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Background Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. Objective To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine auto-injectors and to measure the effect on anaphylaxis guideline adherence. Methods A cohort study was conducted from April 29, 2008-August 9, 2012. Adult ED patients diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up and incidence of biphasic reactions were evaluated. Results The study included 202 patients. Median age of patients was 45.3 years (IQR 31.3 – 56.4); 139 (69%) were female. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs. 33%, OR 2.05, 95%CI 1.04- 4.04) and admitted to ED observation unit (EDOU) (65% vs. 44%, OR 2.38, 95%CI 1.23-4.60) and less likely to be dismissed home directly from ED (16% vs. 29%, OR: 0.47, 95%CI 0.22- 1.00). Eleven patients (5%) had a biphasic reaction. Of these, five (46%) had the biphasic reaction in EDOU; one patient was admitted to intensive care unit (ICU). Six patients (55%) had reactions within 6 hours of initial symptom resolution of whom two were admitted to ICU. Conclusion Significantly greater proportions of anaphylaxis patients received epinephrine and were admitted to EDOU after introduction of epinephrine auto-injectors and order set implementation. Slightly over half of the biphasic reactions occurred within recommended observation time of 4-6 hours. These data suggest that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

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Key Points Question What is the role of patient preference in racial disparities in opioid prescribing for patients with acute pain, and does providing clinicians with additional data about their patients mitigate disparities? Findings In this secondary analysis of 1012 patients with acute pain who were recruited for a multicenter randomized clinical trial, Black patients were less likely than White patients to receive a prescription for opioids, regardless of their treatment preference. These disparities were not mitigated by providing clinicians with additional data about their patients’ preferences and risks. Meaning This study’s findings suggest that differences in patient preference do not explain racial disparities in opioid prescribing; further research is needed to assess the factors associated with these disparities.

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