P0121 - Decreasing admission for children at low-risk of biphasic reaction presenting to a pediatric emergency department with anaphylaxis

Background: Anaphylaxis is common in the pediatric emergency department (PED). In patients treated with intramuscular epinephrine, the observation period following administration is not standardized, benefits of prolonged observation are unclear, and hospitalization rates vary. Concern for biphasic reaction (symptom recurrence within 72-hours) frequently contributes to admission. In children at low-risk of biphasic reaction, recent literature supports PED discharge after four hours of observation. Our 2006 PED guideline recommended 12-24 hours of observation for patients presenting with anaphylaxis and >49% of children at low-risk of biphasic reaction were admitted. The goal of this quality improvement (QI) initiative is to reduce hospitalization for children <18 years of age who are at low-risk of biphasic reaction and present to the PED with anaphylaxis by 75% within 12 months of evidence-based guideline (EBG) revision and implementation of an algorithm to standardize disposition practices.

Methodology: A literature review was performed. A multi-disciplinary team of key stakeholders including pharmacy, nursing leadership, advanced practitioners, and physicians created a disposition-focused EBG for children presenting with anaphylaxis (Figure 1). EBG education was provided at staff meetings and via email with opportunity for feedback and revision. Implemented July 2018, project promotion at daily multi-disciplinary safety huddles occurred at six-month intervals. EBG hardcopies were available throughout the PED for reference.

The EBG stratified patients as high or low-risk of biphasic reaction. Low-risk patients were recommended for PED discharge after four hours of observation. The primary outcome was low-risk patient admission. Balance measures included low-risk patient 72-hour return for biphasic reaction and PED length of stay (LOS). QI methodologies and statistical process control charts were utilized to formulate and monitor goals.

Discussion: There were 117 children in the pre-intervention group and 93 children in the post-intervention group presenting with anaphylaxis. Populations were similar in age, gender and risk. Fifty-seven children pre-intervention and 46 children post-intervention met low-risk criteria for biphasic reaction. The percent of low-risk patients admitted decreased from 49% to 7% in the post-intervention period (p<.0001)(Figure 2). Neither group had 72-hour biphasic reaction returns. Post-implementation, low-risk patient LOS increased from 193 to 225 minutes (p<0.002).

Surpassing our goal, hospitalization of patients at low-risk of biphasic reaction decreased 86% following implementation of a disposition-based algorithm. High levels of provider engagement and EBG acceptance contributed to project success. Increased LOS demonstrated strong observation period compliance.

One-half of children in this initiative met high-risk criteria. Future studies may focus on further stratifying this population to determine if a subset may be safely discharged without prolonged observation. Cost analysis evaluating the impact of risk stratification may also be informative.

Conclusion: We achieved significant improvement in discharging children at low-risk of biphasic reaction presenting to the PED with anaphylaxis without increase in 72-hour returns.