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Improving Anaphylaxis Care: the Impact of a Clinical Pathway

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Improving Anaphylaxis Care: the Impact of a Clinical Pathway Juhee Lee, MD, a Bonnie Rodio, BSN, RN, CEN, CPHQ, b Jane Lavelle, MD, b Megan Ott Lewis, MSN, CRNP, a Rachel English, MS, c ImprovingSarah Hadley, RN, c Jennifer Molnar, Anaphylaxis MSN, CRNP, b Cynthia Jacobstein, MD, b AntonellaCare: Cianferoni, MD, PhD, a a b b a TheJonathan Spergel, Impact MD, PhD, Lisa Zielinski, of RN,a Nicholas Clinical Tsarouhas, MD, TerriPathway Brown-Whitehorn, MD BACKGROUND: abstract Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged METHODS: durations often prompt admission for ongoing observation. Divisions of aAllergy/Immunology and bPediatric Emergency Medicine and cOffice of Clinical Quality Improvement, In a multidisciplinary quality improvement initiative, we revised Children’s Hospital of Philadelphia, Philadelphia, our emergency department (ED) anaphylaxis clinical pathway. Our primary Pennsylvania aim was to safely decrease the recommended length of observation from 8 Dr Lee conceptualized and designed the study, to 4 hours and thereby decrease unnecessary hospitalizations. Secondary conducted data analysis and interpretation, and aims included provider education on anaphylaxis diagnostic criteria, drafted the initial manuscript; Ms Rodio acquired data, supervised improvement interventions, and emphasizing epinephrine as first-line therapy, and implementing a practice reviewed and revised the manuscript; Drs Lavelle, of discharging ED patients with an epinephrine autoinjector in hand. The Tsarouhas, and Brown-Whitehorn supervised all study period consisted of the 18 months before pathway revision (baseline) aspects of the study, including conceptualization RESULTS: and design of the study, interpreted data, and and the 18 months after revision. P reviewed and revised the manuscript; Ms Lewis The overall admission rate decreased from 58.2% (106 of 182) and Ms Molnar conceptualized and designed the in the baseline period to 25.3% (65 of 257) after pathway revision ( < study, conducted data analysis, and reviewed and revised the manuscript; Ms English and Ms Hadley .0001). There was no significant difference in the percentage of patients coordinated and developed tools for data collection returning to the ED within 72 hours, and there were no adverse outcomes and reviewed and revised the manuscript; Ms or deaths throughout the study period. After pathway revision, the median Zielinski helped conceptualize the study, conduct improvement interventions, and reviewed and time to first epinephrine administration for the most critical patients was revised the manuscript; Drs Jacobstein, Cianferoni, 10 minutes, and 85.4% (164 of 192) of patients were discharged with an and Spergel helped analyze and interpret data CONCLUSIONS: epinephrine autoinjector in hand. and reviewed and revised the manuscript; and all authors approved the final manuscript as By revising an anaphylaxis clinical pathway, we were able to submitted. streamline the care of patients with anaphylaxis presenting to a busy DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1616 pediatric ED, without any compromise in safety. Most notably, decreasing Accepted for publication Dec 18, 2017 the recommended length of observation from 8 to 4 hours resulted in a near Address correspondence to Juhee Lee, MD, Division 60% reduction in the average rate of admission. of Allergy/Immunology, Department of Pediatrics, Children’s Hospital of Philadelphia, 3501 Civic Center Blvd, 6th Floor, Philadelphia, PA 19106. E-mail: – [email protected] Anaphylaxis is a severe, multisystem delayed administration has been 5 12 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, reaction that can be life-threatening. associated with fatal anaphylaxis. 1098-4275). The most common triggers of Antihistamines and corticosteroids, anaphylaxis in pediatrics are food although often administered, should be Copyright © 2018 by the American Academy of Pediatrics allergies, which affect 4% to 8% of considered adjunctive therapies. children in the United States and carry FINANCIAL DISCLOSURE: The authors have – The emergency department (ED) indicated they have no financial relationships a high economic1 4 burden of $25 billion plays a vital role in the management of relevant to this article to disclose. per year. anaphylaxis. A patient presents to the Successful management of anaphylaxis ED with a food allergy reaction every 3 To cite: Lee J, Rodio B, Lavelle J, et al. Improving requires prompt recognition of minutes, meeting anaphylaxis criteria Anaphylaxis Care: The Impact of a Clinical Pathway. Pediatrics. 2018;141(5):e20171616 the diagnosis and treatment with every 6 minutes, altogether resulting13 epinephrine. Epinephrine is the in 200000 ED visits annually. only first-line treatment, and Furthermore, ED visits for anaphylaxis Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 141, number 5, May 2018:e20171616 QUALITY REPORT have increased significantly over project to measure the impact this study was exempt from the past decade, particularly14, 15 in of the revision. The team aimed institutional review board oversight, the pediatric population. Since to safely reduce the ED length because no subjects were randomly the first description of biphasic of observation and decrease assigned and no experimental data anaphylaxis, the recurrence of unnecessary hospitalizations. Thewere Intervention collected. symptoms after a period of resolution Secondary aims included provider without re-exposure to the trigger, education on anaphylaxis diagnostic observation periods ranging from – criteria, emphasizing epinephrine The Division of Allergy had 3 to 4 hours to a minimum of 2416 24 as the first-line and most important previously established that the hours have been recommended. therapy, and implementing a practice 2.5-hour observation period for This wide range can lead to of discharging patients with an oral food challenges was safe, with 24 variation in clinical decision- epinephrine autoinjector in hand. biphasic reactions occurring rarely. making, more hospitalizations or METHODS We did recognize, however, that prolonged ED stays, increased costs, patients undergoing food challenges Setting inconsistent discharge care, and are not entirely comparable with caregiver confusion. Fortunately, patients presenting to an ED with ’ ∼ biphasic anaphylaxis appears to be anaphylaxis. Food challenge patients uncommon, with the authors of most The Children s Hospital of ∼ – are prescreened so that 50% Philadelphia (CHOP) is an urban, pediatric studies18, 22 reporting24 rates of ’ will not react and are monitored tertiary, university-affiliated 527- 10% or less. In the current closely during the challenge so anaphylaxis practice parameters, bed children s teaching hospital that anaphylaxis can be treated with over 90000 ED visits per year. 26 4 to 8 hours of 6,observation 25 is expeditiously, should it occur. To recommended. The ED is staffed by board certified acknowledge this difference, and to and/or eligible Pediatric Emergency stay within the range of observation At our institution, a multidisciplinary Medicine attending physicians and team of content experts and length recommended by current pediatricians, fellows, residents, anaphylaxis guidelines, we chose to front-line clinicians reviewed nurse practitioners, physician available evidence and generated decrease the observation length from assistants, registered nurses (RNs), 8 to 4 hours, rather than to 2.5 hours. expert consensus to create a and technicians. Patients are triaged clinical pathway guiding the ED by experienced RNs using the In the revised pathway, discharge management of anaphylaxis in Emergency Severity Index (ESI), was recommended after 4 hours 2011. The pathway was used to with ESI level 1 indicating the of observation subsequent to the implement education, clinical highest acuity. Approximately 7% initial epinephrine administration, decision support that included a of all patients seen within the CHOP as long as the following criteria were templated electronic medical record met: (1) a complete resolution of network have27 at least 1 documented note, and an electronic order set. Designfood allergy. anaphylaxis symptoms (sporadic In the initial version, 8 hours of hives were considered acceptable “ observation was recommended, for discharge), (2) the absence of any ” and as a result, the majority of severe symptoms or anaphylaxis red Our multidisciplinary team consisted anaphylaxis patients were admitted flags, and (3) parental comfort with of physicians, nurse practitioners, to the ED observation unit or an access to an ED in case symptoms and RNs from the divisions of inpatient unit. In 2014, a discrepancy recurred. We compiled a list of Pediatric Emergency Medicine in anaphylaxis management was anaphylaxis red flags on the basis of and Allergy, as well as including noted; in accordance with consensus literature on biphasic anaphylaxis an improvement adviser and data guidelines, patients with oral food and recommended that patients analyst from the Office of Clinical – challenges are discharged 2.5 hours be admitted if any red flag was Quality Improvement. We held 16 24, 28 after epinephrine administration, present : (1) history of biphasic biweekly meetings for several provided that symptoms have or severe reactions, (2) progression 26 months to review literature and resolved. Nationally, an observation of or persistent symptoms, (3) discuss revisions to the existing period of 4 to
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