Pediatric Anaphylaxis in the Emergency Department Clinical Presentation, Quality of Care, and Reliability of Consensus Criteria

Objectives The objective of this study was to describe the quality of emergency department (ED) care for pediatric patients with anaphylaxis. The secondary objectives were to describe (1) the clinical presentation of pediatric patients with anaphylaxis including the proportion of patients meeting each of the National Institute of Allergy and Infectious Diseases (NIAID) consensus criteria and subcriteria and (2) the Interrater reliability (IRR) for applying the NIAID criteria. Methods We conducted a retrospective cross-sectional chart review of patients seen in a pediatric ED during a 2-year period. All charts were reviewed by a trained chart reviewer with 10% abstracted by a second reviewer. Data were analyzed using descriptive statistics including proportions, medians, and interquartile range. Interrater reliability was calculated using Cohen unweighted kappa or percent agreement. Results Of the 250 charts reviewed, 84% (211) met the NIAID criteria for anaphylaxis (IRR, 1.0). Only 68% of patients received epinephrine in the ED or within 3 hours of the ED visit. Adherence was poor and IRR was variable, for measures reflecting documentation of discharge instructions and follow-up with a specialist. The IRR of reviewers for determining which patients met the NIAID criteria overall and for each subcriterion was high. Conclusions Our findings highlight a gap between best practice and ED care. In addition, our results suggest that the NIAID criteria can reliably be used to retrospectively identify pediatric patients with anaphylaxis. Accurately identifying cases is a prerequisite for measuring gaps in management and developing interventions to improve care.