725 A quality improvement approach to non-emergency management of anaphylaxis

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Aims The National Institute for Health and Care Excellence (NICE) Clinical Guideline 134 details best practice in management of patients presenting with anaphylaxis after their emergency treatment is complete. We audited our compliance against these standards with the goal of improving our quality of care. Methods We retrospectively audited care provided to 41 patients presenting to Birmingham Children’s Hospital with anaphylaxis between March 2020 and March 2021 by reviewing details in the emergency department (ED) and inpatient electronic patient records and discharge letters. We created a process map to illustrate the steps taken in management and used this to create a driver diagram to aid quality improvement efforts. We developed change ideas to improve performance against these drivers, implemented them individually and studied the outcome in a cyclical ‘plan-do-study-act’ (PDSA) fashion. Results Performance against the NICE Guideline was mixed. 85% of patients were discharged with adrenaline autoinjectors (or already possessed at least two spares). However, only 41% of letters mentioned training patients and families how to use these autoinjectors. Based on the written record, only 22% of patients left with written Allergy Action Plans, and only 15% were signposted to additional information and support. Approximately half of patients (51%) were not referred for specialist follow-up. A process map unsurprisingly showed that the above tasks should be performed between ward round review and discharge. Our driver diagram used the four main standards from the NICE guideline as the primary drivers. Education and training would potentially address all four main targets for improvement. However, the mandatory training burden for clinical staff is already significant; additional training and ‘working harder’ is not an ideal or sustainable approach, particularly for uncommon conditions. We recognised the need to create a systemic barrier to poor compliance. A documentation change was therefore the first change idea implemented. After discussion in the departmental governance meeting, a discharge checklist on the electronic patient record was preferred to a specific ED proforma to be generated at presentation. Figure 1 shows the checklist as it appears on a discharge letter generated from our electronic patient record. As anaphylaxis is thankfully an infrequent presentation, we do not yet have comparable data to analyse before targeting another driver with a change idea in the next PDSA cycle. Anecdotally, we have demonstrated 100% compliance with NICE Clinical Guideline 134 since implementation. Conclusion We identified weaknesses in our current practice. Applying the principles of continuous quality improvement allowed us to improve our compliance with national best practice for non-emergency management of anaphylaxis. We plan to continue to improve this process through repeated PDSA cycles. It is possible that our performance against the standards was better than our initial results suggest, as the majority of inpatient records in our organisation remain paper-based. For future PDSA cycles, we will also need to study the paper records to ensure that the processes in the discharge checklist are being completed adequately, rather than simply being marked as complete at the point of discharge by the discharging clinician.

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