Background: Penicillin is the most commonly documented drug “allergy” on hospital admission. Patients with listed penicillin allergies have higher rates of treatment failures, antibiotic resistance, and average length of stay. This has downstream implications impacting healthcare utilization, infection prevalence, and cost. However, the majority of these reported allergies are inaccurate, and over 90% of these patients tolerate future use if formally evaluated.
Purpose: MedOne Healthcare Partners introduces a new model for inpatient penicillin allergy de-labeling using two comprehensive medical units—closed units with a rounding nurse and pharmacist to accompany the rounding hospitalist.
Description: This workflow begins with identification of penicillin allergy upon arrival to the unit, followed by delivery of an informational guide to the allergy and a visual cue attached to the patient’s door. During multidisciplinary rounds, a PEN-FAST score is calculated and discussed with the patient. Depending on the risk score, the patient is de-labeled based on history alone (PEN-FAST 0 or previous tolerance of penicillin), offered a single-dose amoxicillin challenge (PEN-FAST 1-2), or referred to Allergy/Immunology for outpatient skin testing (>2 but not anaphylactic IgE-mediated reaction). If de-labeled, the physician documents in the progress note, adds a comment to the allergy section, and deletes the allergy. Patients are provided a wallet-sized card stating the date of their de-labeling, in the event they have inaccurate or outdated penicillin allergy recorded in other health systems. Following completion, the rounding pharmacist documents an IVENT—the hospital’s tracking system for pharmacy interventions.During the first 3 months of data collection, 107 patient encounters were recorded. The most commonly reported reactions were “hives” and “rash” (40%), “not specified” (16%), and anaphylaxis (16%). Based on PEN-FAST score, 67 patients were eligible for amoxicillin oral challenge. 34 patients were offered, and 33 patients were deemed clinically unnecessary based on allergy interview or antibiotic history. Of the patient’s offered an amoxicillin challenge, 22 patients (65%) proved tolerance and were de-labeled. Over the study period, a total of 57 patients (53%) were de-labeled. Of the patients who were de-labeled, 35 were based on history alone (61%) and 22 were based on tolerance of an amoxicillin challenge (39%). 50 patients (47%) were not de-labeled, due to PEN-FAST ≥ 3 (56%), patient refusal (26%), or inability to completely assess the patient (18 %).
Conclusions: This quality improvement initiative showed the viability of inpatient penicillin allergy de-labeling, using a multidisciplinary rounding structure. Further study of this workflow could prove effective at lowering cost, reducing healthcare utilization, and improving patient outcomes.