ANAPHYLAXIS POLICY Author: Sponsor/Executive: Responsible committee: Ratified by: Consultation & Approval: (Committee/Groups which signed off the policy, including date) This document replaces: Learning & Development Manager Resuscitation Lead Director of Nursing Resuscitation Committee Quality Safety & Governance Committee Resuscitation Committee New CPFT Policy Date ratified: 2 November 2017 Date issued: 19 December 2017 Review date: 30 September 2020 Version: 1.0 Policy Number: Purpose of the Policy: If developed in partnership with another agency, ratification details of the relevant agency Policy in-line with national guidelines: P108 Is to provide a clear and safe framework for the effective management of anaphylaxis throughout the Trust which meets legal, national and local guidance and requirements. Yes Signed on behalf of the Trust:.. Tracy Dowling, Chief Executive Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789 1
Version Control Page Version Date Author Comments 1.0 September 2017 June Murrell Resuscitation Lead CPFT 2
Policy Circulation Information Notification of policy release: All recipients; Staff Notice Board; Intranet; Key words to be used in Dt GP search. Anaphylaxis, adrenaline CQC Standards Other Quality Standards 3
CONTENTS Section 1. Introduction... 6 2. Purpose... 6 3. Scope... 6 4. Definitions... 6 4.1 Anaphylaxis... 6 4.2 Clinical staff... 6 5. Duties... 6 5.1 Trust Board... 6 5.2 Chief Executive... 6 5.3 Director of Nursing... 6 5.4 Quality, Governance Patient Safety and Experience Committee... 6 5.5 Clinical Governance Patient Safety and Experience Group... 6 5.6 Resuscitation Committee... 7 5.7 Trust Resuscitation Lead... 7 6. Anaphylaxis... 7 6.1 Common triggers this list is not exhaustive... 7 6.2 Staff that are expected to recognise an anaphylactic reaction... 7 6.3 Staff that are expected to recognise and treat an anaphylactic reaction... 7 6.4 Equipment & Supplies... 8 7. Time course for fatal anaphylactic reactions... 8 7.1 Recognition of anaphylaxis... 9 7.2 Differential diagnosis of anaphylaxis... 10 8. Treatment for anaphylaxis... 10 4
8.1 Treatment: Inpatient Units/ Wards across the trust, JET teams... 11 8.2 Treatment: Registered Nurses that work in the community who carry adrenaline 1 in 1000 injection... 11 8.3 Minor injury units/ (MIU), Ely, Doddington, Wisbech... 11 8.4 Adrenaline I in 1000 auto-injectors... 12 9. Education and Training... 12 9.1 Basic Life Support Training... 12 9.2 Medical Emergency Response Course (MERC)... 13 10. Monitoring Compliance... 14 11. This Document Links to:... 14 12. References and Acknowledgements... 14 Appendix 1... 15 Appendix 2... 16 Appendix 3... 17 Appendix 4.. 18-20 5
1. Introduction Cambridgeshire and Peterborough NHS Foundation Trust (hereafter referred to as the Trust or CPFT ) recognises that any service user suffering from an anaphylactic reaction should receive an urgent medical response from staff who hold the appropriate level of knowledge and skills to ensure the highest standards of care are provided. This policy reflects guidance from the Resuscitation Council UK (RCUK), current legislation, national and local guidance. The British Approved Name adrenaline will be used throughout this document. The Recommended International Non-Proprietary Name for adrenaline is epinephrine. 2. Purpose The overall aim of this policy is to define the responsibilities, competencies, training and performance standards of clinical staff with regard to their role in recognising and managing anaphylaxis 3. Scope This policy will apply to all clinical staff within the trust (see 6.2 and 6.3) Non clinical staff with frequent, regular contact with service users will also be covered within the scope of this policy. 4. Definitions 4.1 Anaphylaxis Anaphylaxis is a severe, life-threatening, 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. 4.2 Clinical staff Clinical staff includes Registered Nurses, Allied Health Professionals, Paramedics, Doctors, Psychologists, Podiatrists, Social Workers, Pharmacists, Nursery Nurses, Therapists, Support Time and Recovery Support Workers, Health Care Assistants, Technical Instructors, Occupational Therapy Assistants and all other staff who have involvement in some aspect of direct clinical care of the service user. 5. Duties 5.1 Trust Board The Trust Board retains overall responsibility for ensuring safe and effective procedures for the management of anaphylaxis within the Trust. 5.2 Chief Executive The Chief Executive is the nominated accountable officer with overall responsibility to ensure there are effective and appropriate systems for the management of anaphylaxis within the Trust. 5.3 Director of Nursing The Director of Nursing has overarching responsibility to ensure there are effective and appropriate systems for management of anaphylaxis within the Trust 5.4 Quality, Governance Patient Safety and Experience Committee This is a Trust Board sub-committee, chaired by a Non Executive Director. If there are any areas of concern that pose a risk or threat to the organisation or delivery of Trust objectives, the Committee will ensure that the appropriate action is taken to ensure these are managed appropriately. 5.5 Clinical Governance Patient Safety and Experience Group This group is responsible for reviewing and approving this policy and to advise accordingly. 6
5.6 Resuscitation Committee The Resuscitation Committee is responsible for ensuring that high quality medical emergency responses are provided to our service users, that all policy and procedures meet legal, national, local guidance and requirements. 5.7 Trust Resuscitation Lead The Trust Team Resuscitation Lead will be responsible for: the provision of anaphylaxis training, in conjunction with the Learning and Development department, within CPFT which meets current legal and national requirements ensuring monitoring and reporting of training compliance meets Trust requirements provide knowledge and expert guidance at senior level through the Resuscitation Committee provide the processes for checking medication and equipment is in date and available in a medical emergency 6. Anaphylaxis Anaphylaxis is a severe potentially life-threatening hypersensitivity reaction. It is generalised / systemic rather than a localised reaction, characterised by rapid onset of airway, breathing and/or circulation problems, usually with skin or mucosal changes. The UK incidence of anaphylaxis is increasing. (section12 page 14) 6.1 Common triggers this list is not exhaustive Stings Nuts Food Antibiotics General Anaesthetics Other Medication Contrast media Other Wasp, Bee, Venom Peanut, Walnut, Almond, Mixed Milk, Fish, Chickpea, Shellfish, Banana, Strawberry Penicillin, Vancomycin, Ciprofloxacin NSAID (non-steroidal anti-inflammatory drugs) Iodine Latex, Hair dye 6.2 Staff that are expected to recognise an anaphylactic reaction All healthcare staff, first-aiders, and non-clinical staff with frequent, regular contact with service users working within the Trust will be expected to recognise symptoms suggestive of an anaphylactic reaction and know how to summon emergency medical help. Healthcare Assistants that administer medicines are expected to recognise symptoms suggestive of an anaphylactic reaction, know how to summon emergency medical aid, but are not expected to treat anaphylaxis, if the patient becomes unresponsive they will commence CPR. Community psychiatric nurses (CPN s) who administer depot antipsychotic medication only, are not required to carry adrenaline 1in1000, they are expected to recognise symptoms and summon emergency medical help, if the patient becomes unresponsive they will commence CPR. 6.3 Staff that are expected to recognise and treat an anaphylactic reaction Healthcare professionals that are expected to be able to recognise and treat an anaphylactic reaction are: Registered Nurses Paramedics Doctors Podiatrists who administer medications/injections Physiotherapists who administer medications/injections 7
All healthcare professionals that have been trained to recognise and treat an anaphylactic reaction are also expected to treat any individual who experiences an anaphylactic reaction in any situation (whether that person is a patient, member of staff or member of the public) with basic life support and first aid. Healthcare staff, first-aiders and non-clinical staff with frequent, regular contact with service users may administer an individuals own adrenaline using an auto-injector e.g. Epipen, Jext, Emmerade, if the individual is unable to self-administer. 6.4 Equipment & Supplies (appendix 4) All healthcare professionals should have immediate access to adrenaline 1 in 1000 injection and associated equipment (see below) when administering any substance that may cause an anaphylactic reaction. They must ensure that they are aware of the location of emergency medicines and equipment in the area in which they are working. They must ensure that the following are available, in date and suitable for use: A minimum of three ampoules of adrenaline 1 in 1000 injection 1ml (keep in original packaging - packs must not be split). 3 x latex free 1 ml syringes 3 x blunt fill filter needle with 5 micron filter 3 x safety needles 23 gauge 25mm (suitable for the majority of patients) 3 x safety needles 21 gauge 38mm (may be needed for obese patients to ensure deep intramuscular injection) 3 x safety needles 25 gauge 16mm (for pre-term and very young infants only. Include in pack if appropriate to your area of work) Current Resuscitation Council (UK) Anaphylactic Reactions - Initial Treatment Algorithm (Appendix 2) Healthcare settings that stock the medicines used as second line treatment for an anaphylactic reaction should use the current Resuscitation Council (UK) Anaphylaxis Algorithm (Appendix 3) The adrenaline 1 in 1000 and equipment should be checked at least weekly to ensure that it is suitable for use e.g. expiry, adrenaline 1 in 1000 not cloudy or discoloured. Avoid storing in hot places such as cars for prolonged periods. During hot weather all community based health professionals who carry adrenaline 1:1000 injection for anaphylaxis should consider placing it in a cool bag if necessary. Do not put freezer blocks in the cool bag Time course for fatal anaphylactic reactions When anaphylaxis is fatal, death usually occurs very soon after contact with the trigger. From a case-series, fatal food reactions cause respiratory arrest typically after 30 35 minutes; insect stings cause collapse from shock after 10 15 minutes, and deaths caused by intravenous medication occur most commonly within five minutes. Death never occurred more than six hours after contact with the trigger. 8
6.5 Recognition of anaphylaxis Patients with symptoms of anaphylaxis should be assessed using the ABCDE approach (see table below) Airway (A), Breathing (B), Circulation (C), Disability (D), Exposure (E) Airway problems (Life-threatening) Breathing problems (Life-threatening) Circulatory problems (Life-threatening) Disability - Neurological problems Exposure Gastrointestinal symptoms Airway swelling e.g. swelling of tongue or throat (pharyngeal and laryngeal oedema) causing upper airway obstruction leading to difficulty in breathing and swallowing. Hoarse voice. Stridor high-pitched inspiratory noise Shortness of breath increased respiratory rate. Wheeze Patient becoming tired. Confusion caused by hypoxia. Cyanosis (a late sign). Respiratory arrest. Signs of shock (pale, clammy). Tachycardia. Hypotension (feeling faint, dizziness or collapse). Decreased conscious level or loss of consciousness. Myocardial ischaemia. Cardiac arrest. Bradycardia usually a late feature often preceding cardiac arrest Sense of impending doom. Problems with airway, breathing and/or circulation may result in confusion, agitation, decreased level of consciousness. Patient history is often the key. Skin and/or mucosal changes present in over 80% of reactions. Erythema - patchy red rash. Urticaria - raised red areas, very itchy. Angioedema - swelling of deeper tissues. May be present - vomiting abdominal pain, incontinence Although skin changes can be worrying or distressing for patients and those treating them, skin changes without life-threatening airway, breathing or circulation problems do not signify an anaphylactic reaction. Reassuringly, most patients who have skin changes caused by allergy do not go on to develop an anaphylactic reaction. 9
6.6 Differential diagnosis of anaphylaxis Life-threatening conditions: Sometimes an anaphylactic reaction can present with symptoms and signs that are very similar to life-threatening asthma this is commonest in children. A low blood pressure (or normal in children) with a petechial or purpuric rash can be a sign of septic shock. Seek help early if there are any doubts about the diagnosis and treatment. Non life-threatening conditions (these usually respond to simple measures): Faint (vasovagal episode) Panic attack Breath-holding episode in child Idiopathic (non-allergic) urticaria or angio-edema 7. Treatment for anaphylaxis The specific treatment of an anaphylactic reaction will depend on the location, the training and skills of the rescuers, the equipment and drugs available. However, all patients that have an anaphylactic reaction (irrespective of the location) should expect the following as a minimum: Recognition that they are seriously ill, an early call for help 999/112. Initial assessment and treatment based on the ABCDE approach (page 9) Adrenaline 1 in 1000 to be administered intramuscularly if available. Dose of adrenaline 1 in 1000 injection for anaphylaxis Administer by intramuscular (IM) injection Adult Child 12 years and over Child 6 years and over to 12 years Child less than 6 years 500 micrograms (0.5ml) IM 500 micrograms (0.5ml) IM 300 micrograms (0.3ml) IM 150 micrograms (0.15ml) IM If no improvement after 5 minutes, administer ONE further dose Note: Regulation 238 of the Human Medicines Regulations 2012 Medicinal products for parenteral administration in an emergency. The exemption applies to: Adrenaline 1 in 1000 up to1mg for intramuscular use in anaphylaxis. Administration of adrenaline 1 in 1000 for treatment of anaphylaxis Adrenaline 1 in 1000 injection must be administered intramuscularly (IM) Adrenaline 1 in 1000 injection MUST NOT be administered intravenously (IV) by CPFT trust staff. The dose of Adrenaline 1 in 1000 is above and (appendix 1) The correct needle length should be used to ensure that the adrenaline is injected into the muscle. The recommended site is the anterolateral aspect of the middle third of the thigh. If an auto injector is used, inject through clothes avoiding seams and pockets. 10
NB Adrenaline 1in 1000 is a life-saving medication for anaphylaxis, it must be administered quickly when anaphylaxis is confirmed. In some situations when a nurse is on their own they may need to administer the adrenaline and then call the emergency services 999. When there is more than one member of staff present i.e. in-patient units, MIU s, the call for the ambulance and the administration of adrenaline 1in 1000 will be simultaneous. 7.1 Treatment: Inpatient Units/ Wards across the trust, JET teams 1. Use ABCDE to assess patient and recognise anaphylaxis (page 9) 2. Call (9)999/112 and tell them you are a health care professional and it is a life threatening situation: anaphylaxis. 3. A healthcare professional will administer adrenaline 1 in 1000 appropriate dose intramuscularly 4. Administer high flow oxygen 15 litre/min via high concentration mask 5. Continue to monitor patient using ABCDE assessment and record on NEWS chart 6. If no improvement 5 minutes after administration of first dose of adrenaline 1 in 1000, administer a second dose of adrenaline 1 in 1000 7. If patient collapses and goes into cardiac arrest commence CPR and apply automatic external defibrillator (AED) 7.2 Treatment: Registered Nurses that work in the community who carry adrenaline 1 in 1000 injection 1. Use ABCDE to assess patient and recognise anaphylaxis (page 9) 2. Call 999/112 and tell them you are a health care professional and it is a life threatening situation: anaphylaxis. 3. Administer appropriate dose of adrenaline 1 in 1000 intramuscularly continue to monitor patient using ABCDE assessment 4. If no improvement 5 minutes after administration of first dose of adrenaline 1 in 1000, administer a second dose of adrenaline 1 in 1000 5. If patient collapses and goes into cardiac arrest commence CPR 7.3 Minor injury units/ (MIU), Ely, Doddington, Wisbech The minor injury units are staffed by registered nurses (RN) and paramedics. Sodium chloride 0.9%, chlorphenamine and hydrocortisone sodium succinate injections can be prescribed and administered by independent non-medical prescribers, or administered in accordance with an MIU Patient Group Direction (PGD) or protocol by authorised staff. 1. Use ABCDE to assess patient and recognise anaphylaxis (page 9) 2. Call (9)999/112 and tell them you are a health care professional and it is a life threatening situation: anaphylaxis. With reference to Appendix 3: 3. A healthcare professional will administer adrenaline 1 in 1000 appropriate dose intramuscularly 4. Administer high flow oxygen 15 litres/min via high concentration mask 5. Administer intravenous (IV) sodium chloride 0.9% 6. Administer IM chlorphenamine and hydrocortisone sodium succinate 7. Continue to monitor patient using ABCDE assessment 8. If no improvement 5 minutes after administration of first dose of adrenaline 1 in 1000, administer a second dose of adrenaline 1 in 1000 9. If patient collapses and goes into cardiac arrest commence CPR and apply automatic external defibrillator (AED) 11
7.4 Adrenaline I in 1000 auto-injectors Adrenaline 1 in 1000 auto-injectors e.g. Epipen, Jext, and Emerade are often prescribed for individuals who are at risk of anaphylaxis; these are for self - administration. Emerade is an auto-injector that is available containing a 500 microgram dose of adrenaline 1 in 1000 which is the dose recommended for adults and children above 12 years of age by RCUK and is presently the only auto-injector that contains this dose. All auto-injectors only have one dose in each auto-injector. Adult in-patient wards Each adult in-patient ward will have in their red emergency bag/emergency resuscitation trolley one 500microgram Emerade auto injector to administer the first dose for adults and children above 12 years of age (see dose of adrenaline 1 in 1000 appendix 1). This must be administered by a healthcare professional (registered nurse, doctor). After administration of the first dose, a second dose of 500 micrograms of adrenaline 1 in 1000 can be drawn up from an ampoule ready in the event that a second dose is required. This should be safely disposed of if it is not required. NOTE In the event of a patient having an anaphylactic reaction a HCA who is in date with their MERC training, can use the auto-injector to administer the appropriate dose of adrenaline 1:1000 if the Trained Nurse is not familiar with how an auto-injector works:, the Trained nurse suddenly becomes unwell and is not able to administer: or any other reason why the trained nurse cannot administer the Adrenaline. (see appendix 1) Children s wards Children s wards have the following auto-injectors containing adrenaline 1 in 1000 in addition to adrenaline 1 in 1000 ampoules: Phoenix: 2 x auto-injectors 300 micrograms for patients aged 12 to18 years weighing less than 30kgs, also they have little muscle mass, so lower doses and shorter needles are appropriate Croft: 2 x auto-injectors 150 micrograms and 2 x auto-injectors 300 micrograms Qualified staff should only use an adrenaline auto-injector that contains a dose other than that recommended by the RCUK if it is the only preparation of adrenaline available. If ampoules of adrenaline 1 in 1000 are available then these should be used and the recommended dose of adrenaline 1 in 1000 administered. See individual manufacturer s information sheets for method of administration as this differs between brands. 8. Education and Training (appendix4) 8.1 Basic Life Support Training Basic life support training includes anaphylaxis which is mandatory annually, new staff will receive basic life support training at induction if it is mandatory for their role. Refresher training is e-learning alternating with face to face training. Basic life support training is for all clinical staff that work in the community, all allied health professionals including psychologists, podiatrists etc. On the e-academy staff will find their training requirements they need to complete for their role and they can book on to courses through the e-academy. 12
8.2 Medical Emergency Response Course (MERC) MERC is mandatory annually for all clinical staff whose work areas are the in-patient units or are on the on-call rota for the in-patient units, additionally for JET staff. Minor injury unit staff attend Resuscitation council Immediate life support course annually. 13
9. Monitoring Compliance Criteria Measurable Lead person / group Compliance dashboards Training attendance including refresher Resuscitation equipment including adrenaline 1 in1000 injection intramuscular Resuscitation checklist Head of Learning and Development Ward and Department staff Frequency Reported to Monitored by Monthly Executive Team General Managers Service Managers Daily Ward or Department Head Executive Team Resuscitation Lead 10. This Document Links to: Management of Medical Emergencies Policy, incorporating Resuscitation and Do not Attempt Resuscitation Medicines Policy Mandatory Training policy Prospectus, course content and Training needs analysis are found at: https://learning.cpft.nhs.uk 11. References and Acknowledgements www.resus.org.uk/anaphylaxis www.nice.org.uk/guidance/cg134/chapter/introduction www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions http://www.legislation.gov.uk/uksi/2012/1916 www.resus.org.uk/resuscitation-guidelines/adult-basic-life-support-and-automatedexternal-defibrillation http://www.theguardian.com/society/2010/feb/07/allergies-sharp-rise-anaphylaxis https://www.allergyuk.org/allergy-statistics/allergy-statistics file:///c:/users/jmurrell/downloads/emergencytreatmentofanaphylacticreactions%20(13).pdf https://www.epipen.com/en/hcp/about-epipen/dosage-and-administration http://www.emerade.com http://www.jext.ie www.emerade-bausch.co.uk/ management of medical emergencies policy 14
Appendix 1 Dose of adrenaline 1 in 1000 intramuscular (IM) injection for anaphylaxis Adult Child 12 years and over 500 micrograms (0.5ml) IM 500 micrograms (0.5ml) IM Child 6 years and over to 12 years 300 micrograms (0.3ml) IM Child less than 6 years 150 micrograms (0.15ml) IM If no improvement after 5 minutes, administer ONE further dose (Note: Regulation 238 of the Human Medicines Regulations 2012 Medicinal products for parenteral administration in an emergency the exemption applies to: Adrenaline 1 in 1000 up to 1mg for intramuscular use in anaphylaxis. Auto-injectors "Medicines legislation restricts the administration of injectable medicines. Unless self administered, they may only be administered by or in accordance with the instructions of a doctor (e.g., by a nurse). However, in the case of adrenaline there is an exemption to this restriction which means in an emergency, a suitably trained lay person is permitted to administer it by injection for the purpose of saving life. The use of an Epipen to treat anaphylactic shock falls into this category. Therefore, first aiders may administer an Epipen if they are dealing with a life threatening emergency in a casualty who has been prescribed and is in possession of an Epipen and where the first aider is trained to use it." (RCUK) 15
Appendix 2 16
Appendix 3 17
Recognise Anaphylaxis Call (9)999/112 Use Anaphylaxis algorithm RCUK2015, ABCDE Use Anaphylaxis initial treatment algorithm RCUK2015, ABCDE Use NEWS Use PEWS Administer Adrenaline 1:1000 intramuscularly (IM) Administer Oxygen Administer intravenous (IV) sodium chloride 0.9% Administer chlorphenamine intramuscularly (IM) Administer hydrocortisone intramuscularly (IM) Adrenaline 1:1000 Chlophenamine Hydrocortisone Sodium chloride 0.9% Airways BVM Oxygen Suction AED Mask for use in resuscitation ILS (Immediate Life Support) external provider PILS (Paediatric Immediate Life Support) external provider MERC (Medical Emergency Response Course) Foundation BLS (Basic Life Support) Refresh annually with MERC refresher Refresh annually APPENDIX 4 Equipment & Training Matrix for Anaphylaxis Responsibility Treatment Medication Equipment Needed Training Requirements Training Interval Team Minor Injury Units Inpatient Wards/ Units (Adults) Inpatient Wards/ Units (Adolescent aged 12-17) Inpatient Wards/Units (Children aged 0-11) Podiatry Surgical Team Windsor Research Unit 18
Recognise Anaphylaxis Call (9)999/112 Use Anaphylaxis algorithm RCUK2015, ABCDE Use Anaphylaxis initial treatment algorithm RCUK2015, ABCDE Use NEWS Use PEWS Administer Adrenaline 1:1000 intramuscularly (IM) Administer Oxygen Administer intravenous (IV) sodium chloride 0.9% Administer chlorphenamine intramuscularly (IM) Administer hydrocortisone intramuscularly (IM) Adrenaline 1:1000 Chlophenamine Hydrocortisone Sodium chloride 0.9% Airways BVM Oxygen Suction AED Mask for use in resuscitation ILS (Immediate Life Support) external provider PILS (Paediatric Immediate Life Support) external provider MERC (Medical Emergency Response Course) Foundation BLS (Basic Life Support) Refresh annually with MERC refresher Refresh annually Responsibility Treatment Medication Equipment Needed Training Requirements Training Interval Team Community Health Care Professionals who administer medication Community Health Care Assistants Bands 2-4 who administer medication Community Psychiatric Nurses (CPN) who administer depot injection School Nurses who administer mediation 19
Recognise Anaphylaxis Call (9)999/112 Use Anaphylaxis algorithm RCUK2015, ABCDE Use Anaphylaxis initial treatment algorithm RCUK2015, ABCDE Use NEWS Use PEWS Administer Adrenaline 1:1000 intramuscularly (IM) Administer Oxygen Administer intravenous (IV) sodium chloride 0.9% Administer chlorphenamine intramuscularly (IM) Administer hydrocortisone intramuscularly (IM) Adrenaline 1:1000 Chlophenamine Hydrocortisone Sodium chloride 0.9% Airways BVM Oxygen Suction AED Mask for use in resuscitation ILS (Immediate Life Support) external provider PILS (Paediatric Immediate Life Support) external provider MERC (Medical Emergency Response Course) Foundation BLS (Basic Life Support) Refresh annually with MERC refresher Refresh annually Responsibility Treatment Medication Equipment Needed Training Requirements Training Interval Team Child and Adolescent Substance Use Service (CASUS) Infection Control Nurses Occupational Health Nurses 20