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 SarahImproving 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 reaction that can be life-threatening. associated with fatal anaphylaxis. ‍ ‍ PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 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,observation25​ 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 6 hours is discussed for history of severe asthma, (4) current 9 pathway. We reviewed our evidence most anaphylaxis patients. asthma flare, (5) hypotension during summary with all clinicians in both ED stay, (6) requires >1 epinephrine Thus, the multidisciplinary team disciplines for further input before dose, or (7) requires fluid bolus. reconvened in 2014 to revise the releasing the updated pathway. In ED anaphylaxis clinical pathway accordance with institutional review To emphasize epinephrine as the and launch a quality improvement board standards at our institution, first-line therapy, we placed a chart Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 LEE et al TABLE 1 ICD Codes Used to Identify Anaphylaxis Patients outlining the diagnostic criteria ICD-9 Codes ICD-10 Codes previously established by expert 995.0 T78.2XXA consensus5 on the main pathway 995.6X T78.00XA screen. We anticipated that this 999.4 T78.01XA would help trigger quick recognition 999.41 T78.02XA of anaphylaxis and facilitate 999.42 T78.03XA prompt treatment. Additionally, we 999.49 T78.04XA T78.05XA highlighted on the pathway screen — — T78.06XA that the first-line treatment of — T78.07XA anaphylaxis is epinephrine, delivered — T78.08XA intramuscularly. — T78.09XA — T80.52XA We also implemented a new practice ICD, International Classification of Diseases; ICD-9, of discharging patients from the ED International Classification of Diseases, Ninth Revision; with an epinephrine autoinjector ICD-10, International Classification of Diseases, 10th in hand (Fig 1). The nurse reviews Revision; —, not applicable. signs and symptoms for which to use the autoinjector, along with indications for returning to the ED. if patients were discharged with an Patient handouts guiding avoidance epinephrine autoinjector in hand. of specific food allergens, along FIGURE 1 QlikView (Qlik, Radnor, PA) was used with information on how to obtain Process of discharging patients with epine­ for data visualization, allowing us to Medical Alert bracelets or necklaces, phrine autoinjector in hand. track our progress over time. are available. Instructions are reviewed verbally and supplemented Measures with written instructions. Patients The primary outcome measure was defined as the percentage of patients are referred to CHOP Allergy for ’ follow-up. “ ” admitted from the ED to either the We used our hospital s data ED observation unit or an inpatient The revised pathway went live on warehouse to extract both unit. The balancing measure was the October 20, 2014 (http://​www.​chop.​ retrospective and ongoing data on ED percentage of discharged patients edu/​clinical-​pathway/​anaphylaxis-​ visits meeting our anaphylaxis cohort returning to the ED within 72 hours emergent-​care-​clinical-​pathway). definition. We defined the cohort for symptoms related to the initial A hospital-wide announcement was populationInternational as patients Classificationseen in the visit. Secondary outcome measures made on the intranet and by internal ofED Diseases, with a diagnosis Ninth Revision of anaphylaxis included time to first epinephrine e-mail to alert providers to this Internationalby using Classification of administration for critical (ESI level 1) update.Study of the Intervention Diseases, 10th Revision and patients and the percentage of patients discharged with an codes (Table 1). epinephrine autoinjector in hand. Our team met weekly for 2 We presumed that few cases of We tracked the median time from ED arrival to administration of the first consecutive months after the anaphylaxis would be missed using ≤ implementation of the revised this method, because clinical decision epinephrine, setting a target goal of pathway in October 2014. We support is offered through the 20 minutes. Although immediate reviewed new anaphylaxis cases and pathway, including a list of suggested administration of epinephrine is the discussed feedback from ED bedside diagnosis codes. Important data fields goal, we felt that 20 minutes would providers. Since then, we have extracted included ESI category; account for all the elements that held monthly meetings to review ED disposition; time to order and composed our measure of time to cases and trends. To investigate administration of medications given, epinephrine: time from ED arrival to whether our measured outcomes including time to first epinephrine placement in the examination room, were due to the pathway revisions, administration; and revisits to the time from rooming to electronic we chose to study and compare the ED within 72 hours. We pulled data order after patient assessment, and cohort population seen in the ED on any encounters with a CHOP time from order to administration. during the 18 months before the primary care site, urgent care center, Our target goal for the percentage of discharged patients leaving with revised pathway (baseline) with the or Allergy clinic within 72 hours ≥ population seen in the 18 months of the initial ED visit. We reviewed an epinephrine autoinjector was after the revision. nursing documentation to determine 80%. We tracked the percentage Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 141, number 5, May 2018 3 TABLE 2 Comparison of Admissions and Revisits for Anaphylaxis Patients Before and After Pathway Revision of patients with a referral order Before Revision: April 20, After Revision: October 20, P for CHOP Allergy follow-up and the 2013–October 19, 2014 2014–April 20, 2016 percentage of patients who were ED anaphylaxis patients 182 257 — seen in the Allergy clinic within 1 and Median age, y 6.5 6 .60 Analysis3 months of the ED encounter. Admitted (%) 106 (58.2%) 65 (25.3%) < .0001 Discharges revisiting ED (%) 1 (1.3%) 5 (2.6%) .99

—, not applicable. For our primary outcome and balancing measures, we compared ≤ the cohorts seen during the 18-month baseline period to the ‍Fig 2, signaling a shift), and this of 20 minutes (Fig 3). The overall 18 months after pathway revision. continues to be sustained beyond the median time to first epinephrine for ’ Proportions were compared by 18-month study period. There was this group was 10 minutes. During ’ using Fisher s exact test. We also no statistically significant difference theP 18-month baseline period, the used Fisher s exact test for our in the rate of patients returning to overall median time was 15 minutes measures related to Allergy referral the ED within 72 hours for symptoms Discharges( = .87). With Epinephrine – U Autoinjector in Hand and clinic follow-up. We used the related to the initial visit: 1.3% Mann Whitney test to compare (1P of 76) at baseline versus 2.6% the median time to first epinephrine (5 of 192) after pathway revision administration for critical (ESI level 1) ( = .99). No patients in either cohort Over the 18 months after the P ≤ patients before and after pathway had an encounter at a CHOP primary pathway revision, 85.4% of patients revision. .05 was considered site, urgent care center, or Allergy being discharged from the ED statistically significant for all clinic for recurrence of symptoms (164 of 192) had an epinephrine analyses. Additionally, we used a run within 72 hours of the initial ED visit. autoinjector in hand. For cases in chart to monitor shifts in admission There were no deaths throughout the which patients were not discharged rate over time as pathway revisions entire study period. Of the 5 patients with an epinephrine autoinjector, our were implemented. We calculated who returned to the ED during ED nurse elicited feedback from ED the centerline as the median of the the 18 months after the pathway providers. The main reason reported monthly percentage of patients revision, 4 patients returned with was that the patient already had an admitted during the prerevision hives alone and 1 patient returned Allergyepinephrine Referrals autoinjector and Follow-up at home. period and extended this line into with increased work of breathing the future to allow for detection of and wheezing. Of the 4 patients who returned with hives, 1 had self- Similar percentages of patients signals of improvement29 by using run chart rules. administered epinephrine at home had an electronic referral order to RESULTS and the remainder were treated CHOP Allergy before (62.1%; 113 of with oral antihistamines and/or 182) and after (64.6%; 166 of 257) Admissions and Return Visits corticosteroids in the ED. The patient pathway revision (Table 3). Despite who returned with respiratory issues this, a higher percentage of patients was treated with epinephrine in were seen for follow-up in the Allergy There were 182 total cases of the ED and ultimately admitted for clinic after pathway revision within anaphylaxis seen in the ED during treatment of an asthma exacerbation. 1 and 3 months of the ED visit (Table 3). the 18-month baseline period before None of these patients required It is possible that some portion of the pathway revision and 257 cases ICU admission. The time from first patients referred to Allergy went to during the 18 months after the ED presentation to subsequent ED an allergist outside our institution, revision. In the baseline cohort, presentation ranged from 13.5 to because there are many other allergy 58.2% of patients (106 of 182) 36.5 hours, all outside the initial practices in our area. were admitted. After the pathway pathway observation period of 8 DISCUSSION Timehours. to Epinephrine revision, the overall admissionP rate was 25.3% (65 of 257), a reduction of 60% from baseline ( < .0001) After implementing our revised (Table 2). The decrease in admissions During the 18 months after pathway ED anaphylaxis clinical pathway, occurred quickly after the revised revision, the median time to first incorporating a decreased pathway was released (as depicted epinephrine administration in the recommended observation length by the run of over 6 consecutive ED for ESI level 1 patients was from 8 to 4 hours, we successfully points, all below the centerline in consistently less than our target goal reduced the overall admission Downloaded from www.aappublications.org/news by guest on September 29, 2021 4 LEE et al FIGURE 2 Run chart tracking admission rate.

rate by nearly 60%. This appears their families. Hospitalization can panels and consensus guidelines to be a safe practice, because the have significant social implications, from specialists in allergy and – percentage of patients returning to including missed time at school immunology, emergency medicine,5,6,​ 8​ 12 the ED remained similar before and and work. Furthermore, the pediatrics, and other fields. ‍ ‍ after the revision. The authors of financial burden on patients can For this reason, an important previous studies have demonstrated be substantially greater33 if they are secondary goal of this project that biphasic anaphylaxis in children hospitalized. Patel et al evaluated was encouraging our ED staff to is uncommon, and with our results, the cost burden of food-induced expeditiously recognize anaphylaxis we support the authors of literature anaphylaxis in the United States and and initiate therapy. The median showing that prolonged observation found that, on average, an ED visit time to first epinephrine during the periods are not generally necessary costs $553 per patient whereas an 18-month period after the pathway 17,30,​ 31​ ≤ after anaphylaxis. ‍ ‍ The authors inpatient admission costs $4719, revision for ESI level 1 patients was of a recent publication described with an annual cost of $4.8 million consistently less than our goal of 20 the infrequency of inpatient for ED visits and $26.6 million minutes, with an overall median of interventions during pediatric for hospitalizations. Morbidity 10 minutes. After noting this trend, hospitalizations for food-induced costs, including lost wages and we have since lowered our target anaphylaxis, further supporting absenteeism, accounted for 85% of goal from 20 to 10 minutes and will the safety of discharging most indirect costs. be continuing to track sustainability. anaphylaxis patients and highlighting Although there was no statistically The mainstay of anaphylaxis the importance of ongoing efforts significant difference from the overall management is the prompt to determine which patients truly median time of 15 minutes in the 32 administration of intramuscular require hospitalization. baseline period, this is still a clinically epinephrine, because delayed significant improvement. Although we did not directly measure administration– has– been associated patient satisfaction or perform cost with both biphasic5 12,17​ 21and fatal To promote successful achievement analysis, we believe that the reduced anaphylaxis. ‍ ‍ ‍ ‍ ‍ This tenant of of this metric, ED clinicians length of observation likely had anaphylaxis therapy is reiterated in participated in several joint a positive impact on patients and numerous multidisciplinary expert educational sessions to review the Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 141, number 5, May 2018 5 FIGURE 3 Run chart tracking median time to first epinephrine administration in ED. Q, quarter.

TABLE 3 Comparison of Allergy Referrals and Clinic Visits for Anaphylaxis Patients Before and After Pathway Revision In consensus guidelines, it is also Before Revision: April 20, After Revision: October 20, P strongly recommended that patients 2013–October 19, 2014 2014–April 20, 2016 discharged with the diagnosis of ED anaphylaxis patients 182 257 — Allergy referral order 113 (62.1%) 166 (64.6%) .62 anaphylaxis leave the hospital Allergy clinic visit within 1 mo 37 (20.3%) 80 (31.1%) .01 with either a prescription– for an Allergy clinic visit within 3 mo 55 (30.2%) 103 (40.1%) .03 epinephrine autoinjector5,6,​ 8​ 12 or the —, not applicable. autoinjector itself. ‍ ‍ ‍ ‍ Despite these recommendations, the authors of studies have shown that a large percentage of anaphylaxis patients pathway and diagnostic criteria for division meetings, included in the do not receive a prescription at anaphylaxis. Triage protocols were weekly RN updates, and posted on ED discharge, and of those who do ∼ reviewed with nursing staff. Team the ED Quality Board and on ED receive an epinephrine autoinjector assessment (physicians and nurses screensavers. These educational prescription,– only 60% fill it jointly evaluating patients brought initiatives allowed for improvement within34 37 a few days of receiving back immediately from triage) was in both prompt and accurate it. ‍ ‍ To ensure optimal safety stressed for anaphylaxis patients. recognition of anaphylaxis, as well as for our patients, we implemented Front-line ordering clinicians, as well timely administration of epinephrine. a process by which patients would as fellows and attending physicians, It is possible that this increased be discharged from the ED with an were encouraged to immediately familiarity with anaphylaxis among actual epinephrine autoinjector in ≥ order epinephrine by using the providers also promoted improved hand and set a goal to achieve this anaphylaxis order set, so that the education and guidance provided to for 80% of discharged patients. nursing staff could expeditiously families, because we saw a significant We attained this goal, with 85% of retrieve and administer the increase in the percentage of patients discharged patients leaving with medication. Data about our progress with Allergy follow-up after the an epinephrine autoinjector during were shared at our multidisciplinary pathway revision. the 18 months after the pathway Downloaded from www.aappublications.org/news by guest on September 29, 2021 6 LEE et al revision. To our knowledge, this is the periods before and after pathway the efficient care of anaphylaxis the first successful implementation revision. patients and help prevent of such a process. We continue to CONCLUSIONS unnecessary hospitalizations. work to sustain our successes, as well In the next phase of our quality as to push to the ideal of 100% of improvement project, we will anaphylaxis patients leaving with an By updating an anaphylaxis clinical continue to track sustainability, with epinephrine autoinjector. pathway, we successfully and safely new goals of ESI level 1 patients This study has several limitations. improved the care of patients receiving epinephrine within 10 Our project was limited to a presenting to a busy pediatric ED minutes of ED arrival and at least 90% pediatric population at a large, with anaphylaxis. Most notably, of discharged patients leaving with an epinephrine autoinjector in hand. urban, tertiary-care center. decreasing the recommended length ABBREVIATIONS Additionally, for our balancing of observation from 8 to 4 hours measure of revisits to the ED, we only for anaphylaxis patients without ’ had information on returns to our severe symptoms or risk factors CHOP: Children s Hospital of own ED and may have potentially for biphasic anaphylaxis resulted Philadelphia missed revisits to an outside hospital in a near 60% reduction in the ED: emergency department ED. However, this is unlikely to have average rate of admission. ESI: Emergency Severity Index been a frequent occurrence, and it A similar pathway could be used RN: registered nurse would have been applicable for both at other organizations to promote

FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 29, 2021 8 LEE et al Improving Anaphylaxis Care: The Impact of a Clinical Pathway Juhee Lee, Bonnie Rodio, Jane Lavelle, Megan Ott Lewis, Rachel English, Sarah Hadley, Jennifer Molnar, Cynthia Jacobstein, Antonella Cianferoni, Jonathan Spergel, Lisa Zielinski, Nicholas Tsarouhas and Terri Brown-Whitehorn Pediatrics originally published online April 3, 2018;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2018/03/30/peds.2 017-1616 References This article cites 37 articles, 5 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2018/03/30/peds.2 017-1616#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine http://www.aappublications.org/cgi/collection/emergency_medicine_ sub Administration/Practice Management http://www.aappublications.org/cgi/collection/administration:practice _management_sub Quality Improvement http://www.aappublications.org/cgi/collection/quality_improvement_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 29, 2021 Improving Anaphylaxis Care: The Impact of a Clinical Pathway Juhee Lee, Bonnie Rodio, Jane Lavelle, Megan Ott Lewis, Rachel English, Sarah Hadley, Jennifer Molnar, Cynthia Jacobstein, Antonella Cianferoni, Jonathan Spergel, Lisa Zielinski, Nicholas Tsarouhas and Terri Brown-Whitehorn Pediatrics originally published online April 3, 2018;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2018/03/30/peds.2017-1616

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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