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. 2022 Feb 1;149(2):e2020045831.
doi: 10.1542/peds.2020-045831.

Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline

Lukas K Gaffney  1   2 , John Porter  3 , Megan Gerling  3 , Lynda C Schneider  4 , Anne M Stack  3 , Dhara Shah  5 , Kenneth A Michelson  3
Affiliations

Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline

Lukas K Gaffney et al. Pediatrics. .

Abstract

Background: Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019.

Methods: A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System.

Results: Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time.

Conclusions: We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.

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Conflict of interest statement

FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.

Figures

FIGURE 1
FIGURE 1
P-chart of monthly anaphylaxis hospitalization rates, with key interventions shown. The date of EBG revision implementation was May 23, 2018. UCL, upper control limit.
FIGURE 2
FIGURE 2
P-charts of monthly medication usage rate for children presenting to the ED with anaphylaxis, with key interventions shown. The left panel (A) shows cetirizine use. The right panel (B) shows corticosteroid use among patients without diagnosis of asthma. LCL, lower control limit; UCL, upper control limit.
FIGURE 3
FIGURE 3
G-chart of number of cases between ED revisits for patients with anaphylaxis who were discharged from the hospital from the ED. CL, center line; UCL, upper control limit.
FIGURE 4
FIGURE 4
Hospitalization rates and 95% CIs over time at BCH (blue) and other PHIS hospitals (orange) for children with anaphylaxis. Hospitalization rate estimates were derived by using logistic regression separately for each study phase.
See this image and copyright information in PMC

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