Development of a Pipeline for Removing Allergy Labels in Patients Undergoing Hematopoietic Stem Cell Transplantation

Abstract

Penicillin allergy is reported by 10-20 % of patients, but when evaluated only 1-2% may have a true allergy. Patients undergoing HSCT have a high likelihood of requiring beta-lactam antibiotics due to increased infection risk, which can be limited by a penicillin allergy label. When a penicillin allergy is recorded, alternatives are needed including more-expensive, broader-spectrum antibiotics, with increases in drug-resistant bacteria, longer hospital stays, higher expenditures, and increases in nosocomial infections such as C. difficile colitis. This group of patients already has extensive pre-treatment testing, and would particularly benefit from allergy de-labeling. This study aimed to develop a self-sustaining, low-cost pipeline between a HSCT clinic and an allergy clinic to identify and successfully de-label low-risk patients who endorse an allergy to penicillin, amoxicillin, amoxicillin-clavulanate, piperacillin-tazobactam, or ampicillin before admission to the hospital. We developed a survey to triage allergy risk, identified key stakeholders in building the pipeline, and underwent four plan, do, study, act (PDSA) cycles. Changes were made in each of the PDSA cycles to minimize cost and uncompensated provider time as well as increase patient retention throughout the pipeline by increasing appointment availability and decreasing reliance on patients to independently progress through the pathway. Of the 410 patients with planned HSCT who were screened over 11 months, we found that 89 (21.7%) patients were listed as having penicillin and/or beta lactam allergy. 98.5% (n=66/67) of participants completed the survey accurately when confirmed by an allergist, and the survey was 100% accurate in predicting de-labeling success in low-risk patients. Of eligible patients, 43.8% (n=39) were successfully de-labeled before their transplant date and 97.4% (n=38) have undergone HSCT to date. This pipeline is maintained by approximately 5 hours of work per week (1 hour of allergy physician time, 4 hours of nurse and/or clinical coordinator time) and no other direct costs. There is an estimated direct savings of at least $1,914.93 per patient de-labeled. We successfully designed and implemented a pipeline between the HSCT clinic and the allergy clinic as a quality improvement initiative to identify and address high rates of reported beta-lactam allergies. We identified and addressed patient-based factors, logistical, temporal, and financial barriers that impacted patient retention and sustainability. This model is expected to have significant and sustained cost-savings for the healthcare system as well as improve patient outcomes, and this hypothesis is currently undergoing formal analysis. We anticipate that this model can be used to create a similar pipeline in other healthcare systems for HSCT patients as well as other clinical settings such as oncology and CAR-T therapy.