title: Demonstration of epinephrine autoinjectors (EpiPen and Anapen) by pharmacists in a randomised, simulated patient assessment: acceptable, but room for improvement.
abstract: BACKGROUND
  Successful treatment of anaphylaxis in the community relies on early and correct use of epinephrine autoinjectors. Community pharmacists supply these devices and have a crucial role teaching patients how to use them. Supply of epinephrine autoinjectors in Australia increased 70-fold in the past decade. New EpiPen and Anapen autoinjectors were launched in Australia in 2011 and 2012, with the potential to cause confusion. However there is no information about how pharmacists demonstrate epinephrine autoinjectors to patients. Therefore the aim of this study was to assess real-world community pharmacist demonstrations of EpiPen and Anapen. We also sought to identify consultation-based predictors of accurate demonstration.
  
  
  METHODS
  Demonstration accuracy was assessed in simulated patient visits to 300 randomly selected pharmacies. Pharmacists were asked by the simulated patient how to use original EpiPen, new-look EpiPen or Anapen, and assessed against the relevant Australasian Society of Clinical Immunology and Allergy (ASCIA) Action Plan for Anaphylaxis. Other anaphylaxis advice provided by the pharmacist was also recorded. Accuracy was analysed descriptively. Binary logistic regression was used to identify predictors of accurate demonstration.
  
  
  RESULTS
  All 300 pharmacies were visited. Of 250 pharmacist demonstrations, 46 (18.4%) accurately demonstrated all four steps on ASCIA Action Plan. Failure to state 'do not touch the needle' (74.8%) or 'massage injection site' (68.8%) reduced accuracy. However 163 (65.2%) accurately demonstrated the three steps required to inject epinephrine (no difference by device, p = 0.15). Associations with accurate demonstration were: checking if the patient had an anaphylaxis action plan (odds ratio, OR = 16.1; 95% CI: 3.86-67.3); stating to call an ambulance after use (OR = 4.0; 95% CI: 1.44-11.1); or explaining side effects of epinephrine (OR = 4.5; 95% CI: 1.48-13.4).
  
  
  CONCLUSIONS
  It is critical that anaphylaxis patients know how to use their prescribed epinephrine autoinjector correctly. Pharmacists have acceptable rates of EpiPen and Anapen demonstration accuracy, although more is needed to improve this. Those who pay attention to the need for action plans, emergency care after epinephrine use, and informing patients about the side effects of epinephrine may have better knowledge about anaphylaxis, and in turn significantly improve demonstration accuracy.
authors.affiliation: Pharmacy Program, Centre for Optimization of Medicines, School of Medicine and Pharmacology, The University of Western Australia, M315, 35 Stirling Highway, Crawley, WA 6009 Australia.
authors.forename: Sandra M
authors.initials: SM
authors.lastname: Salter
authors.affiliation: The Australasian Society of Clinical Allergy and Immunology (ASCIA), Sydney, NSW Australia ; School of Paediatrics and Child Health, The University of Western Australia, Crawley, WA Australia.
authors.forename: Richard
authors.initials: R
authors.lastname: Loh
authors.affiliation: School of Population Health, The University of Western Australia, Crawley, WA Australia.
authors.forename: Frank M
authors.initials: FM
authors.lastname: Sanfilippo
authors.affiliation: Pharmacy Program, Centre for Optimization of Medicines, School of Medicine and Pharmacology, The University of Western Australia, M315, 35 Stirling Highway, Crawley, WA 6009 Australia.
authors.forename: Rhonda M
authors.initials: RM
authors.lastname: Clifford
keywords: Adrenaline; Anapen; Anaphylaxis; EpiPen; Pharmacy practice; Primary care; Self-injectable epinephrine; Simulated patient; Technique