Ambulance Service

Reactions to Natural Rubber Latex (NRL) products impact on providers of care in the Ambulance Service 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).

Many patients do not (or cannot) inform the ambulance team that they have NRL allergy.  Even if they do, it can be difficult to communicate effectively the message to staff about which items are NRL-free and which aren’t. A decision to source as many NRL-free items as possible means that the Ambulance Trust can then send out a very small list of those few items which aren’t NRL-free to staff.

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 latex allergen) or when administering parenteral medication (eg rubber vial stoppers).

Review of equipment in the emergency setting:
It therefore makes sense to phase out all NRL-containing gloves, medical equipment and drugs where possible, and replacing with equipment and medicines that do not contain natural rubber (ie Natural Rubber Latex or Dry Natural Rubber) as standard issue items.

As an interim measure, ensure that you have available a supply (pack) of essential equipment and drugs that do not contain natural rubber in all ambulance vehicles for use on or by NRL-sensitive individuals, and that other NRL-containing equipment can be covered over if necessary.

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 (Policy)
  • A written policy on safe accommodation of NRL-sensitive members of staff (Policy)
  • A written policy for the safe management of patients with known or suspected NRL allergy (Policy)
  • 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 
  • An organisational NRL-free resuscitation policy. ALL products must be NRL free, as it makes no sense to use NRL when it may have been the cause of anaphylaxis. http://www.resus.org.uk/pages/reaction.pdf#search=%22latex%20allergy%22
  • Occupational Health pre-screening questionnaires 
  • Risk-assessments undertaken for your specific ambulance trust
  • A database of recommended products which do and do not contain NRL and which is regularly up-dated 
  • 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 by sensitised staff and for sensitised patients Glove materials
  • Hand washing/care/cream protocols (Hand Care Protocols)
  • 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

Medical assessment
Best practice would suggest that patient assessment is undertaken using a screening tool (Patient screening) to identify at risk individuals. If the patient is unconscious or unable to communicate, a Medic-Alert® 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.

Ideally, the GP (General Practice), Outpatients Dept or Hospital Doctor will have informed the ambulance service 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. Labels for Patients Notes

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. Many ambulance services can do this via their Control room systems.

Consider sharing information on best practice, learning outcomes, locally pooled purchase plans (to keep the price down on quantity) for latex free equipment with other local Trusts.

Emergency equipment
In general, emergency medical and resuscitation equipment should be NRL-free wherever possible and other NRL containing medical equipment covered over (eg stockinette or drill sleeve to cover sphygmomanometer). 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 a latex-free product list is available within areas of emergency treatment.

Gloves
Oral and nasal airways
Oxygen masks and nasal cannulae
Self-inflating bag
Blood pressure monitor
Emergency medication
Tourniquets
IV lines and infusion bags
Equipment tubing
Adhesives and dressings and their packaging
Stoppers in vials
Needle sheaths on pre-filled syringes
Catheters

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.

Employers, as part of their policy need to also ensure that staff do not bring in their own equipment (which may contain NRL) to use.  Ambulance services often have this problem. Directives to inform staff about why they shouldn’t bring in their own items may need to be sent, but it needs close monitoring.

Employers need to have an NRL Policy, which also includes a policy on purchasing equipment. Routinely checking for NRL-content when purchasing new equipment and getting written confirmation from manufacturers/suppliers which states equipment in NRL-free assists in creating a database of NRL-free products.

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 being NRL-free).

*Resuscitation Council (UK) guidance emergency medical treatment of anaphylactic reactions - http://www.resus.org.uk/pages/reaction.pdf#search=%22latex%20allergy%22

Reporting agencies for adverse reactions to Natural Rubber Latex products
The National Patient Safety Agency (NPSA) is a Special Health Authority charged with improving patient safety in the NHS.  It was created in 2001, following the publication of two reports addressing patient safety incidents in the NHS (An Organisation with a Memory and its follow-up, Building a Safer NHS for Patients). http://www.npsa.nhs.uk/

The Medicines and Healthcare Products Regulatory Agency (MHRA) has a voluntary reporting system for reporting cases of NRL sensitisation in both patients and staff: http://www.mhra.gov.uk

Sensitised Staff
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.

Reporting
Employers have a duty to report incidences of occupational dermatitis and asthma attributable to NRL to the Health and Safety Executive under the RIDDOR  (or Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995 requirements).