Yes This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative.

Title: Identifier: Replaces: Across NHS Boards Patient Group Direction for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals working within NHS Grampian NHSG/PGD/ADR/MGPG609 NHSG/PGD/ADR/MGPG483 Organisation Wide Directorate Clinical Service Sub Department Area Yes This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. Author: Subject Key word(s): Policy application: Purpose: PGD Pharmacist, Pharmacy and Medicines Directorate Patient Group Direction PGD patient group direction dental nurse pharmacist physiotherapist podiatrist radiographer Emerade EpiPen Minijet Jext NHS Grampian This Patient Group Direction (PGD) authorises appropriately qualified and trained health professionals to administer adrenaline (epinephrine) to individuals without the requirement for a patient specific prescription written by a medical practitioner. Responsibilities for implementation: Organisational: Corporate: Departmental: Area: Hospital/Interface services: Operational Management Unit: Policy statement: Review: Midwifery/Nursing/Pharmacy/Physiotherapy/Podiatry/Radiology/ Dentistry Management Teams Directors of Nursing/ Midwifery/Pharmacy/Physiotherapy/Podiatry/Radiology/Dentistry Lead nurses, GP practices Line Managers General Managers and Group Clinical Directors Unit Operational Managers It is the responsibility of individual health professionals and their line managers to ensure that they work within the terms laid down in this PGD and to ensure that staff are working to the most up to date PGD. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced. Supervisory staff at all levels must ensure that staff using this PGD act within their own level of competence. This policy will be reviewed at least every two years or sooner if current treatment recommendations change. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609 - i -

This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245. Responsible for review of this document: Responsible for ensuring Registration of this document on the NHS Grampian Information/ Document Silo: Physical location of the original of this document: Job/group title of those who have control over this document: Responsible for disseminating document as per distribution list: PGD pharmacist, Pharmacy and Medicines Directorate Medicines Management pharmacist, Pharmacy and Medicines Directorate Pharmacy and Medicines Directorate Pharmacy and Medicines Directorate PGD pharmacist, Pharmacy and Medicines Directorate Revision History: Date of Approval change date of PGD being Summary of Changes Section heading superseded Sept 2013 Nov 2013 2 yearly update into new template. Sept 2013 Nov 2013 Anapen removed as no longer available. Throughout April 2014 Nov 2013 Minijet manufacturer updated. 3.1 April 2014 Nov 2013 Emerade added. Throughout May 2014 Nov 2013 Addition of AVPU. 2.1 May 2014 Nov 2013 Removal of volume left in device. 3.1 June 2014 Nov 2013 Cardiac and respiratory arrest moved to the end of 2.1 assessment section from breathing and circulation Assess removed from A B C D. Time interval added at Immediate treatment (vii). June 2014 Nov 2013 Specific volumes left in devices removed. Advice 3.1 that some solution may remain added. June 2014 Nov 2013 Removed advice for adults at high risk to use 3.2 Emerade 500 micrograms. Added information about needle selection. June 2014 Nov 2013 Addition of "use a trauma mask at 15 litres/min" 3.4 June 2014 Nov 2013 Addition of where to access anaphylaxis training. 4 Addition of specified dental nurses. June 2014 Nov 2013 Additional recording requirement. Addition of dental 5.2 nurses. June 2014 Nov 2013 Addition of Anaphylaxis algorithm. Appendix 3 UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609 - ii -

Patient Group Direction for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals working within NHS Grampian Part A... 2 1. Introduction... 2 2. Clinical Decision Making... 2 2.1. Patients who may be considered for the administration of adrenaline (epinephrine)... 2 2.2. Patients who may receive the administration of adrenaline (epinephrine)... 5 2.3. Contraindications... 5 2.4. Precautions... 5 2.5. Action to be taken when a patient is excluded from treatment under this PGD 6 2.6. Action to be taken when a patient/parent/guardian or person with parental responsibility does not wish the treatment to be received under this PGD... 6 3. Description Of Treatment Available Under This Direction... 6 3.1. Adrenaline (Epinephrine)... 6 3.2. Dose, route and frequency... 7 3.3. Concurrent medication... 8 3.4. Adverse effects... 8 3.5. Advice to patient... 9 3.6. Follow up treatment... 9 Part B... 10 4. Designated Staff Authorised To Administer Under This PGD... 10 5. Documentation... 11 5.1. Authorisation of administration... 11 5.2. Record of administration... 11 5.3. Consent... 12 6. Further Points... 12 7. Facilities And Supplies To Be Available At Sites For The Administration Of The Drug Specified In The PGD... 12 8. Audit... 13 Part C... 14 9. Management And Monitoring Of Patient Group Direction... 14 9.1. Consultative group... 14 9.2. Professional advisory group approving PGD... 14 9.3. Authorising managers... 14 10. References... 14 Appendix 1... 15 Appendix 2... 16 Appendix 3... 17 Appendix 4... 18 UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-1 -

Patient Group Direction For The Administration Of Adrenaline (Epinephrine) In Cases Of Suspected Anaphylactic Reactions By Qualified Health Professionals Working within NHS Grampian 1. Introduction Part A This PGD is designed to guide all qualified health professionals working within NHS Grampian on the administration of intramuscular (IM) adrenaline in cases of suspected hypersensitivity and anaphylactic reactions. Anaphylaxis is a severe, life-threatening, generalised, or systemic hypersensitivity reaction. This is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes. Patient groups at increased risk are those with existing hypersensitivity and immune disorders such as asthma, haemolytic anaemia, thyroiditis, systemic lupus erythematosus and rheumatoid arthritis. This PGD should be used in conjunction with the recommendations in the current British National Formulary, individual Summary of Product Characteristics and The Resuscitation Council (UK). 2. Clinical Decision Making 2.1. Patients who may be considered for the administration of adrenaline (epinephrine) Administration of IM adrenaline (epinephrine) should be considered for individuals who show signs and symptoms of an anaphylactic reaction. Anaphylaxis is likely when all of the following three criteria are met: (i) (ii) Sudden onset and rapid progression of symptoms. Life-threatening Airway and/or Breathing and/or Circulation problems. (iii) Skin and/or mucosal changes (flushing, urticaria, angioedema). See Resuscitation Council (UK) Anaphylactic reactions Initial treatment - (Appendix 3) which supports the use of adrenaline in this PGD. The ABCDE approach to assess and treat a patient should be followed, as patients can have an Airway, Breathing or Circulation Problem or any combination which is life threatening. See Appendix 4 for Resuscitation Council (UK) Anaphylaxis Algorithm (March 2008). UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-2 -

Airway (i) Airway swelling, e.g. throat and tongue swelling (pharyngeal/laryngeal oedema). The patient has difficulty in breathing and swallowing and feels that the throat is closing up. (ii) Hoarse voice. (iii) Stridor this is a high-pitched inspiratory noise caused by upper airway obstruction. Breathing (i) (ii) Increased respiratory rate. Shortness of breath. (iii) Wheeze. (iv) Hypoxia- which can lead to confusion/agitation. (v) Cyanosis (appears blue) this is usually a late sign. (vi) Patient becoming tired. Circulation (i) (ii) Signs of shock pale, clammy. Increased pulse rate (tachycardia). (iii) Low blood pressure (hypotension) feeling faint (dizziness) which may lead to collapse. (iv) Decreased conscious level or loss of consciousness. (v) Anaphylaxis can cause myocardial ischaemia and electrocardiograph (ECG) changes even in individuals with normal coronary arteries. Disability Airway, Breathing and Circulation problems can all alter the patient s neurological status because of decreased brain perfusion. Using the Alert, responds to Vocal stimuli, responds to Painful stimuli, or Unresponsive to all stimuli (AVPU) method of assessment can determine a patient s conscious level. Patients can also have gastro-intestinal symptoms (abdominal pain, incontinence, vomiting). UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-3 -

Exposure The patient must be exposed ensuring dignity to observe for skin and/or mucosal changes. This is often the first feature and present in over 80% of anaphylactic reactions. (i) (ii) They can be subtle or dramatic. There may be just skin, just mucosal, or both skin and mucosal changes. (iii) There may be erythema a patchy, or generalised, red rash. (iv) There may be urticaria (also called hives, nettle rash, weals or welts), which can appear anywhere on the body. The weals may be pale, pink or red, and may look like nettle stings. They can be different shapes and sizes and are often surrounded by a red flare. They are usually itchy. (v) Angioedema is similar to urticaria but involves swelling of deeper tissues, most commonly in the eyelids and lips, and sometimes in the mouth and throat. ANAPHYLAXIS CAN RESULT IN RESPIRATORY AND CARDIAC ARREST Immediate Treatment (i) Reassure and explain the situation to the patient/parent/guardian or person with parental responsibility. (ii) Assess airway and breathing and identify signs and symptoms of anaphylaxis (see 2.1). (iii) Identify and discontinue trigger factors. (iv) Call for help, e.g. 999, doctor, 2222 Clinical Emergency Team. (v) Patients with airway or breathing problems may prefer to sit up as this will make breathing easier. (vi) Assess circulation (see 2.1). Laying the patient flat with or without leg elevation may be helpful for patients with hypotension. If the patient feels faint, do not sit or stand them up as this may cause cardiac arrest. NB. A sudden change to a more upright position may be dangerous due to the effect on blood flow to the heart. (vii) If the patient presents with signs of clinical shock, airway swelling, or definite breathing difficulties indicating a severe reaction, administer IM adrenaline 1,1000 as recommended, noting the time given and the response. The same dose can be repeated as necessary at intervals of 5 minutes if there is no Improvement in the patient s clinical condition. (viii) Continue to observe the patient supporting and maintaining a clear airway, observing breathing and where available administer oxygen.* (ix) Continuous assessment of the patient is important using the ABCDE approach. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-4 -

(x) Patients who are breathing and unconscious should be placed in the recovery position. (xi) Pregnant patients should lie on their left side to prevent caval compression. (xii) If the patient is not breathing or has no pulse, commence cardio pulmonary resuscitation (CPR) using current guidelines. Continue until: More qualified help arrives You become exhausted Patient shows signs of recovery. For up to date guidance on the Emergency Treatment of Anaphylactic Reactions visit The Resuscitation Council (UK) web site: www.resus.org.uk Oxygen Therapy *Under normal circumstances, oxygen should always be prescribed. However, in a life saving situation, if a healthcare professional is competent to administer oxygen and has the appropriate skills and knowledge to do this, then providing the healthcare professional can account for his/her actions, they may administer oxygen without the need for a prescription or a Patient Group Direction. However, the healthcare professional is accountable and must be answerable for all his/her actions and omissions and must always be able to justify their decisions. The healthcare professional must be able to demonstrate that they have acted in someone s best interests if they have provided care in an emergency and must recognise and work within the limits of their competence. 2.2. Patients who may receive the administration of adrenaline (epinephrine) Individuals displaying the previously described signs and symptoms who are: (i) (ii) (iii) hospital in-patients. hospital out-patients attending out-patient or diagnostic departments. visitors or members of staff. (iv) patients receiving care in the community, including minor injury units, GP practices, Health Centres, clinics, schools, pharmacies, patient s own houses and other community settings. 2.3. Contraindications Contraindications are relative as this product is intended for use in life threatening emergencies. 2.4. Precautions Treatment for those who require extra caution Current guidance, Emergency treatment of anaphylactic reactions, Resuscitation Council (UK) January 2008, annotated with links to NICE guidance July 2012, is to UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-5 -

monitor the response, start with a safe dose and give further doses if a greater response is needed, i.e. titrate the dose according to effect. See section 3.2 for recommended doses. 2.5. Action to be taken when a patient is excluded from treatment under this PGD Not applicable. 2.6. Action to be taken when a patient/parent/guardian or person with parental responsibility does not wish the treatment to be received under this PGD The patient/parent/guardian or person with parental responsibility should be advised of the potential risks. Administer adrenaline if condition deteriorates to unconsciousness. 3. Description Of Treatment Available Under This Direction 3.1. Adrenaline (Epinephrine) Adrenaline (epinephrine) is a sympathomimetic drug which provides physiological reversal of the immediate symptoms of hypersensitivity and anaphylaxis such as laryngeal oedema, hypotension and bronchoconstriction. For advice on choice of needle and injection technique see Emergency treatment of anaphylactic reactions. January 2008. www.resus.org.uk Adrenaline (Epinephrine) is a Prescription-only Medicine (PoM) and can be supplied as: (i) adrenaline (epinephrine) 1:1000 (1mg/mL ampoule) - non-proprietary, available as 0.5mL and 1mL ampoules. (ii) Emerade 500 microgram dose adrenaline (epinephrine) 1mg/mL in a 0.5mL autoinjector device imed. (iii) Emerade 300 microgram dose adrenaline (epinephrine) 1mg/mL in a 0.5mL autoinjector device imed. (iv) Emerade 150 microgram dose adrenaline (epinephrine) 1mg/mL in a 0.5mL autoinjector device imed. (v) EpiPen 300 microgram dose adrenaline (epinephrine) 1mg/mL in a 2mL autoinjector device Meda Pharmaceuticals. (vi) EpiPen Jr 150 microgram dose adrenaline (epinephrine) 500micrograms/mL in a 2mL auto-injector device - Meda Pharmaceuticals. (vii) Jext 300 microgram dose adrenaline (epinephrine) 1mg/mL in a 1.4mL autoinjector device ALK-Abello. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-6 -

(viii) Jext 150 microgram dose adrenaline (epinephrine) 1mg/mL in a 1.4mL autoinjector device - ALK-Abello. (ix) Minijet Adrenaline 1:1000 (1mg/mL) 1mL disposable syringe with 21G 1.5 inch needle for intramuscular (IM) injection (International Medication Systems (UK) Limited). The single use auto-injectors Emerade, EpiPen, Jext or Minijet Adrenaline may be prescribed by doctors for home use so that adrenaline (epinephrine) may be administered before medical help is available). Their use is reserved for specific clinical areas within NHSG, e.g. radiography. Practitioners should be aware that some solution may remain in the device after use but the device is only for a single use. Adrenaline (Epinephrine) 1:10 000 (1mg/10mL) is also available for the intravenous (IV) route but its use is not covered within this PGD. 3.2. Dose, route and frequency Dose Non-proprietary adrenaline Adults - 500micrograms (0.5mL) of adrenaline (epinephrine) 1:1000 (1mg/mL). Infants and Children - The scientific basis for the recommended doses is weak. The recommended doses are based on what is considered to be safe and practical to draw up and inject in an emergency. Table 1. Reference - Emergency treatment of anaphylactic reactions. January 2008. Resuscitation Council (UK) Age Dose of Adrenaline Volume of 1:1000 (1mg/mL) solution Under 6 years 150 micrograms IM 0.15mL 6-12 years 300 micrograms IM 0.3mL Over 12 years 500 micrograms IM (300 micrograms IM if the patient is small or prepubertal) Proprietary adrenaline auto-injectors. 0.5mL (0.3mL) Healthcare professionals should be familiar with the use of the most commonly available auto-injector devices. The dose recommendations for adrenaline in this guideline are intended for healthcare providers treating an anaphylactic reaction. If an adrenaline auto-injector is the only available adrenaline preparation when treating anaphylaxis, healthcare providers should use it. For adults and older children weighing between 30 kg and 60 kg, the usual dose is 300 microgram of Emerade, EpiPen or Jext or a 500 microgram dose of Emerade or Minijet Adrenaline.* For young children (under 30 kg) - a 150 microgram dose of Emerade, EpiPen Jr or Jext. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-7 -

*N.B. Minijet Adrenaline is only suitable for children aged 12 years and over and may not be suitable for small or prepubertal patients over 12 years of age who require a smaller dose. For proprietary and non-proprietary Route The recommended route of choice is intramuscular (IM) injection. The best site for IM injection is the anterolateral aspect of the middle third of the thigh. The needle needs to be long enough to ensure that the drug is injected into the muscle. A 25mm needle is best and is suitable for all ages. In pre-term or very small infants, a 16mm needle is suitable for IM injection. In some adults, a longer length (38 mm) maybe needed - see Resus Council for choice of needle and technique for IM injections. Frequency The same dose can be repeated as necessary at intervals of 5 minutes if there is no improvement in the patient s condition or on assessment of the patient s respiratory rate, pulse and blood pressure. Total dose The dose as detailed above can be repeated at intervals of 5 minutes until the patient improves or emergency medical services/ambulance have arrived. 3.3. Concurrent medication There are no absolute contraindications to the administration of adrenaline under this PGD with any concurrent medication, as adrenaline is intended for use in a life threatening emergency. However, there is large inter-individual variability in the response to adrenaline. In certain clinical practice, it is important to monitor the response; start with the recommended dose and give further doses if a greater response is needed. This approach will therefore allow the management of any effects of interacting drugs, e.g. tricyclic antidepressants, cardiac glycosides. Non selective beta blockers - patients taking these may not respond to the adrenaline injection and require intravenous salbutamol or aminophylline as well but this would be prescribed by the relevant doctor or GP. 3.4. Adverse effects Adverse effects are extremely rare with correct doses injected intramuscularly. Where available, give high flow oxygen as soon as possible using a trauma mask at 15 litres/min. See section 2.1. Medical advice Medical advice must be sought as soon as any patient, visitor or staff member develops any adverse signs of hypersensitivity as outlined in section 2.1. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-8 -

Immediately telephone 2222 (internal hospital) clearly stating clinical emergency team required, ward area/number and hospital name. Within the community setting telephone emergency services (9) 999 requesting urgent assistance. Overdose Overdose is unlikely as the dose is titrated. 3.5. Advice to patient If conscious, prior to the administration of adrenaline (epinephrine) the patient should receive an explanation that they are having an allergic reaction and that IM adrenaline (epinephrine) is going to be administered to relieve the symptoms and help reverse the reaction. Following the administration of adrenaline (epinephrine) when the patient is stable, investigation and follow-up by an allergy specialist would be advised. 3.6. Follow up treatment Hospital in-patients require close observation on the ward. They may need to be transferred to a high dependency facility depending on the severity of reaction and medical decision. Any affected hospital out-patients, staff or visitors, patients in the community or those attending clinics/health centres need to be transferred to a major A and E, i.e. A.R.I, Aberdeen or Dr Grays, Elgin or a high dependency facility depending on the severity of the reaction and the medical decision. The medical practitioner in charge of the patient s care should be informed. Further Information: Suspected reactions should be notified by a medical practitioner to the Consultant Immunopathologist, Immunology, Foresterhill. Ideally, all individuals should be offered immunological follow up. Referral details should include: Full details of the event Time course of the reaction All drugs used Resuscitative measures Patient s response to treatment Previous adverse reactions UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-9 -

4. Designated Staff Authorised To Administer Under This PGD Part B The following staff are authorised to administer the drug specified in this PGD without an individual medical prescription providing the patient falls into one of the categories listed in 2.2 of this PGD. Staff must be employed either directly by NHS Grampian, or contracted to provide NHS services, or providing services in partnership with NHS Grampian under the direction of this authorised PGD. (i) Registered Nurse or Midwife as recognised by the NMC. (ii) Registered Practising Pharmacist as recognised by the GPhC. (iii) Registered Physiotherapist as recognised by the HPC. (iv) Registered Podiatrist as recognised by the HPC. (v) State Registered Radiographer as recognised by the SCoR. (vi) Dental Nurses registered with the General Dental Council who are also either dental hygienists or dental therapists. In addition the following requirements are necessary. Staff must: (i) agree to be professionally accountable for their work (Appendix 1). (ii) be competent to assess the patient s capacity to understand the nature and purpose of the administration in order for the patient to give or refuse consent. (iii) be aware of current treatment recommendations and be competent to discuss issues about the drug with the patient. (iv) have been trained and assessed as being competent in the administration of the drug. All staff will have access to the current PGD. (v) have undertaken an NHSG e-anaphylaxis training session which covers all aspects of the identification and management of anaphylaxis. This can be accessed via eksf or the AT Learning tool. (vi) be competent in basic life support which is required to be updated annually. (vii) maintain their skills, knowledge and their own professional level of competence in this area according to their individual Code of Professional Conduct. (viii) agree to work within the terms of the NHS Grampian PGD. Professional Managers/Nurse managers/lead nurses will be responsible for: (i) Ensuring that the current PGD is available to staff providing care under this direction. (ii) Ensuring that the staff have access to all relevant Scottish Government Health Directorate advice, including any relevant CMO letter(s). (iii) Ensuring that staff have received adequate training in all areas relevant to this PGD and meet the requirements above. (iv) Maintaining a current record of all staff authorised to administer the drug specified in this PGD. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-10 -

5. Documentation 5.1. Authorisation of administration Nurses working in GP surgeries can be authorised to administer the drug specified in this PGD by practice GPs. (NB. GP practices must have adopted NHS Grampian PGD for use in their practice). Nurses in Occupational Health can be authorised to administer the drug specified in this PGD by the Consultant in Occupational Health Medicine, NHS Grampian. Nurses or Midwives working within NHS Grampian can be authorised to administer the drug specified in this PGD by their nurse manager. Registered practising Pharmacists can be authorised to administer the drug specified in this PGD by the Director of Pharmacy and Medicines Management. Radiographers working within NHS Grampian can be authorised to administer the drug specified in this PGD by a Consultant Radiologist. Registered Physiotherapists working within NHS Grampian can be authorised to administer the drug specified in this PGD by their Head of Service. Registered Podiatrists working within NHS Grampian can be authorised to administer the drug specified in this PGD by their Head of Service. TB Nurse Specialists and Health Protection Nurse Specialists can be authorised to administer the drug specified in this PGD by the Consultant in Public Health Medicine. Registered Dental Nurses working within NHS Grampian who are also either dental hygienists or dental therapists can be authorised to administer the drug specified in this PGD by their Head of Service. A certificate of authorisation (Appendix 2) signed by the authorising doctor/manager should be supplied. This should be held in the individual staff records or as agreed locally. 5.2. Record of administration Subsequent to the administration of the drug specified in this PGD, an electronic or paper record must be completed in order to allow audit of practice. This should include: (i) Name and address of patient/parent/guardian or person with parental responsibility, patient CHI No (ii) Date of birth (iii) Consultant/General Practitioner details (iv) Physical examination required, if appropriate (v) Exclusion criteria, record why drug not administered (vi) Reason for giving. Known or suspected causative agent. (vii) Consent to the administration (if not obtained elsewhere) (viii) Drug manufacturer, batch number, expiry date (ix) Site where drug administered, dose and route of administration (x) Signature and name in capital letters of practitioner who administered the drug UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-11 -

(xi) Date drug given (xii) Record of adverse effects (advise patient s doctor). A record of the administration must be made. This can either be done electronically or into the patient s case notes or an out-patient report form completed giving full details of the incident and the treatment given. The incident must always be reported to the medical practitioner in charge of the patient s care. The health professional involved must ensure that the use of drug specified in this PGD is recorded appropriately and reported to the appropriate manager. If the reaction was caused by a drug/medication being administered to a patient, the event should be recorded on Datix, where this is available. The event should also be recorded on a Document of Resuscitation Form (copy to be sent to NHSG resuscitation department) and in the patients medical records. All serious adverse events related to medicines should be reported to the MHRA via the yellow card scheme or on the website at www.yellowcard.gov.uk. These records should be retained: For children and young people, retain until the patient's 25th birthday or 26th if the young person was 17 at the conclusion of treatment. For 17 years and over retain for 6 years after last date of entry. Or for 3 years after death, or in accordance with local policy, where this is greater than above. 5.3. Consent If the patient is unable to give consent due to a life-threatening situation, or if parents or guardians are not present, adrenaline (epinephrine) should be administered where treatment is judged to be in the best interests of the patient. Prior to the administration of the drug, consent must be obtained, preferably written, either from the patient, parent, guardian or person with parental responsibility and documented either in the patient s medical records/notes or on an administration form (see section 5.2). Consent must be in line with current NHSG Staff Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions. See link below. http://intranet.grampian.scot.nhs.uk/ccc_nhsg/15692.html?pmenuid=460& 6. Further Points The health professional involved must ensure that the use of drug specified in this PGD is recorded appropriately and reported to the appropriate manager. 7. Facilities And Supplies To Be Available At Sites For The Administration Of The Drug Specified In The PGD The following should be available at sites where the drug is to be administered: (i) 1st line resuscitation equipment to meet airway and ventilation requirements. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-12 -

(ii) In the community, staff should have pocket masks and/or a bag/valve/mask for assisted ventilation as part of their anaphylaxis kit. (iii) Adrenaline (epinephrine) 1:1000 (1mg/mL), Emerade, EpiPen, Jext or Minijet Adrenaline. (iv) Access to medical support (this may be via telephone). (v) Safe storage areas for medicines and equipment. (vi) Approved equipment for the disposal of used materials. (vii) Clean and tidy work areas. (viii) Copies of the current PGD for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals. 8. Audit All records of administration of the drug specified in this PGD will be filed with the normal records of medicines administration in each practice/service. A designated person within each CHP/practice/service will be responsible for auditing completion of drug forms and collation of data. UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-13 -

Appendix 1 Health Care Professional Agreement To Administer Medicines Under Patient Group Direction I: (Insert name) Working within: e.g. CHP, Practice Agree to administer medicines under the direction contained within the following Patient Group Direction Patient Group Direction for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals working within NHS Grampian I have completed the appropriate training to my professional standards enabling me to administer medicines under the above Patient Group Direction. I agree not to act beyond my professional competence nor outwith the recommendations of the Patient Group Direction. Signed: Print Name: Date: Professional Registration No: UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-15 -

Appendix 2 Certificate Of Authorisation To Administer Medicines Under Patient Group Direction This authorises: Working within: e.g. CHP, Practice To administer medicines under the following Patient Group Direction Patient Group Direction for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals working within NHS Grampian The above named person has satisfied the training requirements and is authorised to administer medicines under the above Patient Group Direction. The above named person has agreed not to act beyond their professional competence nor outwith the recommendations of the Patient Group Direction Signed: Authorising Manager/Doctor Print Name: Date: UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-16 -

Appendix 3 Resuscitation Council UK - Anaphylaxis algorithm UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/PGD/ADR/MGPG609-17 -