At this point, we aren't planning to say publically we are peanut-free, so I guess I misspoke. We are going to say that we don't serve peanuts or peanut butter. Reducing the amount of peanut allergen in our ED just decreases the chance of causing illness in a presumedly already sick child. Maybe one day we will aim to be truly peanut free. Others have done it successfully (like Baystate).
I see this differently, in terms of people with allergies living in the 'real world'. There is a huge range in allergy severity between individuals, and in the ED we are likely to be skewed towards seeing more of the most allergen-sensitive, as they are more likely to have reactions that bring them there. We are caring for these families in a different setting from their usual, one they perhaps didn't have much choice about visiting, at a time when they may feel unwell or tired or be more vulnerable. For example, they may not feel up to or prepared for their usual safe practices of wiping down surfaces. I see it only being to their benefit to try to create a safer environment.
I think the stickiness of peanut butter makes it more problematic than other top 8 allergens. If we had an equally sticky wheat or milk product, I would advocate to remove that too. I think it is one of the most common items that staff eat (even though the food is officially for patients), which means it potentially contaminates them too. Many staff (who rotate through and are hard to train continually) think that hand gel cleans peanut butter off their hands sufficiently, which it doesn't. I also believe I read that statistically, peanut allergies are responsible for a higher percentage of severe reactions. Not that anaphylaxis isn't possible with any food, I'm just talking overall percentages.
I don't think that we should fail to eliminate one allergen just because we can't eliminate them all. When we removed latex from our ED, we didn't worry that others would think we didn't care about them and their medical issues because we were addressing this one. Or at least I didn't. I know that replacing peanut butter with sunflower butter will be to the detriment of the child with the less common sunflower seed allergy. However, I believe that perfect is the enemy of good. Our overall risk of doing harm will still be decreasing with this change.
Making our ED free of all of the top 8 would be harder, given the large number of wheat products we serve (goldfish crackers, saltines, graham crackers, bread) and milk products we serve (formular, milk, cheese, yoghurt, ice cream). String cheese is also popular with staff, but I think is easier to wash off. I haven't checked labels so I could be wrong, but we probably don't have fish or shellfish. We don't serve raw eggs but we do occasionally serve cooked eggs on food trays from the cafeteria for people who need a meal, and I'm sure many of our grain products have cooked eggs. We have soy-based formula, and I don't know what else with soy.
I have heard the following stories related to peanuts and different EDs around the continent. I believe these show there is a problem, and any steps we can take to improve on what we are doing will make things better:
1. A child with anaphylaxis came into the ED lobby and the nurse was eating peanut butter and crackers, and handled the child's paperwork without washing her hands.
2. A child with anorexia and anxiety related to food allergies came into the lobby and the person at reception was dipping apples into peanut butter. She had a panic attack and nearly left AMA.
3. An ED nurse whose child has peanut allergies has often seen other staff eat peanut butter and crackers and then see patients after using hand gel but without washing their hands.
3. A doctor ate peanut butter cookies, washed his hands twice, then cared for a patient with peanut allergies, and the patient promptly went into anaphylaxis.
This is a real issue, and I for one want to make sure we do better before something bad happens that we could have prevented.
Julie Brown, MD, MPH
Associate Professor, University of Washington
Attending Physician, Pediatric Emergency Medicine,
Seattle Children's Hospital, MB.7.520,
Seattle, WA 98105-0371
Office: (206) 987-4016
Fax: (206) 729-3070
CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is: