Reducing Hospitalization Rates for Children With Anaphylaxis

Farbman, Karen S.; Michelson, Kenneth A.; Neuman, Mark I.; Dribin, Timothy E.; Schneider, Lynda C.; Stack, Anne M.

doi:10.1542/peds.2016-4114

Cited by 17 publications

(34 citation statements)

References 19 publications

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“…However, 72hour ED revisits for anaphylaxis were rare (2.1%) at our institution during the study period. 20,21 This made it feasible to accrue a large cohort of children who had severe anaphylactic reactions, and it offers a conservative approach for extrapolation to a population of children with less severe symptoms because discharged children likely have less severe reactions. Finally, discharged patients may have visited different EDs after being discharged from our ED, although this was likely uncommon and we would expect these patients to revisit our institution given it is a large referral center.…”

Section: Discussionmentioning

confidence: 99%

Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study

Dribin

Michelson

Yin

et al. 2020

The Journal of Pediatrics

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Objective To assess whether a history of asthma was associated with anaphylaxis severity in children hospitalized for anaphylaxis. Study design Retrospective cohort study of children £21 years old hospitalized for anaphylaxis from 2009 to 2016. The primary outcome was severe anaphylactic reactions defined by examination findings (stridor, respiratory distress, or hypotension) or administered therapies (³2 dose of intramuscular epinephrine, continuous albuterol, vasopressors, or positive pressure ventilation). Multivariable analyses were used to assess whether a history of asthma was associated with severe anaphylactic reactions, adjusting for patient age, allergen, and history of atopic dermatitis or anaphylaxis. Results Among 603 children hospitalized for anaphylaxis, 231 (38.3%) had a history of asthma. Children with a history of asthma were older (median age, 6.6 years [IQR, 3.6-12.1] vs 4.0 years [IQR, 1.6-9.3]), more likely to have a history of anaphylaxis (38.1% vs 18.0%), and have food as the inciting allergen (68.0% vs 52.2%). Children with a history of asthma were not more likely to have severe anaphylactic reactions (OR, 0.97; 95% CI, 0.67-1.39). Conclusions Children hospitalized for anaphylaxis with a history of asthma were not more likely to have severe anaphylactic reactions compared with children without asthma. This study supports managing children with anaphylaxis based on the severity of symptomatology, and, if validated, clinicians should not consider asthma comorbidity as a stand-alone criterion for hospitalization.

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Section: Discussionmentioning

confidence: 99%

Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study

Dribin

Michelson

Yin

et al. 2020

The Journal of Pediatrics

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“…The study was conducted in a tertiary care pediatric institution and limited to hospitalized children which may limit the generalizability of our findings. It should be noted that our hospitalization and ICU admission rates for patients with anaphylaxis are similar to other U.S. children’s hospitals [13,14]. We studied hospitalized children because our goal was to reduce unnecessary hospitalizations; however, we were unable to assess whether children discharged from the ED received acute therapies such as epinephrine after discharge.…”

Section: Discussionmentioning

confidence: 93%

“…The study was conducted at an urban, tertiary care children’s hospital with an annual ED volume of approximately 60,000 visits. During the study period the hospitalization rate for patients presenting to the ED with anaphylaxis was 44% [14]. Children with anaphylaxis at our institution are typically observed for 4 hours prior to ED discharge and are hospitalized if they have cardiac involvement or receive 2 or more doses of IM epinephrine in the prehospital or ED settings.…”

Section: Methodsmentioning

confidence: 99%

Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies

et al. 2019

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ObjectiveOpportunity exists to reduce unnecessary hospitalizations for children with anaphylaxis given wide variation in admission rates across U.S. emergency departments (EDs). We sought to identify children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies, as these patients may be candidates for ED discharge rather than inpatient hospitalization.MethodsWe conducted a single-center retrospective cohort study of children 1–21 years of age hospitalized with anaphylaxis from 2009 to 2016. Acute inpatient therapies included intramuscular (IM) or racemic epinephrine, bronchodilators, fluid boluses, vasopressors, non-invasive ventilation, or intubation. We derived age-specific (pre-verbal [<36 months] vs. verbal [≥ 36 months]) prediction rules using recursive partitioning to identify children at low risk of receiving acute inpatient therapies.ResultsDuring the study period 665 children were hospitalized for anaphylaxis, of whom 108 (16.2%) received acute inpatient therapies. The prediction rule for patients < 36 months (no wheezing, no cardiac involvement [hypotension or wide pulse pressure]) had a sensitivity of 90.5% (CI 69.6–98.8%) and a negative predictive value of 98.3% (CI 94.1–99.8%) for identifying children at low risk of receipt of acute inpatient therapies during hospitalization. For children ≥ 36 months, the prediction rule (no wheezing, no cardiac involvement, presence of gastrointestinal symptoms) had a sensitivity of 90.8% (CI 82.7–96.0%) and a negative predictive value of 92.4% (CI 85.6–96.7%).ConclusionsWe derived age specific prediction rules for children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies. These children may be candidates for ED discharge rather than inpatient hospitalization.

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“…Previously, we evaluated how our system prioritized children attended for anaphylaxis in the PEU, noting that 66% were underprioritized and thus experienced delays in receiving their treatment [10]. Other authors have reported similar results [11].…”

Section: Introductionmentioning

confidence: 83%

“…Therefore, allergists may and should help to analyze the allergies category in current triage systems jointly with ED specialists. With respect to training, Farbman et al [11] showed how educational measures reduced anaphylaxis-related admission rates. Our results show that carrying out training activities aimed at triage staff and introducing adjustments in the triage system to take account of the peculiarities of anaphylaxis improved identification of patients and dramatically reduced waiting times for medical attention.…”

Section: Discussionmentioning

confidence: 99%

Impact of Specific Training in Anaphylaxis for Triage Nursing Staff in the Pediatric Emergency Department of a Tertiary Hospital

Arroabarren¹,

Alvarez-Garcia²,

Anda³

et al. 2018

J Investig Allergol Clin Immunol

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Reducing Hospitalization Rates for Children With Anaphylaxis

Abstract: We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.

Cited by 17 publications

References 19 publications

Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study

Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study

Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies

Impact of Specific Training in Anaphylaxis for Triage Nursing Staff in the Pediatric Emergency Department of a Tertiary Hospital

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