Concordance with recommended postdischarge care guidelines among children with food-induced anaphylaxis

Improving Care at Emergency Department Discharge for Pediatric Patients with Anaphylaxis Using a Quality Improvement Framework

Introduction

Anaphylaxis is a potentially fatal systemic reaction that requires prompt recognition and targeted treatment. Despite international consensus and national guidelines, there is often incomplete care for pediatric patients discharged from the emergency department (ED) with a diagnosis of anaphylaxis. Our institution experienced wide variability in discharge planning for patients with anaphylaxis. The goal of our study was to improve care at ED discharge for pediatric patients with anaphylaxis using a quality improvement framework. The specific aims were to increase the frequency of patients diagnosed with anaphylaxis who receive an anaphylaxis action plan at ED discharge from 0% to 60% and to increase referrals to an allergy clinic from a baseline of 61%-80% between October 2020 and April 2021.

Methods

Targeted interventions included revisions to the electronic health record system, forging interdisciplinary partnerships and emphasizing provider education. Outcome measures were the proportion of patients receiving an anaphylaxis action plan and an allergy clinic follow-up. The balancing measure was the ED length of stay.

Results

The study showed an increase in anaphylaxis action plans from 0% to 34%. Allergy clinic referral rates improved from 61% to 82% within the same period. The average length of stay of 347 minutes remained unchanged.

Conclusions

Revising the discharge instructions to include an anaphylaxis action plan and reinforcing provider behaviors with educational interventions led to an overall improvement in discharge care for patients with anaphylaxis. Future work will focus on electronic health record changes to continue progress in additional clinical settings.

Epinephrine in anaphylaxis: too little, too late

PURPOSE OF REVIEW

Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike.

RECENT FINDINGS

There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen.

SUMMARY

Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.

Emergency department revisits and rehospitalizations among infants and toddlers for acute allergic reactions

Background and Objective: Allergic reactions, including anaphylaxis, are rising among children. Little is known about health care utilization among infants and toddlers. Our objective was to characterize health care utilization and charges for acute allergic reactions (AAR). Methods: We conducted a retrospective cohort study of trends in emergency department (ED) visits and revisits, hospitalizations and rehospitalizations, and charges among infants and toddlers (ages < 3 years), with an index ED visit or hospitalization for AAR (including anaphylaxis). We used data from population-based multipayer data: State Emergency Department Databases and State Inpatient Databases from New York and Nebraska. Multivariable logistic regression was used to identify factors associated with ED revisits and rehospitalizations. Results: Between 2006 and 2015, infant and toddler ED visits for AAR increased from 27.8 per 10,000 population to 35.2 (P_trend < 0.001), whereas hospitalizations for AAR remained stable (P_trend = 0.11). In the one year after an index AAR visit, 5.1% of these patients had at least one AAR ED revisit and 5.9% had at least one AAR rehospitalization. Factors most strongly associated with AAR ED revisits included an index visit hospitalization and receipt of epinephrine. Total charges for AAR ED visits (2009-2015) and hospitalizations (2011-2015) were more than $29 million and $11 million, respectively. Total charges increased more than fourfold for both AAR ED revisits for AAR rehospitalizations during the study period. Conclusion: Infants and toddlers who presented with an AAR were at risk for ED revisits and rehospitalizations for AAR within the following year. The charges associated with these revisits were substantial and seemed to be increasing.

Epinephrine autoinjector prescription filling after pediatric emergency department discharge

Background: There are known racial and socioeconomic disparities in the use of epinephrine autoinjectors (EAI) for anaphylaxis. Objective: To measure the rates of EAI prescription filling and identify patient demographic factors associated with filling rates among patients discharged from the pediatric emergency department. Methods: This was a retrospective observational cohort study of all patients discharged from a pediatric emergency department who received an outpatient prescription for an EAI between January 1, 2018, and October 31, 2019. The rates of prescription filling were calculated, and multivariable logistic regression was performed to identify sociodemographic factors associated with prescription filling. Results: Of 717 patients included in the analysis, 54.8% (95% confidence interval {CI}, 51.1%-58.5%) filled their prescription. There were no significant associations between EAI fill rates and patient age or sex. In bivariable analysis, non-Hispanic white patients were more likely to fill EAI prescriptions compared with non-Hispanic Black patients (odds ratio [OR] 1.89 [95% CI, 1.11-3.20]), and patients with in-state Medicaid were significantly less likely to fill EAI prescriptions compared with those patients with private insurance (OR 0.69 [95% CI, 0.48-0.98]). However, after multivariable adjustment, there was no significant difference in filling by age, insurance status, or race or ethnicity. Conclusions: Only approximately half the patients had their EAI prescriptions filled after discharge. Filling rates did not vary by sociodemographic characteristics.

Fill rates and access to self-injectable epinephrine prescribed in a pediatric emergency department

BACKGROUND

Despite its life-saving potential in anaphylaxis, self-injectable epinephrine (SIE) is frequently not administered by caregivers prior to arrival in the emergency department (ED). Prescriptions from the ED often go unfilled which may contribute to the failure to receive SIE when needed.

OBJECTIVE

To determine the prescription filling rate and accessibility of SIE devices among families discharged from the Pediatric ED with an SIE prescription.

METHODS

A phone survey was administered to parents of children <18 years of age prescribed SIE in the pediatric ED over 12 months. The survey inquired if they own an SIE device, the device's expiration date as confirmation, and details of their child's allergy. Variables were analyzed for association with owning SIE, having SIE accessible when prompted, and having unexpired SIE accessible.

RESULTS

170 children received prescriptions for SIE and 100 (59%) completed the survey. Eighty-four of 100 (84%) had filled the initial SIE prescription. Sixty-five of 100 (65%) had proof of having SIE, of which 29% (19/65) were expired. Only 46% (46/100) of all respondents had an accessible unexpired SIE. Patients with food allergies and those who'd visited an allergist after their ED visit had higher odds of having unexpired accessible devices.

CONCLUSION

A majority of patients prescribed SIE from the ED fill their prescription; however, less than half have unexpired SIE readily available despite high rates of recurrent anaphylactic emergencies. Focusing on post-discharge planning, particularly follow-up, may prevent children with allergies from being left dangerously unprepared.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway

BACKGROUND

Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation.

METHODS

In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision.

RESULTS

The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand.

CONCLUSIONS

By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Predictors of epinephrine dispensing and allergy follow-up after emergency department visit for anaphylaxis

BACKGROUND

National guidelines recommend that patients with anaphylaxis be prescribed an epinephrine auto-injector (EAI) and referred to an allergy/immunology (A/I) specialist.

OBJECTIVE

To evaluate guideline concordance and identify predictors of EAI dispensing and A/I follow-up in patients with anaphylaxis treated in the emergency department (ED).

METHODS

We identified patients seen in the ED for anaphylaxis from 2010 through 2014 from an administrative claims database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm.

RESULTS

Of 7,790 patients identified, 46.5% had an EAI dispensed and 28.8% had A/I follow-up within 1 year after discharge. On multivariable analysis, those 65 years or older (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.30-0.41) and with a medication trigger (OR 0.24, 95% CI 0.21-0.28) had a lower likelihood of EAI dispensing. Those younger than 5 years (OR 2.67, 95% CI 2.15-3.32) and with food (OR 1.40, 95% CI 1.24-1.59) or venom (OR 4.48, 95% CI 3.51-5.72) triggers had a higher likelihood of EAI dispensing. Similarly, for A/I follow-up, the likelihood was lower for age 65 years or older (OR 0.46, 95% CI 0.39-0.54) and medication trigger (OR 0.66, 95% CI 0.56-0.78) and higher for age younger than 5 years (OR 3.15, 95% CI 2.63-3.77) and food trigger (OR 1.39, 95% CI 1.22-1.58).

CONCLUSION

Overall, 46.5% of patients with anaphylaxis in the ED had EAI dispensing and 28.8% had A/I follow-up. Patient age and triggers were associated with likelihood of EAI dispensing and A/I follow-up. Post-ED visit anaphylaxis management can be improved, with the potential to decrease future morbidity and mortality risk.