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I work in General Practice (GP)

Key issues

Reactions to Natural Rubber Latex (NRL) products impact on GPs and nurses 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.
  4. GPs and practice nurses are very often the first port of call for sensitised individuals who may or may not suspect that the have an NRL allergy. It is important that the GP is able to identify patients with suspected NRL allergy to allow prompt referral to a diagnosing physician (dermatologist or immunologist) for further investigation.

Ensure you have and are familiar with:

These procedures should not be too time-consuming to implement, given the links to example documentation (above), which can act as a basis for creating your own policies, protocols etc.

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Prevention of NRL Allergies - Staff

It is important that you protect yourself against breaches of the skin barrier, which can result from frequent use of skin cleansers and occlusive glove-wear, especially if you have an atopic background (asthma, hay fever or flexural eczema) where damage to the skin from irritants is more common. A compromised skin barrier will increase your chance of developing Type IV rubber chemical or Type I NRL allergy. Hand-disinfectant agents and protective gloves need to be selected with great care and it is also important to use a suitable aqueous based emollient if your skin has any tendency to dry out.

Do not wear NRL gloves where there is no operational need (eg for tasks with no risk of cross-infection from blood-borne pathogens).

If you or your patient are not NRL-sensitive and you choose to wear NRL gloves to protect yourself from blood-borne pathogens choose Powder-Free and Low Protein (<50ug/g) gloves only.

Ensure that gloves comply with national and international standards of performance (British and European Standard BSEN 455). They should carry the 'CE' mark.

Management of sensitised workers:

If you suspect that you may be allergic to NRL, it is best to seek a referral to a dermatologist or immunologist via your GP so that this can be appropriately investigated as soon as signs and symptoms develop.

If you are found to be NRL-sensitive, then it is essential that your work environment is adapted as soon as possible to avoid unnecessary exposure to NRL, which would increase your sensitivity and put you at risk of more severe reactions.

Type I NRL allergy:

If you are diagnosed with Type I allergy, it may be possible for you to continue to work in the clinical environment, although this depends on the severity of reactions you experience (see above).

It is important that you learn to avoid NRL proteins in consumer and medical products both at home and at work. As gloves are the main cause of allergic reactions to NRL, it is essential that you replace NRL gloves with suitable NRL-free gloves for yourself and ensure that you are not working in powdered NRL environments (ie from the use of powdered NRL gloves worn by colleagues).

A minority of allergic workers can only work symptom free in strict NRL-free glove environments so it may become necessary for colleagues to switch to using NRL-free gloves also or that other modifications to the work environment are required.

It is recommended that you wear a Medic-Alert® bracelet.

If you have been advised to carry adrenaline for self-administration (eg Epipen® or Anapen®), colleagues should be instructed on how to use it.

Type IV allergy:

If you are diagnosed with Type IV allergy to a rubber chemical, then you need to find a glove that does not contain the chemical to which you are allergic. The Dermatologist who has diagnosed this should be able to help you with appropriate glove selection.

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Prevention of NRL Allergies - Patients

Management of a patient with Type 1 NRL allergy:

Seek to identify at risk patients by enquiring about latex allergy when appropriate, eg prior to any procedure or if the patient has hand dermatitis. Questions include:

If you suspect NRL allergy in a patient refer the patient to a dermatologist or an immunologist for diagnosis and advice. Remember, an early diagnosis may prevent unnecessary NRL exposure. This is important as continued NRL exposure in someone who is sensitised may induce progression to more severe allergic symptoms.

It is recommended that sensitised individuals wear a Medic-Alert® bracelet.

If a patient has a confirmed NRL allergy diagnosis, label the patient's notes clearly. If you are referring a sensitised patient to hospital for a medical or surgical procedure, remember to mention the patient's NRL allergy, its significance and how to safely manage the patient by telephone or in the referral letter.

It is vital to impress upon referring clinicians the importance of releasing this information to the patient's other health carers (especially carers in the emergency service as they have little time to pre-screen/ prepare for the patient prior to contact) so that standard NRL-containing equipment can be replaced with designated NRL-free equipment for use on sensitised patients instead and allergic reactions avoided.
Contact with natural rubber latex-containing medical equipment and products (including medicines) must be avoided in patients with diagnosed or suspected Type 1 NRL allergy and NRL (protein)-free alternatives used instead. Special care must be taken with procedures that involve contact with mucosal or serosal skin surfaces (eg skin surgery, smear tests, coil fittings, vaginal or rectal examinations etc) or when administering parenteral medication (rubber vial stoppers).

Synthetic examination gloves will suffice for most general practice procedures. Synthetic sterile gloves are only necessary for aseptic or surgical procedures. Vinyl gloves do not afford as good a barrier against cross-infection from blood-borne pathogens as gloves made of NRL-free nitrile or neoprene materials, but may be used for low-risk tasks.

Treatment (eg minor surgery) at the beginning of the working day is preferred, before environmental levels of NRL allergens rise with increased activity in the surgery.

All forward planning and documentation should inform future carers of the patient's sensitisation by effective recording in notes and the use of Labels for Patients Notes.

Possible sources of NRL proteins in General Practice include:

General:

Emergency equipment:
In general, resuscitation equipment should be NRL-free where possible. It is important to be prepared to treat severe allergic reactions. Ensure that a NRL-free product list is available within areas of emergency treatment.

For the more reactive patient or member of staff, other items should be checked for their NRL content.

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 staff are fully trained in resuscitation techniques*.