Changes in Emergency Department Concordance with Guidelines for the Management of Food-Induced Anaphylaxis: 1999-2001 Versus 2013-2015

Background: Awareness about food allergy and food-induced anaphylaxis (FIA) has increased dramatically over the past decade. It remains unclear, however, whether concordance with guidelines for FIA management has improved over time.

Objective: Our objective was to describe changes in emergency department (ED) concordance with guidelines for FIA management.

Methods: We analyzed data from 2 multicenter retrospective studies of patients with food-related acute allergic reactions seen in 1 of 17 EDs during 2 time periods: 1999 to 2001 and 2013 to 2015. Visits were identified similarly across years-for example, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.60, 995.61-995.69, 995.0, and 995.3. Anaphylaxis was defined as an acute allergic reaction with involvement of 2+ organ systems or hypotension. We compared concordance between time periods for 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for an epinephrine autoinjector (EAI), (3) referral to an allergist/immunologist, and (4) instructions to avoid offending allergen.

Results: We compared 290 patients with FIA during 1999 to 2001 and 459 during 2013 to 2015. Any treatment with epinephrine (pre-ED or in the ED) for patients with FIA increased over time (38% vs 56%; P < .001). Prescriptions for EAI at discharge (24% vs 54%; P < .001) and documentation for referral to an allergist/immunologist (14% vs 24%; P = .001) approximately doubled, whereas instructions to avoid the offending allergen did not change significantly (37% vs 43%; P = .08). Receipt of 3+ guideline recommendations remained low but almost quadrupled over the study interval (6% vs 23%; P < .001).

Conclusions: Over the nearly 15-year study interval, we observed clinically and statistically significant increases in ED concordance with epinephrine-related guidelines for FIA. Management gaps remain and interventions to standardize care still appear warranted.