PURPOSE OF THE STUDY.
To assess whether a quality improvement (QI) intervention can safely reduce the hospitalization rate for children presenting with anaphylaxis.
Children diagnosed with anaphylaxis from 2008 to 2014 at an urban, tertiary care pediatric emergency department (ED).
A multidisciplinary team consisting of pediatric emergency medicine physicians, a pediatric ED nurse, a pharmacist, and a pediatric allergist developed an evidence-based guideline (EBG) reflecting the recommendations from the National Institute of Allergy and Infectious Diseases anaphylaxis guidelines. This EBG recommended that children meeting criteria for anaphylaxis receive prompt intramuscular epinephrine and also receive diphenhydramine and a glucocorticoid. Those with persistent symptoms were hospitalized; those with resolution of symptoms were monitored for 4 hours. The EBG recommended hospitalization for children requiring >1 dose of epinephrine as well as those with any wheezing or hypotension. The hospitalization rates before and after implementation of the EBG were compared. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children’s hospitals were analyzed over the study period.
A total of 1169 children diagnosed with anaphylaxis were included in this study, 438 pre-QI intervention and 731 post-QI intervention. By using the EBG intervention, the proportion of children hospitalized decreased from 54% to 36%, with no increase in the rate of ED revisit within 72 hours of discharge. The hospitalization rate across 34 other US pediatric hospitals was static at 52% over the study period.
Using an EBG for anaphylaxis safely reduced unnecessary hospitalization for children with anaphylaxis. This process was enhanced with periodic reminders about the EBG to providers as well as structured feedback if the EBG was not followed.
The authors of this study show the value of employing a consensus recommendation (in this case, from the National Institute of Allergy and Infectious Diseases on recognition of anaphylaxis and appropriate pharmacologic intervention) as part of an EBG. Too often early signs of anaphylaxis are not recognized or are inadequately treated, ultimately leading to a more protracted course, more intense treatment, and/or the need for hospitalization for longer-term monitoring. By using clinical criteria that objectively help the clinician discern if a child is likely having anaphylaxis, early intervention with epinephrine, diphenhydramine, and glucocorticoids increases the likelihood of prompt resolution as well as prevention of late-phase reactions.
- Copyright © 2017 by the American Academy of Pediatrics