P0139 - Minimizing the “kitchen sink” approach: implementing epinephrine focused care for patients with anaphylaxis in Pediatric Emergency Department.

Purpose: Anaphylaxis national practice parameters state that epinephrine is the only medication that prevents morbidity and mortality and should be considered first line therapy. Second line therapies such as steroids and H2 receptor antagonists (H2RA) are helpful in select cases but not universally indicated. Despite these recommendations, the “kitchen sink” approach is often utilized for treatment of pediatric anaphylaxis with routine use of steroids and H2RAs. The goal of this project is to decrease unnecessary medication use for children with anaphylaxis in emergency department (ED) by providing epinephrine-focused care. The project aim was to reduce steroid and H2RA use from 47% and 50% respectively to 30% by December 2019.

Methods: The primary outcome measures were percent of patients receiving steroids and H2RAs. Process measure was frequency of intravenous (IV) line placement. Balancing measures were mean length of stay, admission rate, and return visits to ED (Table 1). A multidisciplinary team designed and implemented the following interventions: a) creating an anaphylaxis clinical pathway emphasizing epinephrine and outlining criteria for second line therapies; b) standardizing unit-based medication kits; c) optimizing electronic medical record (EMR) decision support tools such as order sets and discharge instructions; d) standardizing epinephrine autoinjector education; e) pathway education and attestation.

Results: 869 patients were included (403 in the baseline group and 467 in the intervention group). Special cause variation was detected for use of steroids (47% to 26%, Figure 1) and H2RAs (50% to 18%) as well as IV placements (59% to 27%). Length of stay decreased from 5.4 hours to 4.8 hours (p=0.004). Neither special cause variation nor significant pre-post changes were detected for balancing measures which included admission rate (5.9% to 7%, p=0.5) and return visits rate (3% to 4.9%, p= 0.14).

Conclusion: This pediatric emergency department safely decreased unnecessary medication use by implementing an epinephrine focused approach for patients with anaphylaxis. Future work will be directed toward sustainability efforts.