Use of Order Sets and Epinephrine Autoinjectors Improves Quality of Anaphylaxis Care in the Emergency Setting

New research from the Mayo Clinic suggests that an order set designed to standardize the treatment of anaphylaxis in emergency departments (EDs) may indeed improve quality of care.

Numerous studies have shown problems with anaphylaxis care in hospital EDs. One survey of 34 EDs found that only 19% of patients with food-related allergic events received epinephrine as part of treatment. Another found that only 13% of patients received it for events triggered by stings. Still others have found many patients released without prescriptions for self-injectable epinephrine or visits to the allergist.

These shortcomings prompted a team from Mayo to compile a comprehensive anaphylaxis management order set, which was made available to EDs five years ago. (EDs that ask for the order set also receive training in its proper use and automated medication-dispensing machines stocked with epinephrine autoinjectors.)

The new study, published in May’s edition of The Journal of Allergy and Clinical Immunology: In Practice, evaluated anaphylaxis care at one a tertiary care academic ED in southeast Minnesota before and after it requested the order set. The results were encouraging.

“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,” the study authors wrote.

“Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.”

In all, there were 202 patients who came to the ED with anaphylaxis during the course of the cohort study, which lasted from April 29, 2008, to August 9, 2012. Of those, 139 (69%) were women, and approximately 90% were white. A specific trigger was suspected in 75% of the patients (n = 152) and was unknown in 25% (n = 50).

Just 48 (24%) of the patients received care before implementation of the order set while 154 (76%) received it afterwards. That said, the order set was only used with 88 of the patients (57.2%).

Patients who presented after order set implementation and epinephrine autoinjector introduction were more likely to be treated with epinephrine (51% vs 33%; odds ratio 2.05 [95% CI, 1.04-4.04]).

They were also more likely to be (correctly) admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]) and less likely to be (incorrectly) sent straight home from the ED (16% vs 29%; OR 0.47 [95% CI, 0.22-1.00]).

Still, the order set did not improve care in all metrics. There were no statistically significant differences in the likelihood of receiving an epinephrine autoinjector prescription (62% vs 54%; OR 1.36 [95% CI, 0.71-2.62]) or allergy follow-up (42% vs 44%; OR 0.94 [95% CI, 0.49-1.81]).

The study authors speculated that patients receiving autoinjector prescriptions and allergy follow-up did not rise significantly because both were already very high at this particular ER prior to the order set implementation.

Thus, the researchers wrote, this order set might well improve those metrics at a more typical ER.

The researchers noted that the small sample size and the retrospective nature of the study were potential limitations, but said their research nonetheless supported the idea of order sets for anaphylaxis care.