Standardized guidelines improve management of urticaria in ED
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Key takeaways:
- A greater proportion of surveyed ED providers correctly said they would use second-generation antihistamines for urticaria after the intervention.
- More patients received guideline-recommended treatment as well.
ANAHEIM, Calif. — A quality-improvement initiative helped close knowledge gaps on the treatment of urticaria in the ED, according to study results presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
Jennifer C. Li, MD, allergy/immunology fellow at Massachusetts General Hospital, was inspired to conduct this research, which received the Clemens von Pirquet 1st Place Abstract Award, after observing that many patients with urticaria were receiving first-generation antihistamines and steroids in the ED rather than second-generation antihistamines, which were recommended in 2014 guidelines.
“Urticaria is a common presentation in the ED, accounting for 200,000 to 500,000 ED visits in the U.S. annually,” Li told Healio. “I was prompted to develop these guidelines based on my experience seeing urticaria patients in the ED from hospital consults. The intervention involved creating guidelines for diagnosis and management of urticaria in the ED for emergency medicine providers.”
Specifically, Li collaborated with colleagues in allergy, emergency medicine, pharmacy and nursing at her institution to develop allergy-based guidelines and an educational handout geared toward ED physicians.
As part of the initial evaluation, the guidelines first prompt providers to consider alternative diagnoses for the rash and, once confirming it is in fact urticaria based on evanescent wheals and flares, then consider whether the episode has lasted longer than 24 hours. If not, the patient should be evaluated for anaphylaxis and managed as an acute allergic reaction. If the patient has angioedema, after ensuring the airway is secure, providers should consider a diagnosis of bradykinin angioedema.
In terms of management, the first step is to look at the patient’s chart to see if they’ve seen an allergist in the past. If not, cetirizine is recommended as the initial treatment, followed by fexofenadine or famotidine if recurrence occurs. If urticaria persists, steroids can then be considered, as well as a referral to allergy.
To determine the impact of their guidelines, Li and colleagues conducted a survey of ED providers before (n = 66; 45% residents, 29% attendings, 24% advanced practice providers) and after (n = 29; 66% residents, 24% attendings, 10% advanced practice providers) implementation to assess knowledge on urticaria management.
Researchers also conducted a chart review to compare how patients with urticaria were actually managed in the ED from March 2022 to April 2023, prior to the intervention (n = 68; 71% women; median age, 33 years), with data from May 2023 to August 2023, after the new guidelines were implemented (n = 29; 76% women; median age, 30 years).
When asked about the best first-line therapy to manage an episode of urticaria lasting longer than 24 hours, 55% of ED providers said they would properly use second-generation H1 antihistamines for the first-line treatment of urticaria before the intervention compared with 90% (P < .001) afterward. The proportion of patients actually prescribed this therapy based on chart review increased from 21% to 43% (P = .03).
Also, 29% of ED providers said they would use first-generation HI antihistamines prior to the intervention, compared with only 10% afterward (P = . 07), with a corresponding drop in actual utilization of 55% to 43% (P = .05).
When asked about second-line treatment, 9% of ED providers said they would use H2 antihistamines prior to the intervention compared with 48% afterward (P < .001). There was a nonsignificant decrease in the proportion of providers who said they would use steroids (42% vs. 24%), and actual prescription of steroids for patients remained stable.
“Unfortunately, the use of steroids was still the same so, certainly, there is much more work to do,” Li said during her presentation. “But, what was great is that just a simple educational intervention of providing some guidelines and providing a quick educational pamphlet was able to make these changes.”
In terms of triggers for acute and chronic urticaria, a greater proportion of providers recognized infection as a cause following the intervention (24% vs. 48%; P = .03) and fewer identified food as the cause (47% vs. 21%; P = .04).
Also, more providers correctly acknowledged that Bradykinin-mediated angioedema is not a cause of urticaria from before to after the intervention (57% vs. 79%.
Researchers plan to build on these improvements.
“I was gratified that we were able to yield improvements, though there is more work to be done,” Li told Healio. “Future directions involve looking at this intervention in pediatric patients, expanding to guidelines on angioedema, and developing additional types of interventions, such as in the electronic medical record.”