From the 2021 HVPAA National Conference
Alex Plattner (Washington University in St. Louis), Megan Daugherty, Alexandra Grier, Rebecca Same
Background
Up to 90% of patients with a documented penicillin allergy are not truly allergic to penicillins. These patients are less likely to receive first-line antibiotic regimens due to concern for a penicillin allergy or cephalosporin cross-reaction. Consequently, these patients have higher rates of nosocomial and surgical site infections, longer lengths of stay, and higher costs of care.
Objective
Primary: Evaluate 75% of pediatric patients with documented penicillin allergy admitted to a general medicine floor of St. Louis Children’s Hospital by June 30, 2021.
Secondary: Where appropriate, remove inappropriately documented penicillin allergies through history-taking or by performing inpatient oral penicillin challenge.
Methods
A multidisciplinary team was formed consisting of residents, nurses, pharmacists, Hospitalists, Infectious Disease specialists, and Allergists. A patient/family advocate was included to help develop family-focused educational resources. Root cause analysis was conducted using a fishbone diagram to identify factors that lead to persistent documentation of false penicillin allergies. A key driver diagram was then used to assess how these factors affect the primary aim and potential interventions that could impact these factors. Using a pre-existing risk-stratification tool, an algorithm was developed to determine if patients with documented penicillin allergy were eligible for allergy removal, oral challenge, or referral to allergy clinical for outpatient evaluation. A general medicine floor was identified to conduct a pilot study and perform multiple PDSA cycles to refine the assessment process. Additional tools were developed for residents to navigate the process, including: an order set, note templates, and a checklist. Routine, bidirectional feedback was obtained through regularly scheduled email and in-person communications. Epic reports were created to both prospectively identify admitted patients and retrospectively audit charts to collect process, outcome, and balancing metrics.
Results
Baseline data showed an average of 10 admissions per month with documented penicillin allergy for this particular general medicine floor. Penicillin allergies were not proactively removed prior the start of this project. After completion of the 3rd PDSA cycle, a total of 51 patients were admitted with a documented penicillin allergy (~10 per month). Of these patients, 41% (21/51) were evaluated using the assessment tools, with a higher rate for more recent PDSA cycles. A total of 13 patients were referred to allergy clinic, none of whom have undergone evaluation, and 5 patients had documented allergy successfully removed while admitted. There were no delays in care or adverse reactions from challenges. In one case, a patient had a penicillin allergy re-entered into their chart following successful challenge, but was subsequently removed again.
Conclusions
The assessment and removal of inappropriately documented penicillin allergies among pediatric patients in the inpatient setting is both safe and effective. Although the sample size is small, the success of penicillin challenges in this project echoes the outcomes seen in the outpatient setting. A 4th PDSA cycle is currently underway to refine the algorithm to facilitate more inpatient challenges and to improve the process for allergy clinic referral.
Clinical Implications
Successful removal of inappropriately documented penicillin allergies can lead to reduced nosocomial infections, shorter hospital stays, and reduced cost of care. By increasing the rate of inpatient evaluations, patients can avoid problems associated with outpatient referrals, including long waits and high no-show rates.
