Improving Use of Oral Antihistamines in a Children's Hospital

Compared with first-generation antihistamines (FGAs), second-generation antihistamines (SGAs) are equally effective, longer acting, and better tolerated. We aimed to reduce the proportion of patients receiving FGAs among all receiving antihistamines from baselines of 74% in the pediatric emergency department (PED) and 54% in inpatient units by 50% within 6 months and sustain this change for 6 months.

This multidisciplinary quality improvement initiative was conducted between 2022-2024. Implemented interventions were clinician education, flyers, ensuring cetirizine availability, and clinical pathways updates. The outcome measures were the proportion of patients receiving FGAs (diphenhydramine or hydroxyzine) or SGAs (cetirizine) among all receiving antihistamines. The process measures were educational sessions, knowledge assessments, and clinical pathways usage. The balancing measures were emergency department revisit within 48 hours, median inpatient length of stay, and antihistamine cost. We assessed improvement using statistical process control charts.

The proportion of patients receiving FGAs decreased from 74% to 28% in the PED and from 54% to 36% in inpatient units. Reductions were sustained for 8.5 and 9 months, respectively. Cetirizine use increased from 31% to 75% in the PED and from 54% to 74% in inpatient units. Knowledge scores doubled posteducation. Clinical pathways usage increased from 36 to 44 clinicians monthly. Emergency department revisits and length of stay remained stable. Monthly median antihistamine costs increased in the PED from $53 to $177 and inpatient from $57 to $104.

Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.