Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study

Background: The 2023 US Anaphylaxis Practice Parameter indicated that some patients receiving epinephrine in the community might avoid emergency department (ED) visits; however, the criteria and safety of this approach remain unproven. Objective: To derive and validate a clinical prediction model for identifying children at risk of receiving epinephrine after arriving at the ED. Methods: We conducted a 31-center retrospective cohort study of children aged 6 months to less than 18 years who received 1 prehospital dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used least absolute shrinkage and selection operator regression to derive the model in 70% of the patients to identify prehospital factors associated with epinephrine administration. Internal and external validations included 20% and 10% of the cohort, respectively. Results: The 2318 eligible patients had a median age of 8.4 years (interquartile range, 3.8-13.4), and 15.7% (n = 364) received epinephrine after ED arrival. Prehospital factors associated with the receipt of additional epinephrine included a history of asthma, cardiovascular symptoms before epinephrine, persistent symptoms after epinephrine, and any new/recurrent respiratory, cardiovascular, gastrointestinal, or nonspecific symptoms after epinephrine. In the external validation, 30% (65 of 216) of encounters were classified as low risk. The presence of any risk factor had a sensitivity of 0.93 (95% CI, 0.80-0.98), specificity of 0.35 (95% CI, 0.28-0.43), positive predictive value of 0.25 (95% CI, 0.18-0.33), and negative predictive value of 0.95 (95% CI, 0.87-0.99) for identifying patients who received epinephrine after ED arrival. Conclusions: We developed and validated a clinical prediction model to identify children treated with a single prehospital dose of epinephrine who may not require ED care. Implementation of the model could reduce avoidable ED visits for children with anaphylaxis.