Reactions to Natural Rubber Latex (NRL) products impact on providers of care in the Accident & Emergency department because:
1. They are at increased risk of developing NRL allergy through the repeated use of NRL gloves
2. They may need to manage NRL-sensitive patients, which may be either known in advance or previously undiagnosed.
3. They have a statutory responsibility to reduce risk of sensitisation in themselves, their colleagues and their patients.
In the emergency setting, there is very little time to plan ahead for a specific emergency incident (unlike for example a patient presenting for elective surgery) and it may be difficult to know when you are dealing with a NRL-sensitive patient (eg if unconscious or previously undiagnosed).
Contact with NRL-containing medical equipment, products and drugs must be avoided in patients with diagnosed or suspected Type 1 NRL allergy, and NRL-free alternatives used instead. Special care must be taken with procedures that involve contact with mucosal or serosal skin surfaces (rapid absorption of NRL allergen) or when administering parenteral medication (eg rubber vial stoppers).
Given the lack of risk assessment time in the emergency setting, consideration should be given to phasing out of NRL containing medical equipment and products and replacing these with NRL-free alternatives as standard.
At the very least, NRL examination gloves (the most frequent cause of allergic reactions to NRL in the medical setting) should be replaced with appropriate NRL-free examination gloves as standard.
Doctors, nurses and other healthcare staff in A&E departments:
If gloves, medical equipment or drugs containing natural rubber are used, ensure that you have / are familiar with:
- A written policy on action to protect staff from developing NRL allergy
- A written policy on safe accommodation of NRL-sensitive members of staff
- A written policy for the safe management of patients with known or suspected NRL allergy
- An organisational purchasing programme which only supports powder-free/low-protein NRL glove use and wherever possible NRL-free equipment and product purchasing
- Organisational and local Glove selection guides (see Guidance on Latex Glove Selection here)
- An organisational NRL-free resuscitation policy. ALL products must be latex free, as it makes no sense to use NRL when it may have been the cause of anaphylaxis.
- Occupational Health pre-screening questionnaires
- Risk-assessments undertaken for your specific department
- Minimisation of purchase of NRL-containing products. Check with manufacturers ~ possibly labelled
- An Occupational Health/Health and Safety reporting mechanism for effective diagnostics of in-post staff
- Synthetic alternative gloves for use by sensitised staff and for sensitised patients
- Skin care protocol
- An Education programme to inform new and existing staff
- Posters for patient and staff information, clearly displayed and on file
- A named responsible person for managing Health and Safety
Best practice would suggest that patient assessment is undertaken using a Patient screening tool to identify at risk individuals. If the patient is unconscious or unable to communicate, an allergy identifier bracelet or necklace citing NRL allergy will inform emergency care workers of the patient’s allergy and the need to use equipment and drugs that do not contain natural rubber. However, remember that some sensitised patients may have undiagnosed NRL allergy or may not be wearing an amulet citing their allergy.
If pre-screening suggests that the patient may have an NRL sensitivity, diagnostic confirmation should subsequently be achieved.
Ideally, the General Practice, Outpatients Dept or Hospital Doctor will have informed the A&E Dept of the patient’s sensitisation by phone/referral letter if the patient presents via this route. It is vital to impress upon referring clinicians the importance of releasing this information to the emergency care team so that standard NRL-containing equipment can be replaced with designated NRL-free equipment for use on sensitised patients instead and allergic reactions avoided.
If a patient has a confirmed NRL allergy diagnosis, label the patient’s notes and patient clearly by using warning labels/ armband. Remember to inform future carers of the patient’s allergy, it’s significance and how to manage the patient safely. Patient confidentiality must be taken into account.
Consideration should be given to keeping an electronic register of local patients with NRL allergy, as this should alert the emergency services to the patient’s NRL allergy status prior to contact with the patient.
Consider sharing information on best practice, learning outcomes, locally pooled purchase plans (to keep the price down on quantity) for NRL free equipment with other local Trusts.
In general, emergency medical and resuscitation equipment should be NRL-free wherever possible and other NRL containing medical equipment covered over. It is important to be prepared to treat severe allergic reactions and provide emergency medical care to sensitised patients with NRL-free equipment as far as possible. Ensure that an NRL-free product list is available within areas of emergency treatment.
- Oral and nasal airways
- Oxygen masks and nasal cannulae
- Self-inflating bag
- Blood pressure monitor
- Emergency medication
- IV lines and infusion bags
- Equipment tubing
- Adhesives and dressings and their packaging
- Stoppers in vials
- Needle sheaths on pre-filled syringes
For the more reactive patient other items should be checked for their NRL content.
If the patient has a “NRL-free treatment kit” in their home or on their person, the contents of this may be used as appropriate.
Management of allergic reactions to NRL
Ensure that NRL-free emergency equipment and medicines are readily available to treat any allergic reaction from mild (eg urticaria and asthma) to severe reactions including anaphylaxis (laryngeal oedema / bronchospasm / cardiovascular collapse), and that all staff are fully trained in resuscitation techniques*. Critical emergency medical care should not be delayed to modify NRL-containing equipment, (but see above comment about being prepared, hence the importance of having readily available NRL-free supplies of medical equipment and drugs).
*Resuscitation Council (UK) guidance emergency medical treatment of anaphylactic reactions.
All new staff must be assessed using a pre-employment screening tool by the Occupational Health Department Occupational Health
If staff are identified as sensitised to NRL, Occupational Health must work with the senior member of staff in the department to undertake a risk-assessment to ensure that the working environment is safe for the continuing employment of the affected member of staff. Risk minimisation and education of colleagues is the vital element to working safely in critical care areas.