title: A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department.
abstract: BACKGROUND
  Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines.
  
  
  OBJECTIVE
  To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence.
  
  
  METHODS
  A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated.
  
  
  RESULTS
  The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit.
  
  
  CONCLUSIONS
  Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Veena
authors.initials: V
authors.lastname: Manivannan
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn.
authors.forename: Erik P
authors.initials: EP
authors.lastname: Hess
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Venkatesh R
authors.initials: VR
authors.lastname: Bellamkonda
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: David M
authors.initials: DM
authors.lastname: Nestler
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: M Fernanda
authors.initials: MF
authors.lastname: Bellolio
authors.affiliation: Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
authors.forename: John B
authors.initials: JB
authors.lastname: Hagan
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Kharmene L
authors.initials: KL
authors.lastname: Sunga
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Wyatt W
authors.initials: WW
authors.lastname: Decker
authors.affiliation: Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
authors.forename: James T C
authors.initials: JT
authors.lastname: Li
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Lori N
authors.initials: LN
authors.lastname: Scanlan-Hanson
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Samuel C
authors.initials: SC
authors.lastname: Vukov
authors.affiliation: Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minn. Electronic address: campbell.ronna@mayo.edu.
authors.forename: Ronna L
authors.initials: RL
authors.lastname: Campbell
mesh_terms: D000316:Adrenergic alpha-Agonists / Q000627:therapeutic use; D000328:Adult; D000707:Anaphylaxis / Q000188:drug therapy*; D015331:Cohort Studies; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004837:Epinephrine / Q000627:therapeutic use*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012646:Self Administration / Q000706:statistics & numerical data
chemical_list: D000316:Adrenergic alpha-Agonists; D004837:Epinephrine
keywords: Anaphylaxis; Clinical decision support; Emergency department; Order set; Self-injectable epinephrine