a systemic reaction to a wasp or bee sting who are referred to a specialist allergy service to assess whether venom immunotherapy would be suitable.
Numerator – the number in the denominator who are referred to a specialist allergy service to assess whether venom immunotherapy would be suitable.
Denominator – the number of people presenting with a systemic reaction to a wasp or bee sting.
Data source: Local data collection.
Outcome
a) Prescriptions of venom immunotherapy.
Data source: Local data collection.
b) Incidence of venom-induced anaphylaxis.
Data source: Local data collection.
c) People feel able to manage their condition after treatment for anaphylaxis caused by a wasp or bee sting.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary care providers, emergency departments and specialist allergy services) ensure that there are agreed local pathways in place for people who have a systemic reaction to a wasp or bee sting to be referred to a specialist allergy service for assessment for possible venom immunotherapy. Venom immunotherapy should be offered when suitable as part of the local pathway.
Healthcare professionals (such as GPs and emergency department staff) refer people who have a systemic reaction to a wasp or bee sting to a specialist allergy service for assessment. Healthcare professionals at specialist allergy services assess whether venom immunotherapy is suitable for people referred to them and offer venom immunotherapy if it is suitable.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission specialist allergy services that can offer venom immunotherapy, and that there are agreed local pathways in place for people who have a systemic reaction to a wasp or bee sting to be referred to these services for assessment and treatment.

What the quality statement means for patients, service users and carers

People who have a severe reaction to a bee or wasp sting are offered an appointment at a specialist allergy service to check if they would benefit from treatment (called venom immunotherapy) that can reduce the risk of future reactions to bee or wasp stings.

Source guidance

Definitions of terms used in this quality statement

Specialist allergy service
A service consisting of healthcare professionals with the skills and competencies needed to accurately investigate, diagnose, monitor and provide ongoing management of, and patient education about, suspected anaphylaxis. The service should be age-appropriate if possible.
[Anaphylaxis: assessment and referral after emergency treatment (NICE guideline CG134) recommendation 1.1.9]
Details of local allergy services are available from the British Society for Allergy and Clinical Immunology (BSACI) including information on services with expertise in particular allergies, such as food, drug or venom allergies) or from NHS Choices. The BSACI website can also be used to find allergy services with appropriate expertise to deal with a particular allergy (for example food, drug, venom allergy).
[Expert opinion]
Assessment for venom immunotherapy
A number of criteria are evaluated before giving venom immunotherapy, to identify whether the treatment is safe and appropriate. NICE’s guidance on pharmalgen for the treatment of bee and wasp venom allergy (TA246) and the British Society for Allergy and Clinical Immunology’s guidelines on the diagnosis and management of hymenoptera venom allergy provide criteria for assessment for venom immunotherapy.
[Expert opinion]
Venom immunotherapy should be carried out only by allergy specialists with experience and knowledge in this field and in centres undertaking venom immunotherapy in significant numbers of patients and where the team has expertise in treating anaphylaxis.
[Diagnosis and management of hymenoptera venom allergy (2011) British Society for Allergy and Clinical Immunology (BSACI) guidelines]

Equality and diversity considerations

When referring people to a specialist allergy clinic, any potential difficulties in access such as travelling distance, disability or financial barriers should be taken into account.  

Ongoing training in adrenaline auto-injector use (placeholder)

This quality statement is taken from the anaphylaxis quality standard. The quality standard defines clinical best practice in anaphylaxis and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.

Rationale

Recurrence of an anaphylactic reaction can occur a long time after an adrenaline auto-injector is first prescribed and after a person, and their families or carers, are shown how to use the device. People who have been prescribed an adrenaline auto-injector following an anaphylactic reaction are more likely to be able to self-manage anaphylactic reactions if they are provided with ongoing training on how and when to use their adrenaline auto-injector.

Documentation using the structured assessment guide

This quality statement is taken from the drug allergy quality standard. The quality standard defines clinical best practice in drug allergy and should be read in full.

Quality statement

People with suspected drug allergy have their drug reaction documented using the structured assessment guide.

Rationale

After a person has a suspected allergic reaction to a drug, it is important that full and accurate information is recorded so that prescribing errors and adverse drug reactions can be avoided in the future. A healthcare professional can achieve this by following the structured assessment guide when recording the drug reaction and its severity. The guide is also important for educating patients about the signs, patterns and timings of allergic reactions. This should prevent morbidity and improve health outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that people with suspected drug allergy have their drug reaction documented using the structured assessment guide.
Data source: Local data collection.
Process
Proportion of people with suspected drug allergy who have their drug reaction documented using the structured assessment guide.
Numerator – the number in the denominator who have their drug reaction documented using the structured assessment guide.
Denominator – the number of people with suspected drug allergy.
Data source: Local data collection.
Outcome
a) Medication errors (inappropriate prescribing or administration of drugs).
Data source: Local data collection.
b) Number of repeat allergic drug reactions (including patient-reported episodes).
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (GPs, A&E departments and secondary care services) ensure that people with suspected drug allergy have their drug reaction documented using the structured assessment guide.
Healthcare professionals use the structured assessment guide to document drug reactions of people with suspected drug allergy.
Commissioners (NHS England area teams and clinical commissioning groups) commission services in which people with suspected drug allergy have their drug reaction documented using the structured assessment guide.

What the quality statement means for patients, service users and carers

People with suspected drug allergy should be examined by their GP or, for severe reactions, by A&E staff, who should also ask questions about the symptoms. They should record details of the reaction using a standard approach. They should ask how soon the symptoms started after taking the drug or how many doses were taken, and whether the person has had a similar reaction to that drug or type of drug before. If the doctor thinks that a person might have a drug allergy they should discuss what this means with them (and their family members or carers as appropriate). They should also give them some written information.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendations 1.1.1 (key priority for implementation) and 1.2.3 (key priority for implementation).

Definitions of terms used in this quality statement

Structured assessment guide
The structured assessment guide (boxes 1–3) sets out the signs, allergic patterns and timing of onset of allergic reactions. Healthcare professionals should use boxes 1–3 as an assessment guide when deciding whether symptoms may be caused by a drug allergy.
Box 1 Immediate, rapidly evolving reactions
Anaphylaxis – a severe multi-system reaction characterised by:
  • erythema, urticaria or angioedema and
  • hypotension and/or bronchospasm
Onset usually less than 1 hour after drug exposure (previous exposure not always confirmed)
Urticaria or angioedema without systemic features
Exacerbation of asthma (for example, with non-steroidal anti-inflammatory drugs [NSAIDs])
Box 2 Non-immediate reactions without systemic involvement
Widespread red macules or papules (exanthema-like)
Onset usually 6–10 days after first drug exposure or within 3 days of second exposure
Fixed drug eruption (localised inflamed skin)
Box 3 Non-immediate reactions with systemic involvement
Drug reaction with eosinophilia and systemic symptoms (DRESS) or drug hypersensitivity syndrome (DHS) characterised by:
  • widespread red macules, papules or erythroderma
  • fever
  • lymphadenopathy
  • liver dysfunction
  • eosinophilia
Onset usually 2–6 weeks after first drug exposure or within 3 days of second exposure
Toxic epidermal necrolysis or Stevens–Johnson syndrome characterised by:
  • painful rash and fever (often early signs)
  • mucosal or cutaneous erosions
  • vesicles, blistering or epidermal detachment
  • red purpuric macules or erythema multiforme
Onset usually 7–14 days after first drug exposure or within 3 days of second exposure
Acute generalised exanthematous pustulosis (AGEP) characterised by:
  • widespread pustules
  • fever
  • neutrophilia
Onset usually 3–5 days after first drug exposure
Common disorders caused, rarely, by drug allergy:
  • eczema
  • hepatitis
  • nephritis
  • photosensitivity
  • vasculitis
Time of onset variable
[Drug allergy (2014) NICE guideline CG183, recommendation 1.1.1 (key priority for implementation)]

Advice about carrying personal structured drug information

This quality statement is taken from the drug allergy quality standard. The quality standard defines clinical best practice in drug allergy and should be read in full.

Quality statement

People with a new diagnosis of drug allergy are advised to carry structured information about their drug reaction at all times.

Rationale

Carrying structured information about their drug reaction at all times can minimise a person’s fear of having another reaction, enhance their communication with healthcare professionals and enable the person to better manage their drug allergy.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a new diagnosis of drug allergy are advised to carry structured information about their drug reaction at all times.
Data source: Local data collection.
Process
Proportion of people with a new diagnosis of drug allergy who are advised to carry structured information about their drug reaction at all times.
Numerator – the number in the denominator who are advised to carry structured information about their drug reaction at all times.
Denominator – the number of people with a new diagnosis of drug allergy.
Data source: Local data collection.
Outcome
Self-management of drug allergy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary and secondary care services) ensure that healthcare professionals advise people with a new diagnosis of drug allergy to carry structured information about their drug reaction at all times.
Healthcare professionals advise people with a new diagnosis of drug allergy to carry structured information about their drug reaction at all times.
Commissioners (NHS England area teams and clinical commissioning groups) commission services that advise people with a new diagnosis of drug allergy to carry structured information about their drug reaction at all times.

What the quality statement means for patients, service users and carers

People who have just been told they have a drug allergy are advised to keep the information they have been given about the allergy with them at all times.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendations 1.2.3 (key priority for implementation) and 1.3.4.

Definition of terms used in this quality statement

Structured information about a drug reaction
When a person presents with a new diagnosis of drug allergy they are advised to carry structured information about their drug reaction that includes:
  • the generic and proprietary name of the drug or drugs suspected to have caused the reaction, including the strength and formulation
  • a description of the reaction (see structured assessment guide)
  • the indication for the drug being taken (or description of the illness if there is no clinical diagnosis)
  • the date and time of the reaction
  • the number of doses taken or number of days on the drug before onset of the reaction
  • the route of administration
  • which drugs or drug classes to avoid in future.
If the person is unable to carry this information themselves (for example, neonates or those with additional needs), it may need to be given to a carer or family member instead, but confidentiality and safeguarding must be observed.
[Adapted from Drug allergy (2014) NICE guideline CG183, recommendation 1.2.3 (key priority for implementation)]

Equality and diversity considerations

All written information and advice should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People receiving information about drug allergy should have access to an interpreter or advocate if needed.

Referral to specialist drug allergy services

This quality statement is taken from the drug allergy quality standard. The quality standard defines clinical best practice in drug allergy and should be read in full.

Quality statement

People with a suspected or confirmed anaphylactic reaction, or severe non-immediate cutaneous reaction to a drug, or reaction to a general anaesthetic are referred to a specialist drug allergy service.

Rationale

It is important to ensure appropriate referral to specialist drug allergy services so that all people with drug allergy receive the care they need. Expert clinical opinion suggests that some people who are currently referred do not need specialist services whereas others need specialist referral but this is not offered.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a suspected or confirmed anaphylactic reaction, or severe non-immediate cutaneous reaction to a drug, or reaction to a general anaesthetic are referred to a specialist drug allergy service.
Data source: Local data collection.
Process
a) Proportion of people with a suspected or confirmed anaphylactic reaction to a drug who are referred to a specialist drug allergy service.
Numerator – the number in the denominator who are referred to a specialist drug allergy service.
Denominator – the number of people with a suspected or confirmed anaphylactic reaction to a drug.
Data source: Local data collection.
b) Proportion of people with a severe non-immediate cutaneous reaction to a drug who are referred to a specialist drug allergy service.
Numerator – the number in the denominator who are referred to a specialist drug allergy service.
Denominator – the number of people with a severe non-immediate cutaneous reaction to a drug.
Data source: Local data collection.
c) Proportion of people with a reaction to a general anaesthetic who are referred to a specialist drug allergy service.
Numerator – the number in the denominator who are referred to a specialist drug allergy service.
Denominator – the number of people with a reaction to a general anaesthetic.
Data source: Local data collection.
Outcome
a) Mortality.
Data source: Local data collection.
b) Number of repeat allergic drug reactions.
Data source: Local data collection.
c) Length of hospital stay.
Data source: Local data collection.
d) Inappropriate avoidance of drugs.
Data source: Local data collection.
e) Further anaesthetics without problems.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (GP, A&E departments, dentists and secondary care services) ensure that people with a suspected or confirmed anaphylactic reaction, or severe non-immediate cutaneous reaction to a drug, or reaction to a general anaesthetic are referred to a specialist drug allergy service.
Healthcare professionals refer people with a suspected or confirmed anaphylactic reaction, or severe non-immediate cutaneous reaction to a drug, or reaction to a general anaesthetic to a specialist drug allergy service.
Commissioners (NHS England area teams and clinical commissioning groups) commission local specialist drug allergy services for people with suspected or confirmed anaphylactic reactions, or severe non-immediate cutaneous reactions to a drug, or reactions to general anaesthetics.

What the quality statement means for patients, service users and carers

People are referred to a specialist drug allergy service for advice if they have a severe ‘shock-like’ reaction straight after taking a drug, or if they have a severe skin reaction that develops later, or if they have a reaction to a general anaesthetic.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendations 1.4.2, 1.4.8 (key priority for implementation), 1.4.10 and 1.4.11 (key priority for implementation).
  • Anaphylaxis (2011) NICE guideline CG134, recommendation 1.1.9.

Recording drug allergy status in electronic medical records

This quality statement is taken from the drug allergy quality standard. The quality standard defines clinical best practice in drug allergy and should be read in full.

Quality statement

People with drug allergy have their status documented in their electronic medical record using the recommended coding framework.

Rationale

At present, the coding is not used consistently in electronic documentation systems to differentiate between a side effect and an allergic reaction. Consistent and comprehensive recording of drug allergy status is important to ensure that all patients with confirmed or suspected drug allergy have a full and accurate record of this in their electronic medical record. Accurate recording of drug allergy status will prevent the prescription and administration of drugs inducing allergic reactions and will improve patient safety.

Quality measures

Structure
Evidence of local arrangements to ensure that people with drug allergy have their status documented in their electronic medical record using the recommended coding framework.
Data source: Local data collection.
Process
Proportion of electronic medical records with a drug allergy status documented using the recommended coding framework.
Numerator – the number in the denominator with a drug allergy status documented using the recommended coding framework.
Denominator – the number of electronic medical records.
Data source: Local data collection.
Outcome
a) Mortality.
Data source: Local data collection.
b) Repeat allergic drug reactions.
Data source: Local data collection.
c) Length of hospital stay.
Data source: Local data collection.
d) Inappropriate avoidance of drugs.
Data source: Local data collection.
e) Anaphylaxis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary and secondary care services) ensure that healthcare professionals document a person’s drug allergy status in their electronic medical record using the recommended coding framework.
Healthcare professionals document a person’s drug allergy status in their electronic medical record using the recommended coding framework.
Commissioners (NHS England area teams and clinical commissioning groups) commission services in which healthcare professionals document a person’s drug allergy status in their electronic medical record using the recommended coding framework.

What the quality statement means for patients, service users and carers

People have a note in their electronic medical record of whether or not they have a drug allergy. This should be noted as ‘drug allergy’, ‘none known’ or ‘unable to ascertain’ (doctors aren’t sure whether a reaction is due to drug allergy or not). If doctors aren’t sure they should investigate further.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendation 1.2.1.

Definitions of terms used in this quality statement

Coding framework for drug allergy status
Use 1 from the following coding framework when documenting a person’s drug allergy status in their medical records:
  • 'drug allergy'
  • 'none known'
  • 'unable to ascertain' (document it as soon as the information is available).
[Drug allergy (2014) NICE guideline CG183 recommendation 1.2.1]

Updating information on drug allergy status

This quality statement is taken from the drug allergy quality standard. The quality standard defines clinical best practice in drug allergy and should be read in full.

Quality statement

People with a new diagnosis of drug allergy who are being referred or discharged have their drug allergy status updated in all GP referral and hospital discharge letters.

Rationale

Updating information on drug allergy status and sharing this information among services is important for improving patient safety and reducing the costs associated with treating allergic reactions. Improved communication between primary and secondary healthcare providers will also allow safe prescription of alternative drugs and reduce inappropriate drug avoidance. Full details of the drug and allergic reaction are important if the same drug is needed again and also improve diagnostic accuracy if the patient needs specialist investigation of the allergy.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a new diagnosis of drug allergy who are being referred or discharged have their drug allergy status updated in all GP referral and hospital discharge letters.
Data source: Local data collection.
Process
a) Proportion of GP referral letters for people with a new diagnosis of drug allergy with updated drug allergy status.
Numerator – the number in the denominator with updated drug allergy status.
Denominator – the number of GP referral letters for people with a new diagnosis of drug allergy.
Data source: Local data collection.
b) Proportion of hospital discharge letters for people with a new diagnosis of drug allergy with updated drug allergy status.
Numerator – the number in the denominator with updated drug allergy status.
Denominator – the number of hospital discharge letters for people with a new diagnosis of drug allergy.
Data source: Local data collection.
Outcome
a) Mortality.
Data source: Local data collection.
b) Repeat allergic drug reactions.
Data source: Local data collection.
c) Length of hospital stay.
Data source: Local data collection.
d) Inappropriate avoidance of drugs.
Data source: Local data collection.
e) Anaphylaxis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary and secondary care services) ensure that healthcare professionals update drug allergy status in all GP referral and hospital discharge letters for people with a new diagnosis of drug allergy.
Healthcare professionals update drug allergy status in all GP referral and hospital discharge letters for people with a new diagnosis of drug allergy.
Commissioners (NHS England area teams and clinical commissioning groups) commission services in which healthcare professionals update information on drug allergy status in all GP referral and hospital discharge letters for people with a new diagnosis of drug allergy.

What the quality statement means for patients, service users and carers

People have any new information about drug allergy added to their records. The information is also included by their GP in all letters referring them to a hospital or clinic, and in all letters sent to their GP when they leave hospital.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendation 1.2.7.

Prescription information on drug avoidance: developmental

This quality statement is taken from the drug allergy quality standard. The quality standard defines clinical best practice in drug allergy and should be read in full.
Developmental quality statements set out an emerging area of service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Developmental quality statement

People with a drug allergy have information included on their prescriptions about which drugs or drug classes to avoid.

Rationale

Recording information on drug avoidance on a prescription is important for patient safety. Expert opinion suggests that only some hospitals have prescription forms which include drug allergy status.

Quality measures

Structure
Evidence of local arrangements to ensure that prescriptions have drug allergy information included about which drugs or drug classes to avoid.
Data source: Local data collection.
Process
a) Proportion of paper prescriptions issued in any healthcare setting which have drug allergy information included about which drugs or drug classes to avoid.
Numerator – the number in the denominator which have drug allergy information about which drugs or drug classes to avoid.
Denominator – the number of paper prescriptions issued in any healthcare setting.
Data source: Local data collection.
b) Proportion of electronic prescriptions issued in any healthcare setting which have drug allergy information included about which drugs or drug classes to avoid.
Numerator – the number in the denominator which have drug allergy information about which drugs or drug classes to avoid.
Denominator – the number of electronic prescriptions issued in any healthcare setting.
Data source: Local data collection.
Outcome
a) Mortality.
Data source: Local data collection.
b) Repeat allergic drug reactions.
Data source: Local data collection.
c) Inappropriate avoidance of drugs.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (secondary care) ensure that people with a drug allergy have information included on their prescriptions about which drugs or drug classes to avoid.
Healthcare professionals issue prescriptions which have drug allergy information included about which drugs or drug classes to avoid.
Commissioners (NHS England area teams and clinical commissioning groups) commission services in which people with a drug allergy have information included on their prescriptions about which drugs or drug classes to avoid.

What the quality statement means for patients, service users and carers

People with a drug allergy are given prescriptions which include information on any drugs or types of drug that they should avoid.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendation 1.2.4.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

a severe, life-threatening, generalised or systemic hypersensitivity reaction – it 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.
after complete recovery of anaphylaxis, a recurrence of symptoms within 72 hours with no further exposure to the allergen, managed in the same way as anaphylaxis
denotes a form of anaphylaxis where no identifiable stimulus can be found; all known causes of anaphylaxis must be excluded before this diagnosis can be reached
the diagnosis, prior to assessment by a specialist allergist, for people who present with symptoms of anaphylaxis; 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 these recommendations, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'
the diagnosis, prior to assessment by a specialist allergist, for people who present with symptoms of anaphylaxis; 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 these recommendations, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'

Paths in this pathway

Pathway created: December 2011 Last updated: November 2017

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