Authors’ response: Incidence and clinical management of paediatric emergency presentations of anaphylaxis in Alberta

To the Editor: We thank Dr. Kaplan for the careful review of our study and for the insightful comments (1,2). Overall, we agree with the author's central premise that the proportion receiving a medication becomes a quality indicator only when its denominator represents patients with a genuine clinical opportunity for treatment. Administrative data cannot determine (for each encounter) whether epinephrine was indicated at the time of emergency department (ED) assessment, whether a child had already received a dose before arrival and had an expected response, or whether a visit coded as anaphylaxis represented a valid case with clinical features requiring treatment. In fact, we clearly acknowledged these limitations within the manuscript. Thus, the 41.9% ED administration proportion, considered in isolation, cannot differentiate undertreatment from appropriate restraint. Our conclusion of underutilization, however, reflects a consistent pattern we and others have observed across the care pathway. First, these presentations were assessed upon arrival as high-acuity; 72.8% of children were triaged as resuscitation (CTAS 1; condition requiring immediate intervention) or emergent (CTAS 2; condition requiring rapid intervention [within 15 min]). Moreover, one-quarter arrived by ambulance. Despite these severity measures, only 19.5% of children transported by EMS received epinephrine from paramedics. Prior treatment by families or schools may account for part of this gap; however, North American studies that used chart review to examine this question have repeatedly documented prehospital undertreatment (3–5).