Measuring ‘Epi-Care’ in paediatric anaphylaxis: clinical opportunities, not medication frequencies

Essel et al. provide a valuable population-level account of the growing emergency department (ED) burden of paediatric anaphylaxis in Alberta (1). Their call to bridge gaps in ‘Epi-Care’ is timely. However, the conclusion that first-line epinephrine was severely underused also illustrates a broader problem in anaphylaxis surveillance: a drug-administration proportion becomes a quality measure only when its denominator represents a genuine clinical opportunity to treat. The acknowledged restriction of ED medication data to selected electronic-record sites is therefore not the central issue. Even complete medication capture would not show whether epinephrine was indicated at that point in the care pathway. The reported 41.9% ED administration rate could include undertreatment of ongoing anaphylaxis, but also patients who received epinephrine before arrival and had a prompt, durable response, or encounters coded as anaphylaxis without sufficient clinical detail to reconstruct the treatment decision. Importantly, location-specific rates can support opposite interpretations. Low ED use may reflect either missed treatment or successful prehospital care; high ED use may reflect either appropriate ED recognition or delayed treatment before arrival.