Record and Application to Allergy Triage for Inpatient Penicillin - - PDF document

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Record and Application to Allergy Triage for Inpatient Penicillin - - PDF document

Sep 17, 2022 122 likes •250 views

1/12/2019 Retrospective Review of Penicillin Allergy Documentation within an Electronic Medical Record and Application to Allergy Triage for Inpatient Penicillin Allergy Testing Hannah D. Fjeld, PharmD Candidate 1 ; Ryan W. Stevens, PharmD,

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SLIDE 1

1/12/2019 1

Retrospective Review of Penicillin Allergy Documentation within an Electronic Medical Record and Application to Allergy Triage for Inpatient Penicillin Allergy Testing

Hannah D. Fjeld, PharmD Candidate1; Ryan W. Stevens, PharmD, BCIDP, BCPS2

1University of Alaska/Idaho State University College of Pharmacy; 2Providence Alaska Medical Center

Disclosures

Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

  • Hannah D. Fjeld: Nothing to disclose
  • Ryan W. Stevens: Nothing to disclose
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1/12/2019 2

  • Penicillin (PCN) allergies are the most common self-reported allergy.
  • Estimated population prevalence of 10%.1
  • ~10% of reported penicillin allergies represent an IgE mediated process
  • Impact of PCN allergy listed in patient medical record
  • Cephalosporins are often withheld given concerns of a 3-5% risk of cross

reactivity.2

  • Associated avoidance of beta-lactam antibiotics has been associated with

adverse clinical outcomes, antibiotic resistance and higher cost of care.2

  • Penicillin skin testing (PST) is endorsed by the American Academy of

Allergy Asthma and Immunology to be utilized for pts with self- reported PCN allergies.3

Background

  • 1. Evaluate the number of pts who may be appropriate for inclusion in

a PST protocol using comprehensive eMR review.

  • 2. Evaluate the utility of the current eMR allergy documentation when

used alone vs full eMR review to identify potential candidates for PST.

Objective

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1/12/2019 3

Inclusion Criteria:

  • Documented PCN allergy
  • Inpatient admission at index facility between 9/15/2016 and 9/14/2017
  • Receipt of any antibiotic as an inpatient during above admission

Exclusion Criteria:

  • Documented allergy to multiple beta-lactam classes (i.e. PCN and

cephalosporin) 652 pts included for final review

Methods

Current eMR Allergy Record Documentation Layout

  • Reaction Options
  • Anaphylaxis
  • Hives
  • Shortness of Breath
  • Swelling
  • Rash
  • Nausea and Vomiting
  • Nausea Only
  • Diarrhea
  • Itching
  • Sensitivity
  • Other (See

Comments)

  • Unknown
  • {Blank}
  • Severity
  • High
  • Medium
  • Low
  • {Blank}
  • Open Text Comments
  • Common Comments
  • Notes about

previously tolerating cephalosporin/ penicillin – either patient reported or in patient exposure

  • Notes about when

the reaction occurred (e.g. as a child, in 1958, etc.)

  • Family history
  • Reaction Type
  • Allergy
  • Contraindication
  • Intolerance
  • Unspecified
  • {Blank}
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1/12/2019 4

  • Reaction Options
  • Anaphylaxis
  • Hives
  • Shortness of Breath
  • Swelling
  • Rash
  • Nausea and Vomiting
  • Nausea Only
  • Diarrhea
  • Itching
  • Sensitivity
  • Other (See

Comments)

  • Unknown
  • {Blank}

IgE Mediated Non-IgE Mediated Intolerance Adverse Reaction Triaged Investigator Assigned Reaction Classification Unknown

Objective 1 Evaluate the number of pts who may be appropriate for inclusion in a PST protocol using comprehensive eMR review.

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283 pts 43% 166 pts 26% 38 pts 6% 28 pts 4% 10 pts 2% 127 pts 19%

Give Cephalosporin 76 patients

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1/12/2019 6

76 patients Give Cephalosporin

652 pts

  • 76 Give Ceph

576 remaining Yes No IgE Mediated 100 pts (35%) 183 pts (65%) Non-IgE Mediated 59 pts (46%) 68 pts (54%) Unknown 83 pts (50%) 83 pts (50%) Give Cephalosporin 242 pts

Has pt previously tolerated a cephalosporin and/or PCN within eMR?

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1/12/2019 7

652 pts

  • 76 Give Ceph
  • 242 Give Ceph
  • 183 PST

151 remaining

242 patients Give Cephalosporin 183 pts PST

Unknown High Medium Low Non-IgE Mediated 2 pts 8 pts 6 pts 52 pts Unknown 76 pts 2 pts 3 pts 2 pts Total PST 88 pts Give Cephalosporin 63 pts

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1/12/2019 8

652 pts

  • 76 Give Ceph
  • 242 Give Ceph
  • 183 PST
  • 88 PST
  • 63 Give Ceph

0 remaining

88 pts PST 63 pts Give Cephalosporin

41.6% (n=271) of pts evaluated by full eMR review met inclusion criteria for PST. Of 652 Patients:

  • 381 Give Cephalosporin
  • 271 PST

Evaluation From Full eMR Review

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Objective 2 Evaluate the utility of the current eMR allergy documentation when used alone vs full eMR review to identify potential candidates for PST.

76 patients Give Cephalosporin 242 patients Give Cephalosporin 183 pts PST 88 pts PST 63 pts Give Cephalosporin

Evaluation From Full eMR Review Evaluation Utilizing Allergy Record Alone 652 pts 652 pts 652 pts

  • 76 Give Ceph

576 remaining 652 pts

  • 76 Give Ceph

576 remaining 652 pts

  • 76 Give Ceph
  • 242 Give Ceph
  • 183 PST

151 remaining

69 patients Give Cephalosporin

652 pts

  • 76 Give Ceph
  • 69 Give Ceph

507 remaining 652 pts

  • 76 Give Ceph
  • 242 Give Ceph
  • 183 PST
  • 88 PST
  • 63 Give Ceph

0 remaining

247 pts PST

652 pts

  • 76 Give Ceph
  • 69 Give Ceph
  • 247 PST

260 remaining 652 pts

  • 76 Give Ceph
  • 69 Give Ceph
  • 247 PST
  • 145 PST
  • 115 Give Ceph

0 remaining

115 pts Give Cephalosporin 145 pts PST

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SLIDE 10

1/12/2019 10 32.1% (n=126) of the pts identified as candidates for PST using allergy record alone had no reaction, reaction severity or comments to assess allergy.

Evaluation From Full eMR Review Evaluation Utilizing Allergy Record Alone

41.6% (n=271) meet inclusion criteria for PST. 60.1% (n=392) meet inclusion criteria for PST.

vs

Results

  • Utility of the eMR allergy record to identify potential candidates for PST:
  • Does not appear to facilitate quick and/or accurate assessment of pts

appropriateness for PST

  • Significant number of pts with allergies documented without an associated reaction
  • r reaction severity
  • Further optimization of the eMR’s allergy documentation is needed
  • Recommendations for optimization:
  • Require “hard stops” for allergy reaction
  • Link reaction to associated severity and classification
  • Provide instructions within the record for obtaining comprehensive allergy history

and definitions of reactions

  • Include options for previously tolerated beta-lactams

Conclusions

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1/12/2019 11

  • 1. Chen JR, Tarver SA, Alvarez KS, Tran T, Khan DA. A proactive approach to

penicillin allergy testing in hospitalized patients. J Allergy Clin Immunol Pract. 2017 May - Jun;5(3):686-693.

  • 2. Romano A, Valluzzi RL, Caruso C, Maggioletti M, Quaratino D, Gaeta F.

Cross-reactivity and tolerability of cephalosporins in patients with IgE- mediated hypersensitivity to penicillins. J Allergy Clin Immunol Pract. 2018 Sep - Oct;6(5):1662-1672.

  • 3. Penicillin allergy in antibiotic resistance workgroup. Penicillin allergy

testing should be performed routinely in patients with self-reported penicillin allergy. J Allergy Clin Immunol Pract. 2017 Mar - Apr;5(2):333-334.

References

Questions?

Contact Information: fjelhann@isu.edu