Abstract
Background:
Anaphylaxis is known as an acute, severe hypersensitivity reaction that rapidly initiates after exposure to a triggering agent. It is a life-threatening condition, and early recognition and swift intervention are crucial to saving patients’ lives. Objective: The objective of this study is to assess the ability of certified non-critical care physicians to recognize, manage, and dispose cases of anaphylaxis.
Methods:
A survey consisting of 19 questions was developed by expert emergency consultants to evaluate physicians’ knowledge regarding the recognition, management, and disposition of anaphylactic episodes. Responses were collected through in-person surveys conducted with physicians from various specialties and varying clinical experience levels at a tertiary care center in the Eastern Province of Saudi Arabia.
Results:
In this cross-sectional study, a total of 173 physicians completed the survey, with 81.5% being consultants and 18.5% specialists. Only 5.2% correctly identified all three proposed anaphylaxis clinical scenarios, 16.8% identified two scenarios correctly, and 51.4% identified only one scenario. While 42.8% recognized the first-line management of anaphylaxis, only 24.3% and 24.9% knew the correct epinephrine dose and route, respectively. Regarding the disposition of patients experiencing an anaphylactic episode, 61.9% of responders opted to dispose the case to the emergency department.
Conclusion:
Our study reveals a knowledge gap among non-critical care physicians practicing in a tertiary care center concerning the identification and management of anaphylaxis. Raising awareness of this life-threatening condition is imperative to address this serious issue.
Keywords: Anaphylaxis, diagnosis, management, disposition, epinephrine
1. BACKGROUND
Anaphylaxis is recognized as an acute, severe hypersensitivity reaction that occurs rapidly following exposure to a triggering agent. It is a life-threatening condition, and its early recognition and prompt intervention are essential for preserving patients’ lives (1-3). Anaphylaxis is characterized by a sudden onset of symptoms involving multiple organs, most commonly affecting the skin and mucous membranes. However, not all patients will exhibit a rash or skin manifestations; some may present with symptoms of respiratory distress, persistent vomiting without a rash, or even hypotension alone (1, 2).
In Riyadh, Saudi Arabia, the prevalence of anaphylaxis was estimated to be 0.00026% based on a single tertiary center study published in 2018 (4).
Healthcare physicians should be well-acquainted with the diagnostic criteria for anaphylaxis and its various presentations. By maintaining a high level of suspicion for anaphylaxis, physicians can improve their ability to promptly recognize and manage cases, even in patients with mild symptoms (1). While many cases of anaphylaxis occur in patients with known allergies and identifiable triggering agents, there are instances of idiopathic anaphylaxis. Idiopathic anaphylaxis patients do not have a history of known allergies, and the cause remains elusive despite comprehensive medical history assessment, thorough physical examination, and appropriate laboratory investigations (5).
Treating anaphylaxis is crucial, and any delay in its management can result in severe consequences, potentially leading to fatalities (6). Epinephrine serves as the first-line treatment and should be administered as soon as anaphylaxis is recognized or diagnosed. It is typically administered intramuscularly at a standard adult dose of 0.5 mL of 1 mg/mL (1:1000) epinephrine. In pediatrics, the dosage is weight-dependent, with a recommended dose of 0.01 mg/kg, not to exceed 0.3 mg (7). Anaphylaxis can manifest unexpectedly, and a stable patient can rapidly deteriorate. Therefore, the administration of epinephrine should be swift, as anaphylaxis can have fatal consequences (6, 7).
Managing anaphylaxis is straightforward but time-sensitive. Any delay in recognizing or treating it can have fatal consequences (6, 7). The incidence of mortality and severe outcomes resulting from anaphylaxis can be readily reduced by ensuring that physicians possess the necessary knowledge for early recognition and appropriate management of anaphylactic cases. Therefore, regardless of their specialties, physicians should be well-versed in how anaphylaxis presents and how to administer treatment effectively, aiming to lower mortality rates and prevent serious outcomes.
2. OBJECTIVE
The objective of this study is to assess the proficiency of certified non-critical care physicians in recognizing, managing, and disposing cases of anaphylaxis.
3. MATERIAL AND METHODS
A cross-sectional study was conducted using a validated electronic questionnaire in the English language. The questionnaire was distributed to and completed by non-critical care certified practicing physicians from various specialties at a tertiary hospital in the Eastern Province of Saudi Arabia over 3 months. The questionnaire was modified from a validated survey found in similar published articles and was face-validated by three Emergency Medicine (EM) consultants.
The questionnaire was divided into three main sections. The first section gathered demographic data, including information on medical education and medical specialty. The second section contained questions related to the early detection, diagnosis, and management of life-threatening conditions based on specific criteria. The third section included questions about physicians’ previous experience and training related to the topic of anaphylaxis.
Prior to participating in the study, informed consent was obtained from the participants. The questionnaire was then distributed and completed by a sample size that represented approximately 50% of the staff population of interest, which amounted to around 380 doctors. Subsequently, the collected data was analyzed to assess the participants’ knowledge regarding the early recognition, diagnosis, and management of this life-threatening situation.
Inclusion and exclusion criteria:
The study’s inclusion criteria encompassed all non-critical care certified practicing physicians, including specialists and consultants, working within a tertiary hospital located in the Eastern Province of Saudi Arabia. On the other hand, the exclusion criteria comprised critical care certificated practicing physicians, specifically from the EM, Intensive Care Unit (ICU), and Anesthesia departments. Additionally, physicians holding fellowships in ICU, neonatology, and allergy and clinical immunology were also excluded from the study.
Sample size and technique
The cross-sectional survey included 183 physicians from various departments. The sample size was determined to be 184 using Epi Info, which exceeded the actual collected sample size. This calculation was done at a 95% confidence interval (CI) with a margin of error of 5%.
Materials
An organized, in-person, electronic-based questionnaire was utilized for data collection. This questionnaire was meticulously crafted by three expert EM consultants who thoroughly reviewed recent literature and comparable studies, keeping the study’s objectives in mind. Professional experts further scrutinized the questionnaire for content authenticity.
The data collection process involved the use of this well-structured, in-person, electronic-based questionnaire, which had been developed based on previously published studies and undergone face validation by three EM consultants. The questionnaire is divided into three main sections. The first section gathers demographic information, including the participant’s level of medical education and medical department affiliation. The second section comprises questions related to the diagnosis, management, and disposition of life-threatening conditions, guided by specific criteria. The third section included questions about physicians’ previous experience and training related to the topic of anaphylaxis.
Statistical analysis
The data analysis was conducted using the Statistical Package for the Social Sciences (SPSS). Descriptive statistics were used to report frequencies and proportions for categorical responses. In the analysis of categorical variables, the Chi-square test was employed, accompanied by the Monte Carlo test.
4. RESULTS
A total of 183 non-critical care certified practicing physicians, aged between 27 and 70 years, participated in the study. 173 physicians were enrolled in the study as they fulfilled the inclusion criteria and completed the study questionnaire. Among these participants, 98 (56.6%) were male, and 75 (43.4%) were female. In terms of their employment status, the majority (141, 81.5%) were consultants, while 32 (18.5%) were specialists.
Participants’ years of practice ranged from 1 to 40 years, with the largest group having 11 to 15 years of practice (50, 28.9%).
The study considered two main areas of practice: adults and pediatrics. The majority (141, 81.5%) of participants practiced in the field of adults, while 32 (18.5%) specialized in pediatrics.
The participating physicians belonged to 14 different specialties, with the majority coming from General Surgery (29, 16.8%) and Internal Medicine (27, 15.6%).
The highest response rate was observed among those specializing in General Surgery, with 29 respondents (55.8%) out of 52 board-certified physicians. This was followed by 27 respondents (45.0%) out of 60 from Internal Medicine and 20 respondents (40.0%) out of 50 from Pediatrics. The response rate varied across specialties, ranging from 22.2% to 75.0%.
The level of awareness among non-critical care physicians regarding the diagnosis, management, and disposition of anaphylactic cases was measured through three specific questions for each element.
In the diagnosis section, three different case scenarios were provided, and participants were asked to provide the final diagnosis for each case. Each scenario covered different set of signs and symptoms according to the diagnostic criteria of anaphylaxis. For the first case scenario, 39 physicians (22.5%) correctly identified the diagnosis. In the second question, 42 physicians (24.3%) provided the correct diagnosis, and in the third question, which involved skin manifestation, 92 participants (53.2%) correctly identified the diagnosis. It was easier to identify anaphylaxis once skin manifestations were involved.
The management section included questions such as ‘What is the first-line treatment for this patient?’. About 74 participants (42.8%) correctly answered epinephrine. When asked about the intramuscular dose of epinephrine for anaphylaxis, only 42 (24.3%) gave the correct response. Similarly, 43 participants (24.9%) correctly identified the recommended site for intramuscular epinephrine administration.
Regarding the disposition of anaphylaxis among non-critical care certified practicing physicians in both adult and pediatric areas of practice, the first question asked about the interval for re-administering epinephrine. Fifty-three participants (30.6%) correctly chose the answer of 5 min. In the second question, which inquired about how long to follow up with a patient after an anaphylactic reaction, 48 participants (27.8%) correctly selected the answer of 3–6 h. Regarding disposition, the majority of participants (107, 61.8%) correctly indicated that the patient should be sent to the EM department.
The third part of the questioner was measuring the level of awareness among non-critical care physicians regarding their previous experience and training in anaphylaxis.
When asked if they had ever encountered a patient with anaphylaxis, 52.0% responded affirmatively. However, a significant majority, 83.2%, had not participated in any review or educational activities aimed at increasing their awareness of anaphylaxis. Only 29 individuals (16.8%) reported attending such activities, and among them, 23 (79.3%) had done so more than a year ago.
Tables 1-3 provides the percentages of correct answers in the diagnosis, management, and disposition sections among different specialties. Significantly, there were notable differences in the answers provided by physicians from various specialties, with p-values of 0.015, 0.014, and 0.045 for the diagnosis, management, and disposition sections, respectively.
Table 1. Number of physicians regarding the number of correct answers in diagnosis regarding specialties.
| diagnosis | ||||
|---|---|---|---|---|
| Specialty | 3 correct answers | 2 correct answers | 1 correct answer | No correct answer |
| Dermatology | 4(44.4%) | 1(11.1%) | 3(33.3%) | 1(11.1%) |
| ENT | 0(0.0%) | 0(0.0%) | 1(20.0%) | 4(80.0%) |
| Family medicine | 1(5.6%) | 5(27.8%) | 9(50.0%) | 3(16.7%) |
| General surgery | 2(6.9%) | 4(13.8%) | 16(55.2%) | 7(24.1%) |
| Internal medicine | 0(0.0%) | 5(18.5%) | 16(59.3%) | 6(22.2%) |
| Neurology | 0(0.0%) | 3(37.5%) | 5(62.5%) | 0(0.0%) |
| Neurosurgery | 0(0.0%) | 2(66.7%) | 1(33.3%) | 0(0.0%) |
| OB/GYNE | 1(10.0%) | 1(10.0%) | 6(60.0%) | 2(20.0%) |
| Ophthalmology | 0(0.0%) | 2(18.2%) | 3(27.3%) | 6(54.5%) |
| Orthopedics | 0(0.0%) | 0(0.0%) | 1(20.0%) | 4(80.0%) |
| Pediatrics | 0(0.0%) | 1(5.0%) | 15(75.0%) | 4(20.0%) |
| Psychiatry | 0(0.0%) | 1(11.0%) | 4(44.5%) | 4(44.5%) |
| Radiology | 0(0.0%) | 3(20.0%) | 8(53.3%) | 4(26.7%) |
| Urology | 1(25.0%) | 0(0.0%) | 2(50.0%) | 1(25.0%) |
| P value 0.015 | ||||
Table 3. Number of physicians regarding the number of correct answers in disposition regarding specialties.
| disposition | ||||
|---|---|---|---|---|
| Specialty | 3 correct answers | 2 correct answers | 1 correct answer | No correct answer |
| Dermatology | 0(0.0%) | 2(22.2%) | 2(22.2%) | 5(55.6%) |
| ENT | 0(0.0%) | 4(80.0%) | 0(0.0%) | 1(20.0%) |
| Family medicine | 2(11.1%) | 8(44.4%) | 7(38.9%) | 1(5.6%) |
| General surgery | 1(3.5%) | 10(34.5%) | 11(37.9%) | 7(24.1%) |
| Internal medicine | 1(3.7%) | 6(22.2%) | 16(59.3%) | 4(14.8%) |
| Neurology | 0(0.0%) | 2(25.0%) | 4(50.0%) | 2(25.0%) |
| Neurosurgery | 0(0.0%) | 1(33.3%) | 1(33.3%) | 1(33.3%) |
| OB/GYNE | 0(0.0%) | 1(10.0%) | 8(80.0%) | 1(10.0%) |
| Ophthalmology | 0(0.0%) | 2(18.2%) | 7(63.6%) | 2(18.2%) |
| Orthopedics | 0(0.0%) | 0(0.0%) | 5(100.0%) | 0(0.0%) |
| Pediatrics | 4(20.0%) | 9(45.0%) | 6(30.0%) | 1(5.0%) |
| Psychiatry | 0(0.0%) | 2(22.2%) | 5(55.6%) | 2(22.2%) |
| Radiology | 0(0.0%) | 3(20.0%) | 7(46.7%) | 5(33.3%) |
| Urology | 1(25.0%) | 0(0.0%) | 2(50.0%) | 1(25.0%) |
| P value 0.045 | ||||
In the diagnosis section (Table 1), dermatologists achieved the highest rate of correct answers (44.4%) for all three cases among the participating specialties. Conversely, orthopedic and ENT (Ear, Nose, Throat) surgeons had the highest rate of incorrect answers for all cases (80% each).
Regarding the management questions (Table 2), urologists had the highest rate (25%) of correct answers for all three questions among the different specialties. In contrast, neurosurgeons had the highest rate (66.7%) of incorrect answers as they were unable to answer any question correctly.
Table 2. Number of physicians regarding the number of correct answers in management regarding specialties.
| management | ||||
|---|---|---|---|---|
| Specialty | 3 correct answers | 2 correct answers | 1 correct answer | No correct answer |
| Dermatology | 2(22.2%) | 2(22.2%) | 4(44.4%) | 1(11.1%) |
| ENT | 0(0.0%) | 1(20.0%) | 3(60.0%) | 1(20.0%) |
| Family medicine | 2(11.1%) | 6(33.3%) | 6(33.3%) | 4(22.2%) |
| General surgery | 0(0.0%) | 4(13.8%) | 14(48.3%) | 11(37.9%) |
| Internal medicine | 1(3.7%) | 10(37.1%) | 5(18.5%) | 11(40.7%) |
| Neurology | 0(0.0%) | 0(0.0%) | 6(75.0%) | 2(25.0%) |
| Neurosurgery | 0(0.0%) | 0(0.0%) | 1(33.3%) | 2(66.7%) |
| OB/GYNE | 0(0.0%) | 1(10.0%) | 3(30.0%) | 6(60.0%) |
| Ophthalmology | 0(0.0%) | 0(0.0%) | 7(63.6%) | 4(36.4%) |
| Orthopedics | 0(0.0%) | 0(0.0%) | 2(40.0%) | 3(60.0%) |
| Pediatrics | 1(5.0%) | 3(15.0%) | 10(50.0%) | 6(30.0%) |
| Psychiatry | 0(0.0%) | 0(0.0%) | 9(100.0%) | 0(0.0%) |
| Radiology | 1(6.6%) | 3(20.0%) | 4(26.7%) | 7(46.7%) |
| Urology | 1(25.0%) | 0(0.0%) | 1(25.0%) | 2(50.0%) |
| P value 0.014 | ||||
In the disposition section (Table 3), urology specialists had the highest rate (25%) of correct answers to disposition questions. On the other hand, 55.6% of dermatologists were unable to answer any question correctly.
5. DISCUSSION
Globally, the prevalence of anaphylaxis is estimated to range from 50 to 2000 episodes per 100,000 people, with an admission rate of 0.26%. The fatality rate is approximately 1 per one million cases, except for Australia, where it is notably higher at 6.2% due to food triggers (8,9). However, recent studies have indicated a rising trend in anaphylaxis cases across all age groups over the years (8). For instance, a retrospective study conducted in New Zealand between 2006 and 2015 revealed a 2.8-fold increase in anaphylaxis cases among pediatric patients (10). The wide range in prevalence can be attributed to the absence of a standardized global definition and diagnostic criteria for anaphylaxis, leading to underdiagnosis (11).
Numerous studies have highlighted that one of the reasons for failing to recognize anaphylaxis is when patients do not present with skin rashes or any dermatological manifestations or when there is no specific triggering agent or history of allergies (5, 11). This study aims to evaluate the competency of non-critical care certified physicians in diagnosing, managing, and disposing anaphylaxis cases.
The assessment of physicians’ capacity to identify and diagnose anaphylaxis involved three distinct case scenarios, each with varying presentations. These scenarios were constructed in accordance with the 2020 practice parameter criteria update on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) analysis. These criteria have been validated by experts in the field for both pediatric and adult populations. When any of the three criteria listed below (Table 4) are met, it is more likely that anaphylaxis is occurring (1):
Table 4. Clinical criteria for diagnosing anaphylaxis (1).
| 1 | Acute onset of an illness (minutes to hours) that involves the skin, mucosal tissue, or both, along with either: | Sudden respiratory signs and symptoms Sudden reduced blood pressure and /or end organ dysfunction |
|
| 2 | Two or more of the following that occur promptly after exposure to a potential allergen for the patient, including: | Involvement of skin mucosal tissue Respiratory involvement Reduced blood pressure or associated symptoms Gastrointestinal symptoms |
|
| 3 | Reduced blood pressure (BP) as a result of exposure to a known allergen trigger. | Reduced BP in Adults | <90 mmHg systolic 30% decrease from baseline |
| Reduced BP in children | Low systolic (age specific) 30% decrease from baseline |
||
A total of 183 physicians participated in the study, and 173 of them (141 adult physicians and 32 pediatricians) were included as they met the inclusion criteria and completed all the in-person questionnaires. Among the 173 respondents practicing in both adult and pediatric settings for diagnosing anaphylaxis, only nine (5.2%) answered all three questions correctly, while 46 (26.6%) did not provide any correct answers.
Among all the diagnostic questions, the third question had the highest percentage of correct answers at 92 (53.2%). This is attributed to the inclusion of dermatological symptoms such as skin rash and itchiness, which are more easily recognizable. A 2020 Mexican study underscored the challenge some physicians face in identifying anaphylaxis episodes when they lack skin manifestations (11).
More recently, in 2022, a Turkish study involving 85 doctors revealed that only four doctors were able to correctly recognize the diagnostic criteria of anaphylaxis, while 72 doctors failed to identify cardiovascular and/or gastrointestinal signs and symptoms as diagnostic criteria for anaphylaxis (12). In 2020, three separate cross-sectional studies conducted in the Philippines, Mexico, and India reached similar conclusions, highlighting a significant deficiency in recognizing anaphylaxis (11, 13, 14). Furthermore, a 2021 study in Egypt involving 242 physicians found a clear deficit in knowledge and inadequate practice in managing anaphylaxis cases among Egyptian physicians. Only 37.6% of the participants could correctly identify all clinical scenarios presented in the study survey (3).
The results of this study, along with the aforementioned research, collectively underscore the substantial knowledge gap regarding the diagnostic criteria of anaphylaxis. This knowledge deficit impairs physicians’ ability to recognize and diagnose anaphylaxis, aligning with our initial hypothesis and the findings of the literature review.
Assessing a physician’s ability to recognize signs and symptoms of anaphylaxis in accordance with the GRADE parameters is the initial crucial step in saving a patient’s life. Managing an anaphylactic episode involves critical actions, including early identification, selecting the appropriate first-line medication, ensuring correct dosing, and choosing the right route of administration.
As per the updated Resuscitation Council UK (RCUK) Anaphylaxis Guideline for 2021, epinephrine is the recommended first-line treatment for anaphylaxis. The initial route of administration is intramuscular (IM). In adults, the recommended initial dose of IM epinephrine is 0.5 mg, delivered as 0.5 mL of a 1 mg/mL (1:1000) solution. However, the dosage in pediatrics varies with age, as indicated in Table 5 (7).
Table 5. Recommended doses of IM Epinephrine(1, 7).
| IM Epinephrine dose - Adults | 0.5 mg or 0.5 mL of 1 mg/mL [1:1000] |
| IM Epinephrine dose - Children | |
| > 12 years | 0.5 mg or 0.5 mL of 1 mg/mL [1:1000] (same as adult) 0.3 mg or 0.3 mL of 1 mg/mL [1:1000] (small or prepubertal child) |
| 6-12 years | 0.3 mg or 0.3 mL of 1 mg/mL [1:1000] |
| 6 months -6 years | 0.15 mg or 0.15 mL of 1 mg/mL [1:1000] |
| < 6 months | 0.1-0.15 mg or 0.1-0.15 mL of 1 mg/mL [1:1000] 0.01 mg/kg or 0.01mL/kg of 1 mg/mL [1:1000] not to exceed 0.3 mg |
Additionally, the optimal injection site for IM epinephrine is the vastus lateralis muscle in the mid-anterolateral thigh, as compared to other locations. The vastus lateralis muscle is efficient and adequate for medication absorption due to its favorable blood flow leading to a higher plasma concentrations (15, 16).
Antihistamines and corticosteroids can be cautiously considered as adjuvant treatments in addition to epinephrine in certain cases (7). However, a cohort study conducted in Canada in 2019 examined the adverse outcomes of administering antihistamines and corticosteroids as first-line treatments for anaphylaxis (17). The reason for not recommending them as primary interventions is that antihistamines do not expedite the resolution of cardiovascular and respiratory symptoms in anaphylaxis. Conversely, corticosteroids have been associated with a higher rate of ICU admissions (7).
The statistical results of this study reveal that only eight (4.6%) of the participants answered all three questions in the management section correctly. After analyzing each question separately, 74 (42.8%) out of 173 participants selected injectable epinephrine as the first-line treatment. However, 131 (75.7%) and 130 (75.1%) could not correctly identify the recommended intramuscular (IM) dose and the appropriate localization for IM epinephrine administration in the case of anaphylaxis, respectively.
A 2021 Mexican study, which included 1013 participants, found that 761 of the participants (75.2%) correctly identified the first-line treatment for anaphylaxis. In contrast, only 461 (45.5%) participants correctly identified the epinephrine dose for treating anaphylaxis (18). Additionally, a Turkish study conducted in 2021 concluded that out of 391 physicians, only 341 (87.2%), 167 (42.7%), and 281 (71.9%) of the physicians were knowledgeable about the first-line treatment for anaphylaxis, the correct medication dosage, and the optimal route of administration, respectively (19).
The results underscore a significant knowledge gap concerning anaphylaxis management and the pivotal role of epinephrine as the primary approach. Research studies have consistently demonstrated that delays in administering epinephrine and its underutilization are strongly associated with higher mortality rates in cases of anaphylaxis (20, 21). These findings emphasize the urgent requirement for enhancing physicians’ understanding of the critical importance of prompt anaphylaxis management, as well as the correct dosing and administration of epinephrine.
No studies have assessed physicians’ knowledge concerning repeated doses of IM epinephrine, underscoring the importance of emphasizing the correct interval timing for a second dose. Among all the participants, only 30.6% could correctly identify that a second dose of epinephrine can be re-administered every 5 min in cases of severe anaphylaxis and refractory cases. According to GRADE guidelines, it is recommended to consider repeating a second or third IM epinephrine dose every 5 to 15 min, depending on the patient’s response to the initial injection (1, 22, 23). While most patients respond favorably to a single dose of IM epinephrine, certain studies suggest that approximately 13% to 36% of cases may necessitate an additional dose due to an inadequate response to the initial dose or sudden clinical deterioration (22, 24, 25). Patients requiring a repeated dose often exhibit severe anaphylactic symptoms such as loss of bowel control, respiratory arrest, oxygen saturation below 92%, or cyanosis (26). In cases where repeated IM epinephrine fails to elicit a response, preparation of IV epinephrine with strict adherence to instructions is imperative (22).
Patients experiencing anaphylaxis should undergo observation on a monitored bed for a duration of 3 to 6 h. In this study’s entire sample, only 27.8% of physicians were aware of the recommended observation period. Some clinical recommendations suggest monitoring individuals with uniphasic anaphylaxis for a span of 4 to 12 h, and for severe or persistent anaphylaxis, hospitalization may extend for several days. This period of observation is crucial to observe any side effects of epinephrine, specially arrythmias or any potential biphasic reaction, which involves the recurrence of anaphylaxis without re-exposure to the allergen (1, 23). Managing anaphylaxis should prioritize the development of an emergency action plan, referral of the patient to an allergist, and educating the patient on the proper utilization of an epinephrine auto-injector while helping them identify and avoid triggers (27).
Physicians should possess the ability to promptly recognize anaphylactic reactions in their patients and initiate immediate management. It is strongly recommended to refer any suspected cases of anaphylaxis to the emergency department (ED) to continue the management plan (1, 23). In the survey’s final question, participants were asked, “To which department would you refer a patient with anaphylaxis?” Remarkably, the majority, comprising 107 participants (61.9%), correctly selected EM as the appropriate department. However, it is concerning that 38.1% of physicians did not consider the ED as a suitable choice despite the presented cases being critical and potentially life-threatening. Generally, there is a need for heightened attention to disposition guidelines and recommendations in the context of anaphylaxis studies.
The results of this study strongly underscore the necessity for continuous educational programs and training. The vast majority of our participants exhibited inadequate knowledge regarding the detection and management of anaphylaxis cases, revealing significant deficiencies. Only 16.8% of physicians reported attending educational activities. An Australian study conducted on 156 schoolteachers highlighted the importance of education. The study evaluated their knowledge of recognizing and managing anaphylaxis before and after completing an educational training program. The results demonstrated an improvement in knowledge following the course compared to the pretest results (28). This finding aligns with a 2014 study in Japan that included schoolteachers, school nurses, and childcare workers. It revealed a significant increase in self-efficacy across all groups after attending an educational workshop.
Interestingly, there was no discernible correlation between self-efficacy and a person’s profession or expertise in managing allergic reactions like anaphylaxis among all occupational categories. This suggests that past personal experiences alone were often insufficient to enhance self-efficacy, emphasizing the crucial role of hands-on training in improving the recognition of such cases (29). Furthermore, a 2019 cohort study conducted among medical students and residents aimed to demonstrate the effectiveness of high-fidelity simulation. It concluded that informative training and simulation-based learning can successfully address various knowledge gaps, including delayed recognition of anaphylaxis and inappropriate medication administration (30).
6. CONCLUSION
This single-center study has underscored a notable knowledge gap among non-critical care physicians working in a tertiary center when it comes to recognizing and managing anaphylaxis. This gap is attributed to limited exposure to critical situations and a lack of participation in educational activities related to this subject. Furthermore, it is worth noting that even among those who did attend such educational activities, it has been more than a year since their last participation.
Therefore, raising awareness of anaphylaxis as a critical, time-sensitive condition is imperative to address this significant issue. Various approaches can be employed, including awareness campaigns, in-situ clinical simulation sessions, and the use of memory aid posters. Such efforts are expected to significantly enhance awareness and self-confidence among physicians and healthcare providers, thereby reducing knowledge gaps and enhancing their clinical skills.
Additionally, ensuring the availability and easy access to EpiPens, possibly by incorporating them into other life-saving kits like those used for “Stop the Bleed” and Automated External Defibrillator (AED) scenarios, will encourage, and streamline the management of anaphylaxis patients in a timely manner. To gain a more comprehensive understanding of anaphylaxis knowledge, a nationwide study encompassing all physicians in Saudi Arabia would provide more accurate insights into their awareness and expertise regarding anaphylaxis.
Acknowledgment:
We extend our appreciation to the Quality and Development Center for their valuable contribution in accurately representing the number of consultants and specialists from each specialty who participated in this study. Furthermore, our gratitude goes to all the dedicated data collectors who actively participated in our research efforts.
Author’s Contribution:
NM gave a substantial contribution to the conception and design of the work. DM, DB, RG, RG, FB, AA gave a substantial contribution of data. DM, DB, RG, RG, FB, AA, NM gave a substantial contribution to the acquisition, analysis, or interpretation of data for the work. DM, DB, RG, RG, FB, AA, NM, FK had a part in article preparing for drafting or revising it critically for important intellectual content. All authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflicts of interest:
There are no conflicts of interest.
Financial support and sponsorship:
Nil.
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