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The COVID-19 pandemic has led to severe disruption of healthcare systems and elective planned care.1 While pandemics are infrequent, the disruption of elective care by acute respiratory viral infections is an annual occurrence, including administration of oral food challenges (OFCs) to children with suspected allergy. A major barrier to performing OFCs outside tertiary centres is the risk of adverse events including anaphylaxis.2 3 We recently reported a large series of food challenges in a COVID-19 stepdown facility,4 and here we describe our process of managing anaphylaxis in this setting.
Five regional paediatric allergy clinics across Ireland jointly used a vacant COVID-19 field hospital over 6 weeks. OFCs were performed within a pod system, with each pod containing up to six patients (figure 1). Resuscitation protocols and equipment trolleys were identical to those in hospital. For anticipated anaphylaxis events, patient journey was mapped out prior to commencing challenges at the facility, using a ‘Go/No Go’ principle to anticipate and resolve all issues at each step before proceeding to the next. A simulation exercise was supervised by a base hospital’s resuscitation training team. A resuscitation room was built and equipped on-site and staffed by a consultant paediatric anaesthesiologist. This room was close to both the OFC clinical area and to the main exit, should outward transfer to a base hospital be required. We implanted a traffic light approach according to patient status to guide the role of team members.
Of the 474 OFCs performed, 25 (5%) children experienced anaphylaxis and their clinical information is summarised in table 1. Nine children required transfer from bedside to resuscitation room, and eight patients required outward ambulance transfer to base hospital and an overnight admission. Seven children required two doses of epinephrine, with a median interval between epinephrine doses of 35 min. All transferred patients remained stable following ambulance transport to base hospital, and none required advanced airway management or admission to paediatric intensive care unit. All eight were transferred in compliance with an agreed safety standard, having received two doses of intramuscular epinephrine, not because they remained unstable. There were no biphasic anaphylactic reactions and no further treatment was required apart from routine observations. The most frequently occurring unanticipated event in the field hospital was failure to communicate the need to replenish stocks of consumables. This did not affect the clinical care of any child. An identified risk of performing mass OFCs concurrently is that severe reactions may occur simultaneously or close together. This did occur in our cohort on two occasions, although without any adverse sequelae.
We have demonstrated that offsite OFCs can be safely performed at a large scale in an adapted field hospital through cross-hospital multidisciplinary collaboration. The pod model is suitable in comparison with standard clinical care models, while allowing a larger volume of patients to receive challenges. We believe this report also provides a roadmap for undertaking other similar large-scale initiatives, where a risk of complexity such as an anaphylaxis event is inherent in the process.
Patient consent for publication
Ethical approval was obtained from the ethical committee at Crumlin Children's Hospital, Dublin, Ireland (ethical approval reference number GEN/875/20).
Contributors This letter was designed, directed and coordinated by AAS, DC and KFM. As principal investigator, DC provided overall supervision and contributed to designing, supervising and correcting the manuscript. LF, KFM and AAS designed the methods of the study and related figures. JH and AMB developed the theory and contributed to planning and implementation of the letter. AAS, AMB and JT contributed to the analysis and interpretation of the results. AAS, JJF and CO’C contributed to drafting and revising the manuscript.
Funding This project received funding from the National Treatment Purchase Fund.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.