1. Approach to Perioperative Antibiotic Treatment in
Penicillin Allergic Patients
Anesthesia Department QI Project
Raleigh Anderson MD Jennifer Hong MD MBA
Kristin Barney DO Kenton Howard MD
Diana Heringer MD Corey Tingey DO
Advisors:
Pierre Moine MD
Angela Selzer MD
Colby Simmons DO MBA
Bunch of losers

2. Background for QI Project
“Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.”
The Patient Safety First Campaign recognizes five clinical interventions to improve patient care: 1) through leadership for safety, 2) reducing harm in perioperative care, 3) reducing harm from high risk medications, 4) reducing harm from deterioration, and 5) reducing harm in critical care

3. Epidemiology Prevalence of PCN allergy: 5 - 10%, reports up to 8 - 25%
Confirmed PCN allergy is < 5% of reports
Clinical Infectious Diseases 2016; 63(7):911-3
J Allergy Clin Immunol 2012;130(6):1442.e1-5.
Annals of Allergy, Asthma, and Immunology 2010;105:273e1-78.
UCHealth Antibiotic Stewardship Committee 2018

4. Consequences of PCN allergy label
Penicillin allergies are associated with:
Increased mortality and ICU stays (single-center study)
Prolonged length of stay (0.59 days longer = $64.6 mil), increased rate of CDI, developed multi-drug resistance (retrospective cohort study of 51,582)
Increased multi-organism infections, higher rates of septicemia (retrospective cohort study of 100k+)
MacFadden et al. “Impact of Reported Beta-Lactam Allergy on Inpatient outcomes: A multicenter prospective cohort study.” Clinical Infectious Disease 2016;63(7):904-10
Solensky. “A Novel approach to improving antibiotic selection in patients reporting penicillin allergy.” Ann Allergy Asthma Immunol 2015;115:257-9
Clinical Infectious Diseases 2016; 63(7):911-3
Ann Allergy Asthma Immunol 2015;115:257-9
Sousa-Pinto B et al. Annals of Allergy, Asthma, Immun. 2018;120(2):190-4

5. PLAN DO
STUDY
ACT 1

6. Data from 2017 Interventions for Ortho Reconstructive Surgery
PLAN DO
STUDY
ACT
Data from 2017 Interventions for
Ortho Reconstructive Surgery 1

7. Data from 2017 Interventions for Ortho Reconstructive Surgery
PLAN DO
STUDY
ACT
Data from 2017 Interventions for
Ortho Reconstructive Surgery 1

8. Data from 2017 Interventions for Ortho Reconstructive Surgery
PLAN DO
STUDY
ACT
Data from 2017 Interventions for
Ortho Reconstructive Surgery 1
Last year was implemented an education with the following results.

9. PLAN DO
STUDY
ACT
GOALS for 2018 PDSA Cycle 2
Improve the classification PCN allergies on medical records
Understand provider prescribing habits for PCN allergic patients
Educate patients/providers on antibiotic prescribing for PCN allergic patients
Offer allergy testing for PCN allergic patients
Reinforce protocol for choosing appropriate antibiotics

10. To Date... 2 The project has been implemented:
PLAN DO
STUDY
ACT
To Date... 2
The project has been implemented:
Ortho Reconstructive Surgery
Project expansion for this year:
Ortho Sport Surgery
Ortho Spine
Neuro Spine
Education has been provided to:
Anesthesiology Department
Ortho Residents
Education expansion/reinforcement to:
Perioperative Nursing Staff
Ortho Advanced Practice Providers
Perioperative Testing

11. Qualitative Feedback 2 Apprehension for placing order
PLAN DO
STUDY
ACT
Qualitative Feedback 2
Apprehension for placing order
PA or NP does not physically see and ask patient of allergy and associated reaction
Unaware of algorithm and antibiotic initiative
Habitual ordering of antibiotics per attending preference or prior practices
Ortho residents and APPs are aware of initiative
EPIC order set reminder not implemented
Excitement around optimizing reported allergies on EPIC
Completely supportive and asking patients more specific questions

12. Preoperative Clinic PlansDO
STUDY
ACT
Preoperative Clinic Plans 2
Partnership with Department of Allergy and Immunology
Patients seen in Preprocedure Services Clinic (PPS) with a listed PCN allergy are referred for allergy testing prior to surgery
In allergy clinic, patients have two skin tests followed by two oral challenges and a daily home challenge for three days
Appointment takes approximately four hours
Allergy pharmacy needs at least 24 hours to prepare medications
Prelim results:
All referred patients have had the PCN allergy
removed from chart prior to surgery

13. Preoperative Clinic PlansDO
STUDY
ACT
Preoperative Clinic Plans 2
PROS:
Removing PCN allergy from EMR improves medical accuracy
Variability of practitioner response to a PCN allergy is no longer a factor in choice of antibiotic
Increased likelihood an appropriate cephalosporin is administered
Better SSI coverage, reduced C-Diff infection, reduction in hospital costs
Most patients prefer to have more accurate information about their health and allergies
CONS:
Requires 24 hour notice for pharmacy to prepare medications
Preop Clinic appointments < 5 days prior to surgery do not allow adequate time for PCN testing
Thorough testing takes a long time and patients may not be able to complete prior to surgery
Requires insurance approval
Some patients consider this an “unnecessary” additional medical appointment

14. Waiting on 12 month data… up to March 2018
PLAN DO
STUDY
ACT
Waiting on 12 month data… up to March 2018 2

15. Changing Practice Habits: Strategies for the Future
PLAN DO
STUDY
ACT
Changing Practice Habits:
Strategies for the Future 2
Active forms of continuing education
Internet based CME, online teaching modules
77% of papers reviewed showed improved or maintained physician performance
Multifaceted activities
Reminders, patient-mediated interventions, outreach visits, use of opinion leaders
70% of papers reviewed showed improvement
2 reviews found monetary incentives to significantly improve clinical practice
Formal didactic conferences and passive forms of CME (brochures and printed educational materials) were found to be the least effective
“Changing Physician Behavior: What works?” The American Journal of Managed Care. Jan 2015
Nobody likes you

16. PLAN DO
STUDY
ACT
Continued Efforts 2
Educate surgeons to refer patients with listed PCN allergy for preoperative testing at time of OR booking
Identify prescribing behaviors to the level of the individual and provide constructive feedback (labor intensive!)
Establish PCN allergy testing program within our Preoperative Clinic

17. Questions?