- Email: [email protected]
Adrenaline (epinephrine) autoinjector use in preschools
LETTERS TO THE EDITOR 383
J ALLERGY CLIN IMMUNOL VOLUME 124, NUMBER 2
regular medical providers are more likely to seek medical care and treatment. For instance, asthma action plans typically recommend that the individual seek medical care in response to worsening asthma or poor asthma control. In addition, those who have more severe disease have the need to be followed closely by a physician. Similarly, a higher rate of steroid use in those children being treated by specialists compared with children followed by primary care providers was found, not surprising as these children are more likely to be referred to specialists. Racial differences in asthma control were confirmed. Black subjects showed subtle evidence of poorer asthma control, having higher percentages of nighttime symptoms than nonblack subjects. In conclusion, this study found that despite having access to care, there were still high percentages of children with uncontrolled asthma, indicating that children are in need of additional programs to identify, monitor, and educate those at high risk for asthma morbidity. Tracy Kruzick, MDa Ronina A. Covar, MDa Melanie Gleason, PAa Lisa Cicutto, RN, PhDa Marty White, BSNb Donna Shocks, RNb Stanley J. Szefler, MDa From aNational Jewish Health and bthe Denver Public School System, Denver, Colo. E-mail: [email protected]. Supported by the Colorado Department of Public Health and Environment Cancer, Cardiovascular, and Pulmonary Disease Program as well as GlaxoSmithKline. Disclosure of potential conflict of interest: R. A. Covar is an advisor and consultant for Merck. M. Gleason has received research support from AstraZeneca, GlaxoSmithKline, Merck, Genentech, and the National Institutes of Health and is a member of Board of Directors of the Colorado Asthma Coalition. L. Cicutto has received research support from the Ontario Ministry of Health and Long Term Care, the Ontario Lung Association, AllerGen NCE, the National Institutes of Health, and GlaxoSmithKline. S. J. Szefler is a consultant for GlaxoSmithKline, Genentech, and Merck and has received research support from the National Institutes of Health, the National Heart, Lung, and Blood Institute, the National Institute of Allergy and Infectious Diseases, Ross Pharmaceuticals, and GlaxoSmithKline. The rest of the authors have declared that they have no conflict of interest.
REFERENCES 1. Akinbami LJ. State of childhood asthma, United States, 1980-2005. 2006. National Center for Health Statistics Center for Disease Control. Available at: http:// www.cdc.gov/nchs/pressroom/06facts/asthma1980-2005.htm. Accessed December 12, 2006. 2. Berman S. Continuity, the medical home, and retail-based clinics. Pediatrics 2007; 120:1123-5. 3. Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med 2005;3:159-66. 4. Ortega AN, Belanger KD, Paltiel AD, Horwitz SM, Bracken MB, Leaderer BP. Use of health services by insurance status among children with asthma. Med Care 2001; 3910:1065-74. 5. Griswold SK, Nordstrom CR, Clark S, Gaeta TJ, Price ML, Camargo CA Jr. Asthma exacerbations in North American adults: who are the ‘‘frequent fliers’’ in the emergency department? Chest 2005;127:1579-86. 6. Ferris TG, Crain EF, Oken E, Wang L, Clark S, Camargo CA Jr, et al. Insurance and the quality of care for children with acute asthma. Ambul Pediatr 2001;1:267-74. 7. Fry-Johnson YW, Daniels EC, Levine R, Rust G. Being uninsured: impact on children’s healthcare and health. Curr Opin Pediatr 2005;12:751-2. 8. Halterman JS, Montes G, Shone LP, Szilagyi PG. The impact of health insurance gaps on access to care among children with asthma in the United States. Ambul Pediatr 2008;8:43-9. Available online July 14, 2009. doi:10.1016/j.jaci.2009.05.048
Adrenaline (epinephrine) autoinjector use in preschools To the Editor: Adrenaline (epinephrine) is currently the recommended treatment for anaphylaxis in the community. For Australian preschoolers, autoinjector devices are prescribed for those at high risk of anaphylaxis. EpiPen and EpiPen Junior (Dey Laboratories, Napa, Calif) are the only available adrenaline (epinephrine) autoinjector devices in Australia. It has been reported that the prescription of these devices is increasing1; however, there is little information about how they are used in the community. A recent report from the United Kingdom has shown deficiencies in use of autoinjectors by parents.2 To date, no published report has sought to evaluate whether child care workers can administer an EpiPen. Our primary aim was to assess the ability of childcare workers from preschools to appropriately use an EpiPen autoinjector device and to identify potential difficulties in delivering adrenaline (epinephrine) for anaphylaxis in the preschool setting. All preschools in an urban center in southwestern Sydney were asked to participate in the study if they had undergone training in the use of the EpiPen. Preschools were defined as those who had day education for children aged 3 to 6 years. Preschools were initially contacted by mail to inform them about the study. If staff at the preschool had received specific training in the use of the EpiPen device, they were eligible to participate. After written consent was obtained, an investigator visited the preschool and asked 1 staff member nominated by the school to outline when and from whom previous anaphylaxis education was received. They were then asked whether there was an action plan at the school and where it was located. They were then asked to demonstrate the administration of adrenaline (epinephrine) with the EpiPen trainer, and each step in the use of the autoinjector was marked as correct or incorrect by the investigator. The steps were as follows: (1) remove the device from the container; (2) remove the gray safety cap; (3) place the trainer tip on the upper outer thigh; (4) inject with the black tip; (5) inject by using a correct technique such that the device clicks; and (6) hold the device in place for 10 seconds (>5 seconds was acceptable). No names of staff or schools were recorded on the result sheet to protect confidentiality. Results were deidentified by using a coded, password-protected database. Of the 47 preschools contacted, 19 met the eligibility criteria and agreed to participate. Fourteen schools had received their education greater than or equal to 12 months before being asked to demonstrate the device by the interviewer. Three schools received their education less than 6 months earlier, and 2 did not know when the education was given. Of the 19 preschools, 11 had an anaphylaxis action plan. Staff at 3 (16%) schools demonstrated all 6 steps in the use of the EpiPen perfectly. Of these, the staff at 1 (33%) school had received their education less than 6 months ago. The association between EpiPen training less than 6 months before this study and correct use of the device was not found to be statistically significant (P > .10). The range of services accessed included first aid courses, paramedics, parents, parent support groups, and anaphylaxis nurse educators (who are jointly funded by the State Departments
384 LETTERS TO THE EDITOR
of Education and Health). There are no uniform guidelines as to what is included in these courses; however, the device was demonstrated during education. Of the 3 schools in which the EpiPen was correctly demonstrated, the staff at 2 had received education from different first aid courses, and 1 had received education from a paramedic. Staff in 12 (63%) of 19 preschools made more than 1 error with the trainer; these included attempting to inject with the wrong end of the device. Of the remaining 4 who made errors, 2 held the device in place for less than 10 seconds, and 2 pressed their thumbs over the white end of the device. Because the administration of adrenaline (epinephrine) is the first-line treatment of anaphylaxis, it is important to establish whether preschool staff can use autoinjector devices. Previous studies indicate that there are potential difficulties with parents and health care workers using adrenaline (epinephrine) autoinjectors.2,3 Before enrolling a child at risk of anaphylaxis, one of the most frequent questions asked by parents is whether preschool staff have been trained in the use of an EpiPen. An affirmative answer increases their confidence and provides reassurance. For these reasons, we only included preschools in which previous training (regardless of the type) had been received. Our study demonstrated that the majority of preschool staff who had received training could not demonstrate the EpiPen correctly. The ability to correctly use the device was not related to the timing of the education, although the numbers in our study were low. The majority of preschools had received their education more than 12 months before the interview. The range of education received was diverse, and there was no relationship between the type of education received and the correct use of the device. Multiple mistakes were made by 12 of the 19 staff when demonstrating the device.
J ALLERGY CLIN IMMUNOL AUGUST 2009
The majority of staff at preschools in a major urban center in Sydney cannot demonstrate the correct use of an EpiPen, despite having received training. Resources directed at improving access to good-quality, regulated, and frequent (perhaps monthly) education are needed. Re-evaluation is important, and parents of children with an EpiPen are advised to ensure that staff can use the device before their child attends the school. In addition, a rarely used device such as this appears to be difficult to use and is not intuitive. Placing a red arrow pointing to the black (injection) tip is a simple and inexpensive measure that might help to reduce the rate of error. Small changes like this should be considered until devices that are easier to use are developed. A discussion with the manufacturer about improving the design is needed. Preeti Joshi, MBBS, PhDa Constance H. Katelaris, MBBS, PhDb Brad Frankum, B Med (Hons), FRACPc From athe Department of Allergy, Immunology and Infectious Diseases, Children’s Hospital at Westmead, Sydney, Australia; bthe Department of Immunology and Allergy, University of Western Sydney, and Campbelltown Hospital, Australia; and c the Department of Clinical Education, University of Western Sydney, Sydney, and Campbelltown and Camden Hospitals, Australia. E-mail: [email protected]. Supported by the Australasian Society of Clinical Immunology and Allergy. Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts to disclose. REFERENCES 1. Clare WA, Campbell DE, Kemp AS. EpiPen use in children with food allergies. Med J Aust 2007;187:542. 2. Arkwright PD, Farragher AJ. Factors determining the ability of parents to effectively administer intramuscular adrenaline to food allergic children. Pediatr Allergy Immunol 2006;17:227-9. 3. Mehr S, Robinson M, Tang M. Doctor—how do I use my Epipen? Pediatr Allergy Immunol 2007;18:448-52. doi:10.1016/j.jaci.2009.06.033
J ALLERGY CLIN IMMUNOL VOLUME 124, NUMBER 2
regular medical providers are more likely to seek medical care and treatment. For instance, asthma action plans typically recommend that the individual seek medical care in response to worsening asthma or poor asthma control. In addition, those who have more severe disease have the need to be followed closely by a physician. Similarly, a higher rate of steroid use in those children being treated by specialists compared with children followed by primary care providers was found, not surprising as these children are more likely to be referred to specialists. Racial differences in asthma control were confirmed. Black subjects showed subtle evidence of poorer asthma control, having higher percentages of nighttime symptoms than nonblack subjects. In conclusion, this study found that despite having access to care, there were still high percentages of children with uncontrolled asthma, indicating that children are in need of additional programs to identify, monitor, and educate those at high risk for asthma morbidity. Tracy Kruzick, MDa Ronina A. Covar, MDa Melanie Gleason, PAa Lisa Cicutto, RN, PhDa Marty White, BSNb Donna Shocks, RNb Stanley J. Szefler, MDa From aNational Jewish Health and bthe Denver Public School System, Denver, Colo. E-mail: [email protected]. Supported by the Colorado Department of Public Health and Environment Cancer, Cardiovascular, and Pulmonary Disease Program as well as GlaxoSmithKline. Disclosure of potential conflict of interest: R. A. Covar is an advisor and consultant for Merck. M. Gleason has received research support from AstraZeneca, GlaxoSmithKline, Merck, Genentech, and the National Institutes of Health and is a member of Board of Directors of the Colorado Asthma Coalition. L. Cicutto has received research support from the Ontario Ministry of Health and Long Term Care, the Ontario Lung Association, AllerGen NCE, the National Institutes of Health, and GlaxoSmithKline. S. J. Szefler is a consultant for GlaxoSmithKline, Genentech, and Merck and has received research support from the National Institutes of Health, the National Heart, Lung, and Blood Institute, the National Institute of Allergy and Infectious Diseases, Ross Pharmaceuticals, and GlaxoSmithKline. The rest of the authors have declared that they have no conflict of interest.
REFERENCES 1. Akinbami LJ. State of childhood asthma, United States, 1980-2005. 2006. National Center for Health Statistics Center for Disease Control. Available at: http:// www.cdc.gov/nchs/pressroom/06facts/asthma1980-2005.htm. Accessed December 12, 2006. 2. Berman S. Continuity, the medical home, and retail-based clinics. Pediatrics 2007; 120:1123-5. 3. Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med 2005;3:159-66. 4. Ortega AN, Belanger KD, Paltiel AD, Horwitz SM, Bracken MB, Leaderer BP. Use of health services by insurance status among children with asthma. Med Care 2001; 3910:1065-74. 5. Griswold SK, Nordstrom CR, Clark S, Gaeta TJ, Price ML, Camargo CA Jr. Asthma exacerbations in North American adults: who are the ‘‘frequent fliers’’ in the emergency department? Chest 2005;127:1579-86. 6. Ferris TG, Crain EF, Oken E, Wang L, Clark S, Camargo CA Jr, et al. Insurance and the quality of care for children with acute asthma. Ambul Pediatr 2001;1:267-74. 7. Fry-Johnson YW, Daniels EC, Levine R, Rust G. Being uninsured: impact on children’s healthcare and health. Curr Opin Pediatr 2005;12:751-2. 8. Halterman JS, Montes G, Shone LP, Szilagyi PG. The impact of health insurance gaps on access to care among children with asthma in the United States. Ambul Pediatr 2008;8:43-9. Available online July 14, 2009. doi:10.1016/j.jaci.2009.05.048
Adrenaline (epinephrine) autoinjector use in preschools To the Editor: Adrenaline (epinephrine) is currently the recommended treatment for anaphylaxis in the community. For Australian preschoolers, autoinjector devices are prescribed for those at high risk of anaphylaxis. EpiPen and EpiPen Junior (Dey Laboratories, Napa, Calif) are the only available adrenaline (epinephrine) autoinjector devices in Australia. It has been reported that the prescription of these devices is increasing1; however, there is little information about how they are used in the community. A recent report from the United Kingdom has shown deficiencies in use of autoinjectors by parents.2 To date, no published report has sought to evaluate whether child care workers can administer an EpiPen. Our primary aim was to assess the ability of childcare workers from preschools to appropriately use an EpiPen autoinjector device and to identify potential difficulties in delivering adrenaline (epinephrine) for anaphylaxis in the preschool setting. All preschools in an urban center in southwestern Sydney were asked to participate in the study if they had undergone training in the use of the EpiPen. Preschools were defined as those who had day education for children aged 3 to 6 years. Preschools were initially contacted by mail to inform them about the study. If staff at the preschool had received specific training in the use of the EpiPen device, they were eligible to participate. After written consent was obtained, an investigator visited the preschool and asked 1 staff member nominated by the school to outline when and from whom previous anaphylaxis education was received. They were then asked whether there was an action plan at the school and where it was located. They were then asked to demonstrate the administration of adrenaline (epinephrine) with the EpiPen trainer, and each step in the use of the autoinjector was marked as correct or incorrect by the investigator. The steps were as follows: (1) remove the device from the container; (2) remove the gray safety cap; (3) place the trainer tip on the upper outer thigh; (4) inject with the black tip; (5) inject by using a correct technique such that the device clicks; and (6) hold the device in place for 10 seconds (>5 seconds was acceptable). No names of staff or schools were recorded on the result sheet to protect confidentiality. Results were deidentified by using a coded, password-protected database. Of the 47 preschools contacted, 19 met the eligibility criteria and agreed to participate. Fourteen schools had received their education greater than or equal to 12 months before being asked to demonstrate the device by the interviewer. Three schools received their education less than 6 months earlier, and 2 did not know when the education was given. Of the 19 preschools, 11 had an anaphylaxis action plan. Staff at 3 (16%) schools demonstrated all 6 steps in the use of the EpiPen perfectly. Of these, the staff at 1 (33%) school had received their education less than 6 months ago. The association between EpiPen training less than 6 months before this study and correct use of the device was not found to be statistically significant (P > .10). The range of services accessed included first aid courses, paramedics, parents, parent support groups, and anaphylaxis nurse educators (who are jointly funded by the State Departments
384 LETTERS TO THE EDITOR
of Education and Health). There are no uniform guidelines as to what is included in these courses; however, the device was demonstrated during education. Of the 3 schools in which the EpiPen was correctly demonstrated, the staff at 2 had received education from different first aid courses, and 1 had received education from a paramedic. Staff in 12 (63%) of 19 preschools made more than 1 error with the trainer; these included attempting to inject with the wrong end of the device. Of the remaining 4 who made errors, 2 held the device in place for less than 10 seconds, and 2 pressed their thumbs over the white end of the device. Because the administration of adrenaline (epinephrine) is the first-line treatment of anaphylaxis, it is important to establish whether preschool staff can use autoinjector devices. Previous studies indicate that there are potential difficulties with parents and health care workers using adrenaline (epinephrine) autoinjectors.2,3 Before enrolling a child at risk of anaphylaxis, one of the most frequent questions asked by parents is whether preschool staff have been trained in the use of an EpiPen. An affirmative answer increases their confidence and provides reassurance. For these reasons, we only included preschools in which previous training (regardless of the type) had been received. Our study demonstrated that the majority of preschool staff who had received training could not demonstrate the EpiPen correctly. The ability to correctly use the device was not related to the timing of the education, although the numbers in our study were low. The majority of preschools had received their education more than 12 months before the interview. The range of education received was diverse, and there was no relationship between the type of education received and the correct use of the device. Multiple mistakes were made by 12 of the 19 staff when demonstrating the device.
J ALLERGY CLIN IMMUNOL AUGUST 2009
The majority of staff at preschools in a major urban center in Sydney cannot demonstrate the correct use of an EpiPen, despite having received training. Resources directed at improving access to good-quality, regulated, and frequent (perhaps monthly) education are needed. Re-evaluation is important, and parents of children with an EpiPen are advised to ensure that staff can use the device before their child attends the school. In addition, a rarely used device such as this appears to be difficult to use and is not intuitive. Placing a red arrow pointing to the black (injection) tip is a simple and inexpensive measure that might help to reduce the rate of error. Small changes like this should be considered until devices that are easier to use are developed. A discussion with the manufacturer about improving the design is needed. Preeti Joshi, MBBS, PhDa Constance H. Katelaris, MBBS, PhDb Brad Frankum, B Med (Hons), FRACPc From athe Department of Allergy, Immunology and Infectious Diseases, Children’s Hospital at Westmead, Sydney, Australia; bthe Department of Immunology and Allergy, University of Western Sydney, and Campbelltown Hospital, Australia; and c the Department of Clinical Education, University of Western Sydney, Sydney, and Campbelltown and Camden Hospitals, Australia. E-mail: [email protected]. Supported by the Australasian Society of Clinical Immunology and Allergy. Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts to disclose. REFERENCES 1. Clare WA, Campbell DE, Kemp AS. EpiPen use in children with food allergies. Med J Aust 2007;187:542. 2. Arkwright PD, Farragher AJ. Factors determining the ability of parents to effectively administer intramuscular adrenaline to food allergic children. Pediatr Allergy Immunol 2006;17:227-9. 3. Mehr S, Robinson M, Tang M. Doctor—how do I use my Epipen? Pediatr Allergy Immunol 2007;18:448-52. doi:10.1016/j.jaci.2009.06.033