Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice

doi:10.5847/wjem.j.issn.1920-8642.2013.02.003

Abstract

Abstract:

BACKGROUND: Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.
METHODS: This was an online anonymous survey of a random sample of EM health providers in US EDs.
RESULTS: Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.
CONCLUSIONS: This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.

Key words: Anaphylaxis, Guidelines, Epinephrine (adrenaline), Allergic reaction, Life-threatening reaction, Emergency department, Epinephrine autoinjector, Self-injectable epinephrine

W. Scott Russell, Judith Rosen Farrar, Richard Nowak, Daniel P. Hays, Natalie Schmitz, Joseph Wood, Judi Miller. Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice[J]. World Journal of Emergency Medicine, 2013, 4(2): 98-106.

Figures/Tables 7

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Table 1

Table 2

Gaps where clinical practice differs from guideline recommendations for managing the anaphylaxis in the ED, indirectly suggested by studies of the incidence or management of anaphylaxis at US EDs. All studies evaluated US data only and used a definition of anaphylaxis based on current guideline criteria. Gaps in diagnosis, ED treatment, and discharge are noted.

Citation	Study			Gaps
Citation	Design	Description	Population	Definition/Dx	Treatment in ED	At discharge
Adult studies
Campbell et al, 2011^[28]	Retrospective, consecutive cohort study	Compared dx and tx of ED patients ≥ 50 years and < 50 years who met NAID/FAAN dx criteria for anaphylaxis between 4/2008 and 6/2010	n=220 patients	Anaphylaxis was often not dx in ED patients presenting with allergic reactions despite multisystem organ involvement (authors suggested this related to 1) lack of universally accepted dx criteria; 2) low recognition of "vague" sx as part of dx, (eg, shortness of breath, light-headedness); 3) lack of sensitive/ specific biomarkers)		Prescription for epinephrine, 63.8%, overall; 40.7% for patients ≥ 50 yr, and 32.1% for patients ≥ 65 yr Post-ED allergist evaluation, 36.4%
Campbell et al, 2008^[27](also reported in Decker et al,2008^[29])	Retrospective medical record review	Assessed incidence of anaphylaxis (1990-2000)based on dx criteria in random sample of 2 442 patients at tertiary care AMC and community hospital EDs in Olmsted Co, Minn^*	n=848 patients: 248 with ICD-9 (or HICDA) codes related to anaphylaxis; 600 with associated dx	Patients meeting criteria for anaphylaxis: 157 of 248 with ICD-9 codes; 54 600 with associated dx (authors suggested variability due to the lack of universally accepted definition of anaphylaxis)		Prescription for epinephrine, 36.6% (more likely in patients who received epinephrine in ED) Referral to allergist, 31.3% (more likely for prescribed epinephrine at discharge)
Clark et al, 2004^[9]	Retrospective cohort study)	Evaluated ED visits for physician-dx'd, food-related acute allergic reactions over a 1-yr period in 21 North American AMCs (the Multicenter Airway Research Collaboration)	n=678 patients randomly selected from 5 296 identified charts using food allergy codes and less specific related ICD-9 codes		Epinephrine, 16% Diphenhydramine, 90% Parenteral CCS, 50%	Prescription for epinephrine, 16% (more likely in patients who received epinephrine in the ED) Referral to allergist, 12% Written instructions for avoidance, 40% Wide variability in discharge plans noted
Clark et al, 2005^[10]	Retrospective cohort study	Evaluated ED visits for physician-dx'd insect sting allergic reactions over a 1-yr period in 15 North American AMCs (the Multicenter Airway Research Collaboration)	n=617 patients randomly selected from 1 523 identified charts using specific allergy codes and less specific related ICD-9 codes		For patients with anaphylaxis: Epinephrine, 16% Antihistamines, 70% Parenteral CCS, 49%	Patients with systemic reactions (i.e., anaphylaxis or at risk of anaphylaxis): Prescription for epinephrine, 27% Referral to allergist, 20% Written instructions for avoidance, 15%
Gaeta et al, 2007^[20]	Retrospective review of nationally representative sample of ED visits using the National Hospital Ambulatory Medical Care Survey	Assessed national trends in ED visits for/managementof anaphylaxis (1993-2004)using ICD-9 codes for acute allergic reactions and anaphylaxis	n=12.4 million ED visits		Epinephrine, 11% Most ED physicians relied on 2^nd line agents, particularly H1 antagonists, to tx acute allergic reactions Substantial controversy about how/when to use epinephrine for acute allergic reactions in ED
Harduar-Morano et al, 2010^[19]	Retrospective review of ED data from the Florida Agency for Health Care Admini-stration	Assessed FL anaphylaxis cases (2005-2006) by ICD-9-CM codes or using an algorithm based on the 2^ndSymposium criteria	n=3 024 records of anaphylaxis episodes (ICD-9 codes, 1 283; algorithm, 1 741)	Lack of standard definition and dx criteria resulted in cases not dx'd or mis-dx'd: 58% of cases were missed using ICD-9 codes alone	Epinephrine: ICD-9 cases (n=111), 10%; algorithm cases (n=180), 11%
Ross et al, 2008^[32]	2-mo retro-spective review of the National Electronic Injury Surveil-lance System database	Evaluated incidence and severity of food allergic reactions presenting to US EDs	n=173 ED-food allergic events reported at 34 sites	Cases meeting criteria for anaphylaxis: 38% received dx; 62% did not	Epinephrine, 19% Antihistamines, 87% Parenteral CCS, 65%
Rudders et al, 2010a^[33]	Retrospective medical record review	Evaluated dx and tx of patients with stinging insect hypersensitivity reactions presenting to 3 EDs in Boston, MA (2001-2006)	n=153 patients		In patients with systemic reactions (i.e., anaphylaxis or at risk of anaphylaxis): Epinephrine, 9% Antihistamines, 76% Parenteral CCS, 55%	In patients with systemic reactions (i.e., anaphylaxis or at risk of anaphylaxis): Prescription for epinephrine, 68% Referral to allergist, 11% Written instructions for avoidance, 3%
Pediatric studies
Bohlke et al, 2004^[1]	Retrospective review of dx	Estimated incidence of anaphylaxis in relation to specific dx by ICD-9 codes and by sampling related dx w/o specific codes	n=229 422 patients ≤18 yr enrolled in HMO in WA between 3/1/1991 and 12/31/1997	In 753 possible cases, 67 anaphylaxis episodes identified by ICD-9 codes and 18 more by sampling related dx (authors suggested this reflected 1) lack of a std case definition; 2) variability among criteria used)	Epinephrine, 79% Parenteral antihistamine, 51% Parenteral CCS, 34%
Gupta et al, 2011^[30]	Randomized, population-based, cross-sectional survey of US homes with children ≤ 18 yr	Identified prevalence and severity of childhood food allergy (6/2009-2/2010)	n=38 480 children	Disparities in determining etiology of food allergy related to under dx and underestimates of childhood food allergy in the US	Disparities in management of food allergy in ED noted	Disparities in discharge management of food allergy inoted
Huang et al, 2012^[31]	Retrospective case review	Evaluated dx and tx of 118 680 anaphylaxis encounters at a pediatric ED (2004-2008) using ICD-9 codes	n=213 anaphylaxis episodes in 192 patients: 62 by ICD-9 code for anaphylaxis and 151 that were coded, allergic reaction, but fulfilled the criteria of anaphylaxis or were tx'd as anaphylaxis	Significant miscoding of anaphylaxis: 71% of episodes received ICD-9 code for allergic rx, not anaphylaxis (confusion related to lack of standard dx criteria)	Epinephrine, overall, 79%: 75% of allergic reactions, 81% of coded anaphylaxis Histamine-1-receptor antagonists, 92% Histamine-2-receptor antagonists, 46% Parenteral CCS, 89%	Prescription for epinephrine at ED discharge, 63%
Rudders et al, 2010b^[34]	Retrospective medical record review	Evaluated dx and tx of children presenting with food-related anaphylaxis at 3 EDs in Boston, MA (2001-2006)	n=1 255 patients		Epinephrine, 20%	Prescription for epinephrine, 43% Referral to allergist, 22% Written instructions for avoidance, 36%
Russell et al, 2010^[8]	Retrospective cross-sectional descriptive study	Evaluated anaphylaxis dx and tx of patients ≤21 yr (2002-2006) in pediatric ED (Children's Hospital of Alabama; Birmingham, AL); patients were identified using ICD-9 code for allergic rx and by 2^ndSymposium criteria	n=124 cases from 740 patient visits with ICD-9 code related to allergic rx	Substantial lack of agreement on criteria used to define and identify anaphylaxis	Epinephrine, 51% Antihistamines, 92% Parenteral CCS, 78%	Prescription for epinephrine, 63% Referral to allergist, 33%
Current Survey of US ED Providers
Russell et al, 2013	Cross-sectional survey of US ED health care providers	Initial assessment of concordance between how US EDs manage aanaphylaxis and current guideline recommendations for diagnosis, treatment, discharge	n=207 EM providers (nurses, physician assistants, physicians)	Respondents reporting that in their EDs: No definition of anaphylaxis: 90% Definition of anaphylaxis based on current guidelines: 9%	Respondents reporting that in their EDs: Majority (>75%) of patients received epinephrine in ED: 42% ≤50% of patients received epinephrine in ED: 40% Antihistamines preferred in some EDs as first-line treatment	Respondents reporting that in their EDs: Majority (>75%) of patients received prescription for epinephrine: 48%; ≤50% of patients received prescription for epinephrine: 31% Referral to allergist for >50% of patients: 42%; for >75% of patients: 17% Written information about anaphylaxis: 95%; anaphylaxis action plan: 71%

Table 2

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