Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice

Abstract

BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.METHODS:This was an online anonymous survey of a random sample of EM health providers in US EDs.RESULTS:Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.CONCLUSIONS:This is the first cross-sectional survey to provide “real-world” data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.

Adherence to Anaphylaxis Guidelines: Real-World Data From the Emergency Department of a Tertiary Hospital

“…However, in our study, H1 antihistamines (88%) and corticosteroids (85.4%) were the most frequently used drugs in the treatment of anaphylaxis in ED. These results are similar to those found in other studies [4][5][6]12,15,18,24].…”

“…However, there is a clear discrepancy between the information provided by guidelines on the management of anaphylaxis and the actual use of adrenaline as a first-line drug. In our study adrenaline was administered only to 42% of the population, clearly indicating that there is a deficit in the treatment of this disease, which has also been described in several studies [4][5][6][12][13][14]. Huang et al, which included only patients younger than 18 years, found that 79% of their patients had received epinephrine in the ED [15].…”

“…These studies have confirmed major discrepancies with the recommendations of treatment and follow-up [4][5][6][7].The objective of this study was to evaluate anaphylaxis management and the adherence of clinicians to anaphylaxis guideline recommendations. We conducted a oneyear study in children and adults who presented to the emergency department (ED) of a tertiary hospital and were diagnosed with anaphylaxis.…”

Recurrent anaphylaxis in the United States: time of onset and risk factors

“…Potential reasons include uncertain diagnosis, fear of side effects, and fear of misusing the auto‐injector . In a survey of 207 ED providers in the US, only 9% used the agreed‐upon criteria established by the National Institute of Allergy and Infectious Diseases (NIAID) for diagnosis of anaphylaxis . The low positive predictive value (68%) of these criteria makes it a challenge for ED providers given the need to have a broad differential diagnosis .…”

“…25 In a survey of 207 ED providers in the US, only 9% used the agreedupon criteria established by the National Institute of Allergy and Infectious Diseases (NIAID) for diagnosis of anaphylaxis. 26 The low positive predictive value (68%) of these criteria makes it a challenge for ED providers given the need to have a broad differential diagnosis. 27 In addition, physicians may not be aware of the proper way to administer epinephrine, which appears to affect patients' improper use as well.…”