The antimicrobial stewardship program (ASP) is designed to help optimize antimicrobial use across the spectrum of inpatient and outpatient services. The penicillin challenge initiative falls under this umbrella. ASP provides advice in selecting the most appropriate antimicrobial agent, dose, and duration to achieve the best clinical outcome with the fewest possible side effects. Unaddressed penicillin allergies are a public health issue. 10% of US patients have a penicillin allergy label, and fewer than 1% have an actual allergy with clinical significance according to the CDC. Use of broader spectrum antibiotics may be less effective, leading to antibiotic resistance and increased incidence of c-diff. Adherence to using the best antimicrobial agents has tremendous individual and global health outcome implications. Penicillin category drugs are among the safest, most-effective, least- expensive antibiotics.

The objectives of our project were: 1) Describe the allergy response and how it is used to stratify risks. 2) Identify the process in which the best practice advisory (BPA) is flagged in Epic and the subsequent plan of care. 3)
Recognize the health care impacts of de-labeling penicillin allergic patients.
The penicillin challenge is a safe, cost-effective, timely process to improve a public health issue directly impacting patient outcomes and health care costs globally. Participation of infectious disease has served to reduce wait times for patients and families to get into allergy specialty offices. This serves to enhance the patient's experience. Since the beginning of our project, we have encountered some data retrieval pitfalls and process failures which we are actively working with our quality groups on. It has become evident that widespread standardized protocols are needed. Our networking has provided opportunities and benefits to capture more patients. We have only encountered mild reactions to date. As of May 2023, we have been able to de-label approximately 17% of the patients in which a BPA has been fired.

SMART aim: Increase the % of patients with appropriate PCN allergy labels who present to ID clinic from 0 to 10% by December 2022.

Measure name: penicillin allergy de-labeling

Measure type (outcome, process, balancing): outcome measure

Type (individual, practice): group/practice

Measure: numerator/denominator: # patients with PCN allergy label who present to ID clinic successfully de- labeled/# of patients with PCN allergy identified patients in ID clinic

How are results presented (e.g., run chart): Percentage of total patients successfully de-labelled

QI methodology (improvement model/PDSA, LEAN, etc.): PDSA

Describe tests of change or interventions: Improve screening prior to appointment scheduling/create provider tip sheet/create order set/improve follow-up communication and tracking/provide a narrative summary of the project results/create a nursing triage in-basket for scheduling/QI/IT meetings to establish process mapping and failure modes with interventions and improve Epic data reporting/transition to nurse-driven project focus with help of ID pharm D/expand to include penicillin allergic inpatient challenges and follow-up. Following an internal review to improve detection of penicillin allergy label, we started working on increasing local expertise with the project through nursing grand rounds, our annual provider update.

Michelle Craver BSN, RN, CCCTM

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