Unnecessary hospitalizations for children with anaphylaxis have dropped following a multicomponent quality-improvement intervention at Boston Children’s Hospital, according to a new report.
Despite guidelines intended to assist emergency physicians in deciding whether to hospitalize patients with anaphylaxis to monitor for biphasic reactions, national hospitalization rates vary widely.
In response to hospitalization rates above 50% for children with anaphylaxis, Dr. Karen S. Farbman and colleagues from Boston Children’s and Harvard Medical School implemented the quality-improvement initiative, which aimed at reducing the proportion of children with anaphylaxis who are hospitalized by 25 percent.
They began by developing an evidenced-based guideline, which recommended that children meeting criteria for anaphylaxis receive prompt intramuscular epinephrine, along with diphenhydramine and a glucocorticoid.
Children whose symptoms did not resolve were hospitalized, and those whose symptoms resolved were monitored for four hours. The guideline also recommended hospitalization of children requiring >1 dose of epinephrine, those presenting with wheezing and patients with any hypotension.
The researchers emailed key aspects of the guideline annually to division faculty, published and distributed to physicians and nurses a pocket-sized brochure that highlighted all divisional guidelines, and integrated the anaphylaxis recommendations with order-entry sets in electronic health records to facilitate adherence.
The mean anaphylaxis hospitalization rate decreased from 54 percent at baseline to 36 percent shortly after introduction of the guideline, and the improvement was sustained throughout the three-year analysis period, the researchers report in Pediatrics, online May 25.
Overall, 140 potential admissions were avoided, while the median emergency department length of stay increased from 220 minutes to 244 minutes (reflecting greater adherence to a four-hour observation period). The number of patients with anaphylaxis seen between each 72-hour revisit, a surrogate for safety, did not change after implementation of the quality improvement initiative.
“Our quality improvement team found that by consolidating high-quality evidence into a local evidence-based guideline and making it easily accessible, we were able to influence provider practice,” the researchers note.
“Regarding the generalizability of this quality improvement initiative, local contexts may differ, and adherence may be limited,” they add. “Also, in remote areas, there may be legitimate reluctance to send patients far from the health care setting. Finally, our results may not generalize to settings in which there is not a culture of evidence-based guideline utilization.”