Reducing Emergency Department Observation Time for Patients with Low-Risk Anaphylaxis

Historically, patients with anaphylaxis are observed for at least 4 hours after receiving epinephrine to monitor for biphasic reactions. In April 2020, the Joint Task Force on Practice Parameters (JTFPP) released updated anaphylaxis guidelines, recommending a 1-hour observation time for patients at low risk for biphasic anaphylaxis. We conducted a QI initiative with the aim to decrease our pediatric emergency department (ED) observation time for patients with low-risk anaphylaxis from 240 to 120 minutes within 9 months.

A multidisciplinary team of allergy/immunology and ED physicians and nurses identified barriers to early discharge using a fishbone diagram. Interventions included education, electronic medical record optimization, and feedback. Risk factors for biphasic anaphylaxis included persistent symptoms after epinephrine, need for more than 1 epinephrine dose, hypoxia, hypotension, and reaction to a drug or unknown trigger. Balancing measures were observation times for anaphylaxis with risk factors and return visits within 72 hours of discharge for biphasic reactions. We used statistical process control to analyze changes in measures over time.

Despite an increasing ED length of stay for all discharged ED patients during this QI initiative, the observation time for patients with low-risk anaphylaxis decreased from 233 to 154 minutes (34%) in 5 months, which was sustained for 7 months. There was no change for patients with risk factors. There were no missed biphasic anaphylactic reactions during the intervention period.

We successfully reduced the ED observation time for patients with low-risk anaphylaxis by 79 minutes without increasing return visits.