Epinephrine autoinjector administration diagrams differ from evidence-based best practice
Key takeaways:
- A patient should be supine or sitting when an epinephrine autoinjector device is administered per best practice guides.
- The patient was standing in several administration diagrams.
SAN DIEGO — Standing vs. supine or sitting was the position in which an epinephrine autoinjector device was administered in several written and visual examples showing administration, according to a poster presented here.
This finding was presented at the 2025 American Academy of Allergy, Asthma and Immunology/World Allergy Organization Joint Congress.
“When you’re actually equipping patients with the automated epinephrine injectors, make sure that you are demonstrating, you have the person in the correct position and you have the correct diagrams to show them how to use the pen and not assume that they’re going to find the right diagram,” Deryn Thompson, PhD, MN, MACN, FANA, registered nurse and lecturer in nursing at University of South Australia, told Healio.
In this study, Thompson, Sacha Palmer, MN(NP), Grad CCAFHN, FANA, WCHN, and 24 post-grad allergy nurse students identified 16 written/visual epinephrine autoinjector device administration examples from health professional organizations (n = 7), product information sites (n = 4), patient support groups (n = 3) and consumer medicine (n = 2) in an “ultra-rapid” grey literature review. The aim was to determine if these diagrammatic examples support and demonstrate best practice positioning guidelines.
Notably, Thompson told Healio this investigation came out of the 2024 online Professional Certificate of Allergy Nursing short course she teaches at the University of South Australia. In class, Palmer highlighted a clinical case where an ED health professional scolded a parent for giving their child automated epinephrine lying down, not standing up.
“One allergy nurse student said, ‘well, with giving the EpiPens, can’t you give it standing or sitting?’ ... because when you look at the diagrams, they’ve all got the patient standing, but our best practice says about having the patient supine or sitting [since] they may have breathing difficulties,” Thompson told Healio.
“There was silence in the virtual (online) classroom for a few minutes as we’re processing this,” Thompson said. “We as clinicians and tutors realized the students were correct.”
During the evaluation of the written and visual examples they collected, Thompson noted that standing was the position the epinephrine autoinjector device was administered in multiple diagrammatic examples, one of which was the product information diagram.
“We found ambiguity and conflicting information between the diagrams of how to administer the EpiPen with the person literally standing, as opposed to the person being supine or sitting,” Thompson told Healio.
The poster also said that only two of the five identified health professional organizations — World Allergy Organization and Chinese University of Hong Kong, Allergy — had diagrammatic information on epinephrine autoinjector administration position in their anaphylaxis action plans that supported best practice guides.
In the action plans from the remaining three organizations, supine position was either stressed alongside incorrect administration product information diagrams (Australasian Society of Clinical Immunology and Allergy [ASCIA]; Allergy and Anaphylaxis Australia) or positioning was not stressed with no ambiguous diagrams (AAAAI), according to the poster.
“Once alerted, ASCIA acted very quickly to amend their online information, but the already printed plans and diagrammatic product information changes take time, due to product regulatory changes,” Thompson told Healio.
Thompson also highlighted that some located pictures showing how to use the epinephrine autoinjector had the device pointing at the wrong site and incorrect thumb placement.
“Were they using a real device and had it upside down, it would be going through their thumb, and there’d be no epinephrine for the patient,” Thompson told Healio.
Following this review, an important question came up at an allergy nurse meeting regarding how allergists and allergy nurses position themselves when showing the patient how to use the device, Thompson said.
“[Palmer is] a nurse practitioner, and in her clinic, she has to come around from her desk and show the patient,” Thompson told Healio. “Through this, she realized that she was actually standing there as she demonstrated the pen, due to room set-up restraints. Some nurses concurred they had similar issues, but all have amended this in their practice demonstrations.”
With this question and the results from the grey literature review in mind, Thompson encourages health care professionals who demonstrate epinephrine autoinjector device administration to check their diagrams on administration and anaphylaxis action plans.
“Check your action plans [to make sure] they make correct statements, diagrams align and there’s nothing ambiguous on there because we know that one of the biggest disappointments that patients quote is, ‘I’m getting conflicting information from different health professionals,’” Thompson told Healio.
“If we can all be on the same page, we’d have much better patient outcomes,” she said.
Moving forward, Thompson said a robust literature review on this topic should be conducted.
“We actually need to do a deeper literature search making comparison between the diagrams and the written information across the major anaphylaxis resource sites globally,” Thompson told Healio. “But also, we’ve got that subset within educational institutions, hospitals and health care centers that have created their own plans, so it’s opened our eyes to an important issue.”
Those interested in this year’s Professional Certificate in Allergy Nursing short course in July can visit the University of South Australia website.
For more information:
Deryn Thompson, PhD, MN, MACN, FANA, can be reached at deryn.thompson@unisa.edu.au.