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SOCIO-DEMOGRAPHIC DIFFERENCES IN PATIENTS HOSPITALIZED FOR ANAPHYLAXIS IN THE UNITED STATES
Ann Allergy Asthma Immunol 121 (2018) S1−S17
Contents lists available at ScienceDirect
Oral Concurrent Sessions Adverse Drug Reactions, Insect Reactions, Anaphylaxis
A001
A002
EDUCATIONAL OUTCOMES OF AN ANAPHYLAXIS SIMULATION ACTIVITY AMONG MEDICAL STUDENTS AND RESIDENTS S. Mawhirt*, L. Fonacier, M. Aquino, Mineola, NY Introduction: Failure to recognize anaphylaxis or delayed epinephrine auto-injector (EAI) administration may result in poor patient outcomes. Clinical simulation is an educational method used for environment-controlled, team-based learning. Methods: We aimed to identify knowledge gaps in anaphylaxis diagnosis and treatment through direct observations of trainees in a case-based simulation activity. Students and residents participated in an IRB approved, algorithmic, medication-induced anaphylaxis case utilizing a patient-simulator, SimMan3GÒ . The participants completed a pre-simulation assessment, received a clinical vignette, and were instructed to diagnose and treat SimMan3GÒ . Incorrect or delayed treatments resulted in patient-simulator clinical deterioration at pre-determined times. Observations were recorded by two reviewers. After the simulation, the participants engaged in an educational debriefing, anaphylaxis instructional course, post-simulation assessment, and evaluation survey. Results: Thirty-eight medical students/residents (n=10 group teams) completed the course. The median time to diagnose anaphylaxis was 4:48 (minutes:seconds). The median time from diagnosis to EAI administration was 64 seconds. All groups recognized anaphylaxis after 3 organ-system involvement developed and 9 groups treated with epinephrine after hypotension ensued. Nausea and urticaria were the most unrecognized manifestations. Only 1 group administered an EAI correctly; 6 groups treated with intravenous epinephrine. The mean pre- and post-simulation assessment scores were 78% § 14% and 93% § 7%, respectively, (p<0.001). All agreed that the simulation was clinically practical. Conclusions: All groups eventually diagnosed anaphylaxis but the majority of participants were inexperienced in EAI administration. Participant knowledge of anaphylaxis improved in the immediate, post-simulation period. Repeated simulation would be useful to assess knowledge retention. Results of simulation diagnosis and treatment
HIGHER STARTING DOSE PROTOCOLS IN CORONARY ARTERY DISEASE PATIENTS WITH ASPIRIN HYPERSENSITIVITY E. Liang*, C. Kim, S. Samant, J. Sheikh, Los Angeles, CA Introduction: Aspirin is a cornerstone of atherosclerosis therapy, but 1.5% of coronary artery disease (CAD) patients report aspirin allergy. Past protocols of challenge and/or desensitization for aspirin allergy excluded acute coronary syndrome (ACS) patients and/or started at low doses. Recent studies propose higher starting doses with fewer steps. The safety and efficacy of these newer protocols are not established, especially in the acute setting where the ability to tolerate aspirin is time-sensitive. Methods: A retrospective chart review was conducted for all inpatient allergy consults for patients with suspected CAD and aspirin allergy. Three categories of aspirin protocols were evaluated for patient characteristics, safety, and efficacy: challenge (graded or direct without premedication), challengedesensitization (starting dose 20.25-40.5 mg with premedication), and slow desensitization (starting dose 0.1 mg with premedication). Results: From 2007 to 2017, 144 aspirin challenges or challengedesensitizations in patients without a history of anaphylaxis to aspirin were done with 98.9% success. A total of 126 procedures were done prior to cardiac intervention, and though 107 presented with ACS, none had direct cardiovascular complications from the aspirin protocol. There were 18 reactions (12.5%): 14 mild and 4 moderate, with 1 requiring epinephrine. Three were AERD patients with expected reactions, 4 were challenges who then underwent successful challenge-desensitization. There was no difference in the number of reactions between the challenge-desensitization versus the slow desensitization group (p=0.10). Conclusions: Higher dose starting protocols for CAD patients with self-reported aspirin allergy are safe and effective, with similar success rate to protocols starting at lower doses.
A003 SOCIO-DEMOGRAPHIC DIFFERENCES IN PATIENTS HOSPITALIZED FOR ANAPHYLAXIS IN THE UNITED STATES S. Zafar*,1, C. Nabors2, S. Pal2, S. Yandrapalli2, A. Zafar3, 1. Edison, NJ; 2. Valhalla, NY; 3. Philadelphia, PA
= von Pirquet Award Recipient.
Introduction: Anaphylactic shock is a life-threatening emergency that can lead to significant morbidity and mortality. Data from European studies have shown significant disparities in
https://doi.org/10.1016/j.anai.2018.09.002 1081-1206/© 2018 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
S2
Abstracts: Oral Concurrent Sessions / Ann Allergy Asthma Immunol 121 (2018) S1−S17
healthcare utilization for anaphylaxis, however there are limited studies describing the association between socioeconomic status and patient characteristics for hospitalizations related to anaphylaxis in the United States. Methods: We utilized the National Inpatient Sample database years 2005-2014 to identify hospitalizations for anaphylactic shock (ICD-9 codes 995.0, 995.6x). The analysis focused on socio-demographic characteristics, medical comorbidities, and in-hospital death. We also performed an unadjusted analysis of trends in hospital costs and mortality rate. Results: Between 2005 and 2014, anaphylaxis hospitalizations increased from 6,351 to 8,075. Of these, most were experienced by women (56.7%), whites (55.1%), paid for by private insurance (46.5%), and were more frequent in patients residing in areas with the highest income quartile (26.9%). Comorbidities frequently present in patients hospitalized for anaphylaxis were hypertension (36.6%), chronic pulmonary disease (28.8%), and electrolyte disorders (20.0%). Costs per hospitalization increased from $4,521 to $6,672 (2006-2015). The percentage of in hospital deaths rose from 0.86 (2006) to 0.93 (2015) and mean length of stay rose from 2.5 days (2005) to 2.7 days (2015). Conclusions: There has been a modest increase in hospitalizations and in-hospital deaths from anaphylaxis in the last decade. In this study, more hospitalizations were associated with topquartile income zip codes and private insurance. Further study is needed to determine whether these trends reflect disparities in access to healthcare or other factors that could affect health outcomes.
low-risk individuals. Larger prospective studies are necessary to confirm these observations.
A004
Introduction: Emergency Department (ED) management of anaphylaxis has not kept pace with advances in knowledge. Epinephrine use and utilization of guideline-based practice recommendations remains sub-optimal, particularly in children. We implemented a clinical pathway in our pediatric ED in August 2017 to improve care. Methods: Cases were identified using ICD-9 and ICD-10 diagnosis codes. We used statistical process control to analyze process and outcome measures for 3 years before and 10 months after initial pathway implementation. Results: 936 patients were included. After pathway implementation, we found special cause variation with a downward shift in the mean time to epinephrine for Emergency Severity Index 1 patients from 11.3 to 4.3 mins. Further, the proportion of anaphylaxis patients receiving ED IV placement decreased from 40.7% to 19.9%. When an H1 antihistamine was used, the choice of a less-sedating H1 blocker in combination with an H2 blocker increased from 15.8% to 52.8%. Mean ED length of stay (LOS) for discharged patients with anaphylaxis (229 mins) and proportion of patients admitted to the hospital (26%) did not change after pathway implementation. Conclusions: An anaphylaxis clinical pathway emphasizing early epinephrine use and reassessment prior to IV placement improved outcomes. Further analysis will seek to determine if the ED observation period may be safely shortened to decrease LOS for low risk patients.
DIRECT ORAL AMOXICILLIN CHALLENGE WITHOUT PRELIMINARY SKIN TESTING IN PATIENTS WITH REPORTED PENICILLIN ALLERGY N. Scanlon*, M. Kuruvilla, Atlanta, GA Introduction: 10% of hospitalized patients report penicillin allergy; studies indicate that »98% are not truly allergic. Unconfirmed penicillin allergy labels pose public health risks, and evaluation is recommended to improve antibiotic stewardship. While the most widely accepted protocol is penicillin skin testing (PST) followed by oral amoxicillin challenge, time constraints and resources may preclude this. Recent literature supports the safety and efficacy of direct oral amoxicillin challenge in low-risk individuals. Methods: We retrospectively evaluated data and oral challenge outcomes from adult patients in clinic with a penicillin allergy label over a 6-month period. Direct oral amoxicillin challenge was recommended in patients with history of benign rash, benign somatic symptoms, or unknown history associated with last penicillin exposure more than 12 months ago. Those with severe reactions or reactions within 12 months of evaluation were not challenged. Patients were monitored for 60 minutes following challenge. Results: Of 355 encounters, 14% of patients had a penicillin allergy label. 76% of those met inclusion criteria. Penicillin-associated reactions varied, and 88% reported reactions more than 10 years prior. 8% of patients were de-labeled based on history alone. 53% of patients offered amoxicillin challenge consented, and none developed immediate, or to our knowledge, delayed hypersensitivity reactions. 15% of patients developed subjective and self-limited symptoms not deemed to constitute true IgE-mediated reactions. Conclusions: This study adds to the accumulating body of evidence supporting the safety and efficacy of direct provocative challenge without preliminary skin testing to exclude penicillin allergy in
Outcomes of Patients with Penicillin Allergy Labels
Left: Outcomes of all 50 patients with penicillin allergy labels in allergy clinic over a 6-month period. Right: Outcomes of 20 patients who underwent oral amoxicillin challenge in allergy clinic.
A005 IMPROVING EMERGENCY CARE FOR ANAPHYLAXIS: IMPACT OF A CLINICAL PATHWAY IN A PEDIATRIC EMERGENCY DEPARTMENT J. Brown*, J. Foti, S. Fenstermacher, K. Kazmier, E. Shephard, N. Deam, H. Clifton, L. Rutman, P. O'Hare, Seattle, WA
Allergy Diagnostics and Immunotherapy
A100 PREDICTIVE DECLINE IN PEANUT SKIN TEST AND RAST AMONG PEANUTALLERGIC CHILDREN UNDERGOING HIGH-DOSE ORAL IMMUNOTHERAPY I. Randhawa*,1, T. Morphew2, N. Marsteller1, 1. Long Beach, CA; 2. Bothell, WA
Contents lists available at ScienceDirect
Oral Concurrent Sessions Adverse Drug Reactions, Insect Reactions, Anaphylaxis
A001
A002
EDUCATIONAL OUTCOMES OF AN ANAPHYLAXIS SIMULATION ACTIVITY AMONG MEDICAL STUDENTS AND RESIDENTS S. Mawhirt*, L. Fonacier, M. Aquino, Mineola, NY Introduction: Failure to recognize anaphylaxis or delayed epinephrine auto-injector (EAI) administration may result in poor patient outcomes. Clinical simulation is an educational method used for environment-controlled, team-based learning. Methods: We aimed to identify knowledge gaps in anaphylaxis diagnosis and treatment through direct observations of trainees in a case-based simulation activity. Students and residents participated in an IRB approved, algorithmic, medication-induced anaphylaxis case utilizing a patient-simulator, SimMan3GÒ . The participants completed a pre-simulation assessment, received a clinical vignette, and were instructed to diagnose and treat SimMan3GÒ . Incorrect or delayed treatments resulted in patient-simulator clinical deterioration at pre-determined times. Observations were recorded by two reviewers. After the simulation, the participants engaged in an educational debriefing, anaphylaxis instructional course, post-simulation assessment, and evaluation survey. Results: Thirty-eight medical students/residents (n=10 group teams) completed the course. The median time to diagnose anaphylaxis was 4:48 (minutes:seconds). The median time from diagnosis to EAI administration was 64 seconds. All groups recognized anaphylaxis after 3 organ-system involvement developed and 9 groups treated with epinephrine after hypotension ensued. Nausea and urticaria were the most unrecognized manifestations. Only 1 group administered an EAI correctly; 6 groups treated with intravenous epinephrine. The mean pre- and post-simulation assessment scores were 78% § 14% and 93% § 7%, respectively, (p<0.001). All agreed that the simulation was clinically practical. Conclusions: All groups eventually diagnosed anaphylaxis but the majority of participants were inexperienced in EAI administration. Participant knowledge of anaphylaxis improved in the immediate, post-simulation period. Repeated simulation would be useful to assess knowledge retention. Results of simulation diagnosis and treatment
HIGHER STARTING DOSE PROTOCOLS IN CORONARY ARTERY DISEASE PATIENTS WITH ASPIRIN HYPERSENSITIVITY E. Liang*, C. Kim, S. Samant, J. Sheikh, Los Angeles, CA Introduction: Aspirin is a cornerstone of atherosclerosis therapy, but 1.5% of coronary artery disease (CAD) patients report aspirin allergy. Past protocols of challenge and/or desensitization for aspirin allergy excluded acute coronary syndrome (ACS) patients and/or started at low doses. Recent studies propose higher starting doses with fewer steps. The safety and efficacy of these newer protocols are not established, especially in the acute setting where the ability to tolerate aspirin is time-sensitive. Methods: A retrospective chart review was conducted for all inpatient allergy consults for patients with suspected CAD and aspirin allergy. Three categories of aspirin protocols were evaluated for patient characteristics, safety, and efficacy: challenge (graded or direct without premedication), challengedesensitization (starting dose 20.25-40.5 mg with premedication), and slow desensitization (starting dose 0.1 mg with premedication). Results: From 2007 to 2017, 144 aspirin challenges or challengedesensitizations in patients without a history of anaphylaxis to aspirin were done with 98.9% success. A total of 126 procedures were done prior to cardiac intervention, and though 107 presented with ACS, none had direct cardiovascular complications from the aspirin protocol. There were 18 reactions (12.5%): 14 mild and 4 moderate, with 1 requiring epinephrine. Three were AERD patients with expected reactions, 4 were challenges who then underwent successful challenge-desensitization. There was no difference in the number of reactions between the challenge-desensitization versus the slow desensitization group (p=0.10). Conclusions: Higher dose starting protocols for CAD patients with self-reported aspirin allergy are safe and effective, with similar success rate to protocols starting at lower doses.
A003 SOCIO-DEMOGRAPHIC DIFFERENCES IN PATIENTS HOSPITALIZED FOR ANAPHYLAXIS IN THE UNITED STATES S. Zafar*,1, C. Nabors2, S. Pal2, S. Yandrapalli2, A. Zafar3, 1. Edison, NJ; 2. Valhalla, NY; 3. Philadelphia, PA
= von Pirquet Award Recipient.
Introduction: Anaphylactic shock is a life-threatening emergency that can lead to significant morbidity and mortality. Data from European studies have shown significant disparities in
https://doi.org/10.1016/j.anai.2018.09.002 1081-1206/© 2018 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
S2
Abstracts: Oral Concurrent Sessions / Ann Allergy Asthma Immunol 121 (2018) S1−S17
healthcare utilization for anaphylaxis, however there are limited studies describing the association between socioeconomic status and patient characteristics for hospitalizations related to anaphylaxis in the United States. Methods: We utilized the National Inpatient Sample database years 2005-2014 to identify hospitalizations for anaphylactic shock (ICD-9 codes 995.0, 995.6x). The analysis focused on socio-demographic characteristics, medical comorbidities, and in-hospital death. We also performed an unadjusted analysis of trends in hospital costs and mortality rate. Results: Between 2005 and 2014, anaphylaxis hospitalizations increased from 6,351 to 8,075. Of these, most were experienced by women (56.7%), whites (55.1%), paid for by private insurance (46.5%), and were more frequent in patients residing in areas with the highest income quartile (26.9%). Comorbidities frequently present in patients hospitalized for anaphylaxis were hypertension (36.6%), chronic pulmonary disease (28.8%), and electrolyte disorders (20.0%). Costs per hospitalization increased from $4,521 to $6,672 (2006-2015). The percentage of in hospital deaths rose from 0.86 (2006) to 0.93 (2015) and mean length of stay rose from 2.5 days (2005) to 2.7 days (2015). Conclusions: There has been a modest increase in hospitalizations and in-hospital deaths from anaphylaxis in the last decade. In this study, more hospitalizations were associated with topquartile income zip codes and private insurance. Further study is needed to determine whether these trends reflect disparities in access to healthcare or other factors that could affect health outcomes.
low-risk individuals. Larger prospective studies are necessary to confirm these observations.
A004
Introduction: Emergency Department (ED) management of anaphylaxis has not kept pace with advances in knowledge. Epinephrine use and utilization of guideline-based practice recommendations remains sub-optimal, particularly in children. We implemented a clinical pathway in our pediatric ED in August 2017 to improve care. Methods: Cases were identified using ICD-9 and ICD-10 diagnosis codes. We used statistical process control to analyze process and outcome measures for 3 years before and 10 months after initial pathway implementation. Results: 936 patients were included. After pathway implementation, we found special cause variation with a downward shift in the mean time to epinephrine for Emergency Severity Index 1 patients from 11.3 to 4.3 mins. Further, the proportion of anaphylaxis patients receiving ED IV placement decreased from 40.7% to 19.9%. When an H1 antihistamine was used, the choice of a less-sedating H1 blocker in combination with an H2 blocker increased from 15.8% to 52.8%. Mean ED length of stay (LOS) for discharged patients with anaphylaxis (229 mins) and proportion of patients admitted to the hospital (26%) did not change after pathway implementation. Conclusions: An anaphylaxis clinical pathway emphasizing early epinephrine use and reassessment prior to IV placement improved outcomes. Further analysis will seek to determine if the ED observation period may be safely shortened to decrease LOS for low risk patients.
DIRECT ORAL AMOXICILLIN CHALLENGE WITHOUT PRELIMINARY SKIN TESTING IN PATIENTS WITH REPORTED PENICILLIN ALLERGY N. Scanlon*, M. Kuruvilla, Atlanta, GA Introduction: 10% of hospitalized patients report penicillin allergy; studies indicate that »98% are not truly allergic. Unconfirmed penicillin allergy labels pose public health risks, and evaluation is recommended to improve antibiotic stewardship. While the most widely accepted protocol is penicillin skin testing (PST) followed by oral amoxicillin challenge, time constraints and resources may preclude this. Recent literature supports the safety and efficacy of direct oral amoxicillin challenge in low-risk individuals. Methods: We retrospectively evaluated data and oral challenge outcomes from adult patients in clinic with a penicillin allergy label over a 6-month period. Direct oral amoxicillin challenge was recommended in patients with history of benign rash, benign somatic symptoms, or unknown history associated with last penicillin exposure more than 12 months ago. Those with severe reactions or reactions within 12 months of evaluation were not challenged. Patients were monitored for 60 minutes following challenge. Results: Of 355 encounters, 14% of patients had a penicillin allergy label. 76% of those met inclusion criteria. Penicillin-associated reactions varied, and 88% reported reactions more than 10 years prior. 8% of patients were de-labeled based on history alone. 53% of patients offered amoxicillin challenge consented, and none developed immediate, or to our knowledge, delayed hypersensitivity reactions. 15% of patients developed subjective and self-limited symptoms not deemed to constitute true IgE-mediated reactions. Conclusions: This study adds to the accumulating body of evidence supporting the safety and efficacy of direct provocative challenge without preliminary skin testing to exclude penicillin allergy in
Outcomes of Patients with Penicillin Allergy Labels
Left: Outcomes of all 50 patients with penicillin allergy labels in allergy clinic over a 6-month period. Right: Outcomes of 20 patients who underwent oral amoxicillin challenge in allergy clinic.
A005 IMPROVING EMERGENCY CARE FOR ANAPHYLAXIS: IMPACT OF A CLINICAL PATHWAY IN A PEDIATRIC EMERGENCY DEPARTMENT J. Brown*, J. Foti, S. Fenstermacher, K. Kazmier, E. Shephard, N. Deam, H. Clifton, L. Rutman, P. O'Hare, Seattle, WA
Allergy Diagnostics and Immunotherapy
A100 PREDICTIVE DECLINE IN PEANUT SKIN TEST AND RAST AMONG PEANUTALLERGIC CHILDREN UNDERGOING HIGH-DOSE ORAL IMMUNOTHERAPY I. Randhawa*,1, T. Morphew2, N. Marsteller1, 1. Long Beach, CA; 2. Bothell, WA