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Reducing Admission for Anaphylaxis in a Pediatric Emergency Department Using a Clinical Decision Support Tool
Katherine H Wolpert1, Rebecca Kestle2, Nicholas Weaver2
1From the Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash.
Insights
A new clinical decision support tool (CDST) significantly reduced hospitalizations for low-risk pediatric anaphylaxis patients. This quality improvement initiative ensured no increase in 72-hour return rates and demonstrated cost savings.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Quality Improvement
- Allergy and Immunology
Background:
- Anaphylaxis is a severe allergic reaction requiring prompt medical attention.
- Current guidelines for managing pediatric anaphylaxis lack clear indications for prolonged observation or hospitalization.
- This ambiguity can lead to unnecessary hospital admissions for low-risk patients.
Purpose of the Study:
- To implement a disposition-focused clinical decision support tool (CDST) in a pediatric emergency department (PED).
- To reduce the hospitalization rate for low-risk pediatric anaphylaxis patients from 49% to ≤12%.
- To evaluate the impact of the CDST on patient safety and healthcare costs.
Main Methods:
- A multidisciplinary team developed and implemented an evidence-based CDST for pediatric anaphylaxis management.
- The CDST stratified patients into low-risk and high-risk categories, recommending discharge for low-risk cases after a 4-hour observation.
- Data on hospitalization rates, 72-hour return visits, and emergency department length of stay were collected pre- and post-intervention.
Main Results:
- Hospitalization of low-risk pediatric anaphylaxis patients decreased significantly from 49% to 7% post-implementation (P < 0.0001).
- There was no significant increase in 72-hour return rates for anaphylaxis-related concerns among low-risk patients (P = 0.83).
- Median emergency department length of stay slightly increased, but the median cost per low-risk encounter decreased by $377 (P = 0.013).
Conclusions:
- An evidence-based, disposition-focused CDST effectively reduces hospitalizations for low-risk pediatric anaphylaxis.
- The implementation of the CDST improved patient safety by avoiding unnecessary admissions without increasing return visits.
- This quality improvement initiative resulted in significant cost savings for patient encounters.
Introduction:
Anaphylaxis is a life-threatening condition necessitating emergent management. However, the benefits of prolonged observation and indications for hospitalization are not well established. Through the implementation of a disposition-focused clinical decision support tool (CDST), this quality improvement initiative aimed to reduce hospitalization for low-risk patients presenting to the pediatric emergency department (PED) with anaphylaxis from 49% to ≤12% within 12 months of implementation.
Methods:
The intervention included patients 18 years and younger of age presenting with anaphylaxis to the PED. A multidisciplinary team identified a 2006 evidence-based guideline as a significant contributor to hospitalization. The updated guideline incorporated a disposition-focused CDST that stratified patients as low-risk or high-risk and recommended discharge of low-risk patients after a 4-hour observation period. The primary outcome measure was the percentage of low-risk patients hospitalized. Balancing measures included low-risk patient 72-hour return rate and PED length of stay for all comers. Secondary outcomes included a focused cost analysis.
Results:
Fifty-three children preintervention and 43 children postintervention presenting with anaphylaxis met low-risk criteria. Postimplementation, hospitalization of low-risk patients decreased from 49% to 7% (P < 0.0001). No low-risk patients returned in 72 hours for an anaphylaxis-related concern (P = 0.83). The median PED length of stay increased from 189 to 193 minutes (P < 0.0001). The median cost per low-risk encounter decreased by $377 (P = 0.013).
Conclusions:
After implementing an evidence-based disposition-focused CDST, hospitalization of low-risk patients presenting to the PED with anaphylaxis significantly decreased without an increase in 72-hour returns. In addition, patient encounters demonstrated cost savings.
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