Intervention improves referral rates for penicillin allergy delabeling in pediatric clinic
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Key takeaways:
- The intervention involved multiple cycles of plan, do, study and act, as well as a dashboard and daily emails.
- Percentages of patients with allergy appointments rose from 9% to 27%.
WASHINGTON — An intervention increased the number of patients with a penicillin allergy label who were referred to an allergist, according to a poster presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.
The prevalence of penicillin allergy labels also fell, Renée J. Crawford, DO, chief resident, department of pediatrics, Phoenix Children’s Hospital, and colleagues wrote.
Need for delabeling
“We’re aware that 90% of those with a penicillin allergy label actually can tolerate the medication,” Crawford told Healio. “Unfortunately, they’re given antibiotics that actually aren’t the best for the different type of infection that they have.”
For example, these patients receive more vancomycin, fluoroquinolones and clindamycin, which the researchers characterized as less effective.
These patients also experience increased rates of MRSA, enterococcus that is vancomycin-resistant, Clostridioides difficile and surgical site infections, the researchers continued.
Inaccurate penicillin allergy labels also are associated with prolonged hospitalizations, increased readmission rates, and higher inpatient and outpatient costs.
The researchers further noted previous studies indicating additional costs of $609 per hospital admission with false labels and savings of $1,915 per patient per year when these allergies are delabeled.
The AAAAI, CDC and the Infectious Diseases Society of America all recommend referrals to allergists when patients have suspected drug allergies as well, the researchers continued.
“It’s very important that we do our due diligence to ensure that any allergy label they have is a true allergy label,” Crawford said.
In their study, Crawford and her colleagues aimed to determine the baseline penicillin allergy rate at their clinic, which treats general and complex care pediatric patients, between July 1, 2020, and June 30, 2021.
The researchers also set a goal of referring 30% or more of their patients with a penicillin allergy label to allergy specialists for confirmation by July 1, 2023, in addition to tracking the number of patients they delabeled.
Intervention, results
Before July 2021, 7% of the patients at the clinic had a penicillin allergy label.
“Only about 17.5% of those patients were being referred to allergists,” Crawford said.
Also, she said, only 9% of them had an appointment with an allergist within the following 24 months.
The staff implemented multiple cycles of plan, do, study and act — or PDSA — to train its residents and patient care medical group providers in referring these patients to the Phoenix Children’s Hospital allergy department for confirmation testing.
The researchers additionally stocked the clinic with amoxicillin so these providers could conduct same-day penicillin allergy challenges.
“In collaboration with our allergists, we created an algorithm that our clinicians can follow,” Crawford said.
The algorithm identifies patients with penicillin allergy labels who are at mild, moderate, high or severe risk for true allergy.
“Severe, moderate or high, we would always refer them to our allergy clinic,” Crawford said. “Mild? Then we could delabel them ourselves.”
In January 2023, the researchers collaborated with the facility’s chief data analysis officer to create a dashboard that included daily emails to the staff indicating which patients on the schedule had penicillin allergy labels.
“Then he’d send a monthly report of that dashboard to the division chief, and the division chief got to see who in her division was actually meeting those goals — and also to see who wasn’t,” Crawford said.
This information, which came up during division meetings too, created some friendly competition, Crawford said.
“An attending would go, ‘Wait, a resident saw that patient. That doesn’t count!’” she said. “So, they started getting on it and said, ‘Hey, you saw a patient with this allergy label. Did you address it?’”
The electronic health records were updated to include a section where providers could address penicillin allergy labels as well.
“Whether it’s a sick visit, whether they’re there for their well child check, it includes a section about the penicillin drug allergy label and, if it was addressed, whether the parent said no, they didn’t want to talk about it,” Crawford said. “It’s a better way of tracking.”
After the intervention, 52% of patients with a penicillin allergy label had been referred to an allergist, and 27% of them had an appointment within the next 24 months.
“When we place that referral, the parents get a text, and they set the appointment themselves,” Crawford said. “Sometimes they don’t do it. It’s not like you’re calling them to remind them to make those appointments, so we try to have them do it while we’re in the room.”
Crawford acknowledged that the 24-month timeframe is not ideal either.
“We really try to help and to work with them to be seen sooner,” she said.
Also, penicillin allergy prevalence fell to 4.4%.
“We clearly are meeting our goal, but we have a new goal of 70% referrals,” Crawford said. “I checked the median, and we’re hitting about 63% referrals as well.”
Communication also is part of the program.
“What the allergists do, which is great, is they give the family a certificate and a letter,” Crawford said. “They fax the letter to their PCP, to their pediatrician, and to the pharmacist that’s on file, as well as any other physicians they request.”
That way, all the patient’s relevant health care providers are aware that the allergy has been delabeled, she continued.
Next steps
Crawford called the program successful and expects its results to be sustainable.
“One of the great things is that this is now part of the culture of our gen peds complex care unit,” Crawford said.
Crawford and her colleagues want to expand the program into their facility’s hospitalist division, including surgery and other departments.
“The emergency department is interested,” she said. “They’re looking to implement this as well because they can also do those drug challenges or sensitizations while they have the patient.”
The improvements in antimicrobial stewardship are another benefit.
“This type of study is also what our infectious diseases colleagues want us to do,” Crawford said, “making sure that we are giving the proper antimicrobials for the different types of infections for the most common etiologies.”
Next, the researchers will continue to track the number of patients de-labeled through the program so they can assess its impact on care.