Downstream consequences of diagnostic error in pediatric anaphylaxis

Predictors of severe and recurrent adult anaphylaxis, and gaps in the cascade of care: a retrospective, single-centre study 2009-2018

BACKGROUND

Anaphylaxis is a severe, potentially fatal, systemic allergic reaction. Understanding predictors of recurrent and severe anaphylaxis in adults, and identifying gaps in ongoing anaphylaxis care, is needed to minimise its impact.

AIMS

To evaluate the risk factors in adults with severe and recurrent anaphylaxis presentations and to evaluate the management of patients in regard to the recommended cascade of care.

METHODS

We completed a retrospective audit of adults with confirmed anaphylaxis who presented to an inner-city emergency department from 1 January 2009 through 31 December 2018. Data recorded included demographics, background history, medication use, severity, co-factors, triggers, management, discharge disposition and referral for follow-up. Data were managed in REDCap and analysed using Stata. Associations were assessed through odds ratios (ORs) and t tests.

RESULTS

Six hundred sixteen individuals had 689 episodes of anaphylaxis over the audit period. Age over 65 (OR: 5.4 (95% confidence interval, CI: 2.3-13.2), P < 0.0001) and history of asthma (OR: 1.6 (95% CI: 1.03-2.5), P = 0.03) were independent risk factors for severe anaphylaxis. History of food allergy (P < 0.001) and food as the trigger were associated with recurrent presentations (OR: 2.1, 95% CI: 1.1-3.9, P = 0.01). Only 19% of patients met the recommended cascade of care, with post-adrenaline monitoring and recommending follow-up with an allergy specialist demonstrating the largest gaps. There were increased presentations with time but no difference in triggers or severity.

CONCLUSIONS

Increased age and asthma were identified as risk factors for severe presentations. History of food allergy was a risk factor for recurrent presentations. Further research is needed on the gaps in care for adults with anaphylaxis to identify the reasons why, so we can better care for these patients.

Physicians' Approach to Anaphylaxis in Childhood

METHODS

A questionnaire form consisting of a total of 18 questions was prepared. Six questions concerned demographic data; 7 questions inquired about physician's knowledge level about treatment of anaphylaxis. In the last part, 5 different case scenarios were given, and their diagnoses and treatments were asked.

RESULTS

A total of 120 physicians participated in the study. Of the participants, 66.7% were residents. The rate of correct answer about dose of epinephrine was 57.5%. The rates of making correct diagnoses in anaphylaxis case scenarios 1, 2, and 3 were 60%, 73.3%, and 91.7%, respectively, whereas epinephrine administration rates were 54%, 67.5%, and 92.5%, respectively. When the answers of all these questions given by the residents and specialists and among physicians who updated and did not update were compared, there were no statistically significant differences except epinephrine administration rate and its route (P < 0.05).

CONCLUSIONS

The results of the current study suggest that physicians' knowledge levels were inadequate in making the diagnosis of anaphylaxis, and physicians use epinephrine in conditions without hypotension or an undefined possible/known allergen contact. Information about epinephrine administration was partially correct. It is currently considered to be the simplest measure to have a written anaphylaxis action plan including diagnostic criteria for anaphylaxis.

Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis

BACKGROUND

Community use of epinephrine for the treatment of anaphylaxis is low. Knowledge of rates of epinephrine use in the pre-hospital setting along with identification of barriers to its use will contribute to the development of policies and guidelines.

OBJECTIVES

A search was conducted on PubMed and Embase in April 2020. Our systematic review focused on 4 domains: (1) epinephrine use in the pre-hospital setting; (2) barriers to epinephrine use in the pre-hospital setting; (3) cost evaluation and cost-effectiveness of epinephrine use; and (4) programs and strategies to improve epinephrine use during anaphylaxis.

METHODS

Two meta-analyses with logit transformation were conducted to: (1) calculate the pooled estimate of the rate of epinephrine use in the pre-hospital setting among cases of anaphylaxis and (2) calculate the pooled estimate of the rate of biphasic reactions among all cases of anaphylaxis.

RESULTS

Epinephrine use in the pre-hospital setting was significantly higher for children compared with adults (20.98% [95% confidence interval (CI): 16.38%, 26.46%] vs 7.17% [95% CI: 2.71%, 17.63%], respectively, P = .0027). The pooled estimate of biphasic reactions among all anaphylaxis cases was 3.92% (95% CI: 2.88%, 5.32%). Our main findings indicate that pre-hospital use of epinephrine in anaphylaxis remains suboptimal. Major barriers to the use of epinephrine were identified as low prescription rates of epinephrine autoinjectors and lack of stock epinephrine in schools, which was determined to be cost-effective. Finally, in reviewing programs and strategies, numerous studies have engineered effective methods to promote adequate and timely use of epinephrine.

CONCLUSION

The main findings of our study demonstrated that across the globe, prompt epinephrine use in cases of anaphylaxis remains suboptimal. For practical recommendations, we would suggest considering stock epinephrine in schools and food courts to increase the use of epinephrine in the community. We recommend use of pamphlets in public areas (ie, malls, food courts, etc.) to assist in recognizing anaphylaxis and after that with prompt epinephrine administration, to avoid the rare risk of fatality in anaphylaxis cases.

Infant anaphylaxis: Diagnostic and treatment challenges

Immediate administration of intramuscular epinephrine to a patient experiencing anaphylaxis is the first-line therapy for this life-threatening allergic reaction. Alhough anaphylaxis is generally a rare occurrence, it has dire consequences if left untreated. In infants, anaphylaxis is typically triggered by exposure to egg, cow's milk, or peanuts. The rapid onset of symptoms in multiple organ systems makes an accurate diagnosis in infants difficult because there are numerous ways in which anaphylaxis may present. The symptoms of infant anaphylaxis are often underrecognized or misdiagnosed for less serious illnesses or even normal findings, including drooling, loose stools, and irritability. Because infants are mostly nonverbal-and most pediatric emergency department visits for anaphylaxis cases are the first diagnosis-ascertaining potential exposure to common allergens is difficult; this further complicates diagnosis in these youngest patients for whom the clinical presentation of anaphylaxis varies widely. A key factor in diagnosing anaphylaxis is the temporal profile of symptom development following allergen exposure; however, some children with anaphylaxis develop symptoms that reoccur hours or days after an initial anaphylactic reaction, making diagnosis challenging. Advanced practice nurses are often the first health care provider to encounter a patient who may be experiencing anaphylaxis. Although diagnostic criteria exist for anaphylaxis, specific criteria for the diagnosis of anaphylaxis in infants have not been developed. As such, it is important to understand and recognize the variable presentation of anaphylaxis in infants and to rapidly diagnose and treat with epinephrine.

Capturing anaphylaxis through medical records: Are ICD and CPT codes sufficient?

OBJECTIVE

The identification of anaphylaxis cases is imperative for optimal clinicalprovider knowledge deficiencies in diagnosis and treatment and the efficacy of reimbursement codes, such as International Classification of Diseases (ICD) and current procedural terminology (CPT) codes, in detecting anaphylaxis.

DATA SOURCES

Pubmed.

STUDY SELECTIONS

Recent and clinically relevant literature on anaphylaxis and provider knowledge, ICD, CPT, Healthcare Common Procedural Coding System (HCPCS), and E-codes were selected and reviewed.

RESULTS

Reimbursement codes are used to detect anaphylaxis in administrative claims databases. Inaccurate recognition of the diagnosis by providers, underreporting, and cause identification are challenges faced by health researchers using reimbursement codes for anaphylaxis case identification. Anaphylactic shock-specific ICD codes were noted to have a positive predictive value (PPV) of 52% to 53% of anaphylaxis events compared with physician chart review, which was improved to 63% to 67.3% when used in conjunction with anaphylaxis symptom-specific ICD, CPT, HCPCS, and E-codes 31, 34, and 35.

CONCLUSION

Education of providers to properly diagnose and treat anaphylaxis requires systematic and educational investments. The ICD codes specific to anaphylactic shock have suboptimal PPV to identify anaphylaxis in administrative claims databases. Use of algorithms incorporating other reimbursement codes improve the PPV, but they are limited by inaccurate diagnoses and underreporting of anaphylaxis. Future ICD-11 reclassification may improve anaphylaxis detection by reimbursement codes.

Missed Registration of Disease Codes for Pediatric Anaphylaxis at the Emergency Department

Background

It is important to register anaphylaxis codes correctly to study the exact prevalence of anaphylaxis. The purpose of this study was to analyze the clinical characteristics and disease codes of inaccurately registered groups in pediatric anaphylaxis patients.

Methods

This study reviewed the medical records of all pediatric patients who presented to the university hospital emergency department over a 5-year period. Study subjects were divided into 2 groups: the accurate group, including those registered under anaphylaxis codes, and the inaccurate coding group, including those registered under other codes.

Results

From a total of 79,676 pediatric patients, 184 (0.23%) had anaphylaxis. Of these, 23 (12.5%) and 161 (87.5%) patients were classified to the accurate and inaccurate coding groups, respectively. Average age, time from symptom onset to emergency department presentation, past history of allergy, and penicillin and cephalosporin as causes of anaphylaxis differed between the 2 groups. Cardiovascular (39.1% vs. 5.6%, p=0.001) and respiratory symptoms (65.2% vs. 42.2%, p=0.038) manifested more frequently in the accurate group, while gastrointestinal symptoms (68.3% vs. 26.1%, p=0.001) were more frequently observed in the inaccurate coding group. Fluid administration (82.6% vs. 28.0%, p=0.001), steroid use (60.9% vs. 23.0%, p=0.001), and epinephrine use (65.2% vs. 13.0% p=0.001) were more common treatments for anaphylaxis in the emergency department in the accurate group. Anaphylaxis patients with cardiovascular symptoms, steroid use, and epinephrine use were more likely to be accurately registered with anaphylaxis disease codes.

Conclusions

In the case of pediatric anaphylaxis, more patients were registered inaccurately under other allergy-related codes and simple symptom codes, rather than under anaphylaxis codes. Therefore, future research on anaphylaxis should consider inaccurately registered anaphylactic patients, as shown in this study.

Diagnosis and management of drug-induced anaphylaxis in children: An EAACI position paper

Drug hypersensitivity reactions (DHR) constitute a major and common public health problem, particularly in children. One of the most severe manifestations of DHR is anaphylaxis, which might be associated with a life-threatening risk. During those past decades, anaphylaxis has received particularly a lot of attention and international consensus guidelines have been recently published. Whilst drug-induced anaphylaxis is more commonly reported in adulthood, less is known about the role of drugs in pediatric anaphylaxis. Betalactam antibiotics and non-steroidal anti-inflammatory drugs are the most commonly involved drugs, probably related to high prescription rates. Diagnosis relies on the recognition of symptoms pattern and is based on complete allergic workup, particularly including skin tests and/or specific IgE. However, the real diagnostic value of those tests to diagnose immediate reactions in children remains not well defined for a significant number of the drugs. Generally, a drug provocation test is discussed to confirm or exclude an immediate-onset drug-induced hypersensitivity. Although avoidance of the incriminated drug (and related drug) is the rule, rapid desensitization is useful in selected subgroups of patients. There is a need for large, multicentric studies, to evaluate the real diagnostic value of the currently available skin tests. Moreover there is also a need to develop new diagnostic tests in the future to improve the management of these children.

Underuse of Epinephrine for Pediatric Anaphylaxis Victims in the Emergency Department: A Population-based Study

Purpose

Epinephrine is a key drug for treating anaphylaxis; however, its underuse is still a significant issue worldwide. The objective of this study was to compare epinephrine use between pediatric and adult patients who were treated with anaphylaxis in the emergency department (ED).

Methods

The data were retrieved from the National Sample Cohort of South Korea, which contains claim data from the National Health Insurance Service. We included patients who visited the ED with a discharge code of anaphylaxis between 2004 and 2013. We assessed prescription information of epinephrine, antihistamine and systemic steroid, previous medical history and discharge disposition from the ED. The study population was categorized based on age at the visit.

Results

A total of 175 pediatric and 1,605 adult patients with anaphylaxis were identified. Only 42 (24%) of the pediatric patients were treated with epinephrine, while 592 (36.9%) of the adult patients were treated with epinephrine (P = 0.001). Furthermore, the pediatric patients were less likely to be treated with systemic steroid than the adult patients (6.9% vs. 12.3%, P = 0.047). The odds ratios for the administration of epinephrine relative to the baseline in the 19-65 age group were 0.34 (95% confidence interval [CI], 0.15–0.67), 0.56 (95% CI, 0.28–1.03) and 0.79 (95% CI, 0.45–1.33) in the < 7, 7–12 and 13–18 age groups, respectively.

Conclusions

The pediatric patients with anaphylaxis experienced a lower rate of epinephrine injection use than the adult patients and the injection use decreased as age decreased.