Improving ED Discharge for Pediatric Patients with Anaphylaxis

Purpose/Objectives: Anaphylaxis is a life threatening, systemic allergic reaction that is often under recognized and undertreated. International consensus advises that all patients with anaphylaxis that are discharged from an emergency department (ED) setting receive a written personalized anaphylaxis emergency action plan, an epinephrine autoinjector or prescription with teaching on its use, and a referral to an allergist. Despite these guidelines, patients at our institution consistently received incomplete discharge care. Our objective was to increase the frequency of Allergy referrals and anaphylaxis action plans for patients with anaphylaxis that are discharged from our ED using a quality improvement (QI) framework. Specifically, our SMART goals were to increase allergy referrals for patients that meet anaphylaxis criteria from a baseline of 67% to 80% and to increase the frequency of these patients receiving anaphylaxis action plan at ED discharge from 0% to 60% by May 2021 and sustain our target goals for 6 months.

Design/Methods: Our ED is a part of a freestanding tertiary academic pediatric hospital that treats approximately 300 patients per year that meet the criteria for anaphylaxis. Prior to the start of our project, there were no existing written discharge materials containing an anaphylaxis action plan. Our allergy referral rate was also below our target rate of 80%. Using the Institute for Healthcare Improvement (IHI) Model for Improvement we implemented several Plan-Do-Study-Act (PDSA) cycles which included revising our current electronic discharge instructions, educational initiatives for physicians, physician assistants, nurse practitioners, nurses and pharmacists, and changes to our EHR (electronic health record) to improve anaphylaxis recognition within our ED from October 2020 to May 2021. Primary process/outcome measures included the proportion of patients receiving allergy referrals at discharge and the proportion of patients receiving an anaphylaxis action plan at discharge. Balancing measures included ED length of stay and admission rates.

Results: The percentage of discharged patients with an anaphylaxis action plan improved significantly, with a shift in our data center line from 0% to 34% from October 2020 to May 2021. Allergy referral rates are trending toward special cause variation, with five consecutive months showing referral rates above our baseline.

Conclusion/Discussion: Revising our discharge instructions to include an anaphylaxis action plan template and reinforcing provider behaviors with educational interventions lead to an overall improvement in discharge care for patients with anaphylaxis. Future interventions including changes to our EHR are planned to sustain these changes over time.