Improving the Accuracy of Penicillin Allergy Labels Among Pediatric Inpatients

Purpose/Objectives: Maintaining an active, accurate drug allergy list is imperative to patient care. This is particularly relevant in the inpatient setting where medications, specifically antibiotics, may need to be acutely administered. Documentation of allergies in the electronic health record (EHR) is often incomplete with unclear information which can make appropriate antibiotic choice challenging. The penicillin allergy label, frequently reported, is often applied in childhood and remains in the EHR unquestioned and inadequately documented well into adulthood. Mislabeled penicillin allergies can contribute to unnecessary avoidance of first line antibiotics and exposure to broad-spectrum antibiotics with more side effects. Our global aim of this initiative was to improve the completeness and accuracy of penicillin allergy labels in pediatric inpatients.

SMART aims: To improve the accuracy of penicillin allergy labels upon admission, our objectives are to achieve 2 smart aims: (1) increase the rate of complete documentation of penicillin allergy labels from 20% to 70% and (2) increase in the rate of penicillin allergies delabeled from 1% to 20%. Completeness of the allergy label is defined as having a documented reaction, reaction type, and severity in the EHR.

Design/Methods: Baseline data was collected from pediatric inpatients 0-18 years old with a documented penicillin allergy January 2020 to December 2020 at a tertiary academic medical center.
In August 2020, we formed an interdisciplinary team of stakeholders including representatives from the departments of pharmacy, performance services, hospital medicine, allergy, and infectious disease. Interventions began in January 2021 with pediatric resident education followed by the addition of an allergy review prompt in the admission History & Physical. We then implemented a clinical pathway for penicillin allergy risk stratification and operationalized the allergy reconciliation process expanding education to pharmacy, nursing, hospitalist attendings, and hospital leadership.

Results: Within the first 6 months following the start of interventions, the percentage of patients who had completely documented penicillin allergy increased from a baseline mean of 20% (23/116) to 33% (20/61). The percentage of patients whose penicillin allergy was delabeled increased from a baseline of 1% (2/137) to 3% (3/87). Our balancing measure, the number of adverse drug reactions involving penicillin occurring on the inpatient unit, has remained at zero reflecting no change during this period.

Conclusion/Discussion: Using QI methodology and implementation of a clinical pathway, we have increased completeness of penicillin allergy documentation and delabeling of inaccurate allergies for patients admitted to general pediatric services. Our measures will be tracked over time to ensure continued improvement with further efforts focused on optimization of EHR prompts, tracking the use of the clinical pathway as a process measure, and expanding to patients admitted on other services.