Improving Anaphylaxis Care: The Impact of a Clinical Pathway

Quindelyn Cook; A. Wesley Burks

doi:10.1542/peds.2018-2420X

J Lee, B Rodio, J Lavelle. Pediatrics. 2018;141(5):e20171616

PURPOSE OF THE STUDY.

To evaluate the clinical impact of a revised anaphylaxis clinical pathway with reductions in emergency department (ED) observation time, increased provider education on anaphylaxis, and patient accessibility to epinephrine auto-injectors.

STUDY POPULATION.

The study population included pediatric ED patients at an urban, tertiary university-affiliated children’s hospital, before and after changes to a clinical anaphylaxis pathway.

METHODS.

This was a multidisciplinary quality improvement initiative, performed at an urban, tertiary university-affiliated children’s hospital ED to update the anaphylaxis clinical pathway. ED observation time was reduced from 8 to 4 hours, with the goal to reduce anaphylaxis-related admissions. Provider education on anaphylaxis and prompt epinephrine use was improved, and all patients were discharged from the ED with an epinephrine auto-injector. Data were analyzed 18 months before and after the pathway update. Patients with anaphylaxis were identified by using International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision codes. Their medical records were reviewed to evaluate ED management and follow-up care. The study authors set a target epinephrine administration time of ≤20 minutes after ED arrival and a goal of ≥80% of patients being discharged from the hospital with epinephrine. Statistical analysis was performed by using Fisher’s exact test for the primary end point and subject follow-up data. The Mann–Whitney U test was used to compare the median time of first epinephrine administration for critical patients before and after implementation of the new clinical pathway. A P value ≤.05 was considered statistically significant.

RESULTS.

A 60% reduction from baseline (P < .0001) was noted for anaphylaxis-related admissions; 106 of 182 cases (58.2%) required admission before the pathway revision, compared with 65 of 257 (25.3%) after. No statistically significant difference was noted in the rate of patients returning to the ED within 72 hours for recurrence of anaphylaxis-related symptoms (1.3% baseline versus 2.6% after revision; P = .99). The median time to first epinephrine administration for critical patients before the pathway change was 15 minutes. After pathway revision, it decreased to 10 minutes, which met the target goal of <20 minutes. The target goal of >80% of discharged patients leaving with personal epinephrine auto-injectors was also met; 164 of 192 (85.4%) patients filled or received auto-injectors. In regard to safety, there were no deaths during the study period. There were no ICU admissions. Postrevision, a greater proportion of patients were seen for allergy and/or immunology follow-up (113 of 182 [62.1%] before and 166 of 257 [64.6%] after, respectively).

CONCLUSIONS.

The study authors concluded that the revised clinical anaphylaxis pathway improved patient care by reducing the anaphylaxis-related admission rates, ensuring prompt delivery of epinephrine to critical patients, and increasing epinephrine auto-injector carriage rates for discharge patients. Future directions include evaluating sustainability of the updated pathway and improving efficiency of care delivery.

REVIEWER COMMENTS.

This quality improvement initiative improved management of anaphylaxis in a pediatric ED. Anaphylaxis is a life-threatening event, and prompt treatment with epinephrine is vital. By reducing the observation period, the study authors demonstrated that the rate of anaphylaxis-related admissions could be reduced. This study was performed at a large tertiary-care pediatric hospital, which is a limitation; however, a similar endeavor could be performed at a smaller community hospital as well. For patient populations living in resource-poor areas, prompt recognition and treatment of anaphylaxis could mitigate prolonged ED observation periods, admissions, and prevent unnecessary transfers to tertiary-care centers. The authors of this study reiterate the importance of good provider education regarding the recognition and prompt treatment of anaphylaxis with epinephrine. It is impressive that >80% of their subjects were discharged with an epinephrine auto-injector in hand. The price of auto-injectors makes them cost prohibitive for some families despite insurance coverage. Finding ways, as this study has shown, to improve access to epinephrine is important as well.