Development of a model care pathway for the management of Hymenoptera venom allergy: evidence-based key interventions and indicators

Abstract

Background: Hymenoptera venom allergy (HVA) is an underestimated condition representing an important cause of morbidity and mortality worldwide. Preventing future allergic reactions in patients who have already developed a systemic reaction is based on the correct management of the acute phase of the reaction followed by a correct diagnosis and, where indicated, prescription of adrenaline autoinjectors and VIT. A possible strategy to optimize care processes and to improve outcomes is the implementation of a Diagnostic and Therapeutic Care Pathways, also known as Integrated Care Pathways or Clinical Pathways (CPWs). The aim of the care pathway is to enhance the quality of care by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To our knowledge, currently in Italy as well as in Europe, there is no CPWs codified for the management of HVA patients. This paper describes the development of the clinical content of a care pathway for the management of HVA. Methods:The methodology applied is based on the eight step method to build the clinical content of an evidencebased care pathway suggested by Lodewijckx et al. Results:Three hundred and seventeen different clinical activities were extracted from the selected literature. The expert panel was involved in their evaluation, expressing a judgment of relevance through the Delphi study. As a result, 126 clinical activities were appraised to be valid and feasible. The final recommendations (126) were translated into 123 key interventions. Six indicators were produced by the clinical activities. Conclusion:A set of 123 key interventions and of six process indicators were found to be appropriate for the development and standardization of the clinical content of the Hymenoptera venom allergy care pathway.

Skin prick tests are not useful for the qualification for venom immunotherapy in children

“…In doubtful cases, such as double sensitization or negative results of standard diagnostic tests, in a patient with confirmed history of SR, more advanced procedures of CRD with the evaluation of sIgE to certain venom components or basophil activation test (BAT) is recommended. 2 , 4 , 7 , 8 , 10 , 14 , 21 , 24 , 29 The BAT should be carried out in highly specialized laboratories for diagnostic purposes, only in specific situations. Its role as a diagnostic tool in patients with mast cell disorders and negative venom-specific IgE and skin test results remains controversial.…”

“…For additional diagnostic insight, measuring sIgE for venom components (component resolved diagnosis, CRD) may increase analytic sensitivity, detection of cross-reactivity and determination of individual sensitization profiles. 4 , 7 , 8 , 9 The basophil activation test (BAT), increasingly used, may also be helpful in some doubtful cases. 10 …”

Anaphylaxis viewed by experts: unmet needs

“…They established an active collaboration between allergy clinicians and their counterparts in emergency medicine, with a system of quick filing report of patients discharged from ED with the suspicion of anaphylactic reaction, directed to a central allergy unit with positive outcomes. Other similar initiatives have been taken elsewhere [38,39]. Thus, there is a need to optimize care pathways for patients at risk of anaphylaxis, including patient/caregiver education and training in all regions to improve global anaphylaxis management.…”

“…In addition, according to an international survey, at the time of discharge from the emergency room, many patients do not receive any advice relating to trigger avoidance or emergency protocol [5 ▪▪ ]. Therefore, there is a manifest need to implement current local, national or international guidelines, and to the develop clinical care pathways to correctly manage anaphylaxis patients [38,39].…”