Allergy Documentation Research Articles

P-1757. Standardizing the Penicillin Allergy Documentation Program and Optimizing the Use of Beta Lactam Antibiotics In a Tertiary Care Hospital

Abstract Background The adoption of standardized penicillin allergy assessment protocols and the optimization of beta-lactam antibiotic usage have been advocated by international guidelines on Antibiotic Stewardship Programs (ASPs). However, the precise effects of conducting these assessments on allergy documentation and antibiotic prescription practices remain inadequately characterized. Methods A retrospective quasi-experimental study was devised to assess the repercussions of implementing a standardized penicillin allergy assessment initiative led by the Antimicrobial Stewardship Team, comprising Infectious Disease (ID) Physicians, clinical pharmacists, and nurses. Commencing January 2022, nursing personnel conducted comprehensive evaluations of hospitalized patients with documented penicillin allergies, with subsequent review by clinical pharmacists. The pre-intervention phase encompassed randomly selected adult patients with reported penicillin allergies admitted between January 2019 and December 2021. The principal study endpoint was the accurate delineation of penicillin allergies in the electronic health record (EHR), encompassing clarification of allergic reactions and removal of erroneously labelled allergies. Secondary endpoint was beta-lactam antibiotic utilization within 90 days of hospitalization. Results A total of 360 patients were enrolled, comprising 140 during the intervention phase and 220 during the pre-intervention phase. The proportion of patients with updated allergy information surged from 22% to 53% post-implementation of the program (P < 0.0001), with inappropriate allergy designations rectified in 18 (5%) patients. Notably, the program's implementation did not alter the proportion of patients receiving beta-lactam antibiotics (22% vs. 25%; P = 0.51). Conclusion The adoption of a standardized penicillin allergy assessment initiative exerted a significant influence on allergy documentation within the EHR, without imposing excessive burdens on clinical team. This initiative facilitated the updating of allergy information for the majority of patients and rectified inaccurately labelled penicillin allergies. Disclosures All Authors: No reported disclosures

Incomplete documentation of β-lactam allergy in long-term care facility residents increases risk of high-risk antibiotic use for Clostridioides difficile infection.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

AAAAI Position Statement on Changing Electronic Health Record Allergy Documentation to “Alerts” to Lead to Easily Understood, Actionable Labels

The term "allergy" is inaccurate for the vast majority of the contents in the current allergy fields of electronic health records (EHRs). While EHRs have transformed access to health information and streamlined the delivery of care, their ability to reliably indicate medications, vaccines, or foods that mandate avoidance versus preferences or mild intolerances, is suboptimal. The current systems are reactive instead of being proactive and frequently fail to communicate the appropriate course of action. This Position Statement of the American Academy of Allergy, Asthma and Immunology (AAAAI) advocates for a change in terminology. The section of the EHR currently labeled "allergies" should be renamed "alerts." The term "alert" accurately captures the purpose of this section without incorrectly assigning an allergic mechanism, and prioritizes easily understood and actionable labels. This change has the potential to simultaneously improve patient safety and care. This shift will be the first step in the transformation of the alerts section of the EHR. This document provides a framework for categorizing what should be included in this section. Enacting these changes will require EHR and clinical decision support vendors, healthcare and data standard regulators, allergists, and the larger health care community to work together to bring about these important advances.

Multifaceted implementation strategy to improve the evaluation of penicillin allergies in perioperative patients: a pre-post feasibility implementation study.

The U.S. Centers for Disease Control and Prevention encourages nurses to evaluate penicillin allergies as part of hospital-based antibiotic stewardship programs. We evaluated the feasibility of an implementation strategy to improve nurses' comprehensive documentation of penicillin allergies. We defined feasibility as the uptake and acceptability of documentation procedures. Six-month pre-post feasibility implementation study. Outpatient surgical areas of an academic medical center located in the U.S. The implementation strategy was guided by the Capability, Opportunity, Motivation Model for Behavior Change and included, building an interdisciplinary coalition to iteratively evaluate the implementation effort, educational meetings with surgical prescribers and perioperative nurses, the development and distribution of educational pocket cards, and structured communication messages in the electronic medical record. A total of 426 patients with 487 penicillin allergy records (216 records pre-implementation period, 271 records post-implementation period) were analyzed. Penicillin allergy documentation contained the following information in the pre- versus post-implementation period: symptoms of the reaction (87% vs 87%), timing/years since reaction (8% vs 26%), onset of reaction in relation to taking penicillin (0% vs 21%), how symptoms resolved (0% vs 21%), and penicillin re-exposure (3% vs 21%). Focus groups revealed nurses perceived documentation procedures as highly acceptable. Major drivers of acceptability included the perceived effectiveness of a detailed allergy history and self-efficacy in conducting a detailed allergy history. Nurses perceived the comprehensive documentation of penicillin allergy history intervention as acceptable, and uptake improved following a theory-informed implementation strategy. We offer implementation strategy components to facilitate nurses' engagement in penicillin allergy evaluation.

Optimizing preoperative antibiotic use through improved penicillin allergy documentation.

Penicillin allergy documentation in the electronic health record (EHR) lacks detail with regard to type of reaction, history of reaction, and other tolerated β-lactams. Because of concern for penicillin allergy cross-reactivity with cefazolin, patients with a reported penicillin allergy are frequently prescribed suboptimal preoperative antibiotics, which have been associated with negative patient outcomes, including increased risk of surgical site infection. The purpose of this study was to increase preoperative use of cefazolin via improvement to the documentation of penicillin allergies in the EHR. This single-center, quasi-experimental quality improvement study compared patients with a self-reported penicillin allergy admitted for select elective surgeries before and after implementation of a penicillin allergy questionnaire. The primary outcome was receipt of cefazolin for surgical prophylaxis. Secondary outcomes were the proportion of patients with detailed penicillin allergy documentation, the proportion of patients with surgical site infections occurring within 30 days of surgery, and the proportion of patients who received the full antibiotic dose before the first surgical incision. A total of 100 patients were included in the preintervention group, while 85 patients were included in the postintervention group. Cefazolin use was higher in the postintervention group (13.0% vs 41.2%; P < 0.001). The postintervention group also had a larger proportion of patients with detailed allergy documentation (2.0% vs 50.6%; P < 0.001) and who received the full preoperative antibiotic dose before the first incision (25.0% vs 48.2%; P = 0.001). There was no statistical difference between the groups in the incidence of surgical site infection at 30 days after surgery (3.0% vs 1.2%; P = 0.63). Preoperative cefazolin use was higher in patients with a reported penicillin allergy after implementation of a penicillin allergy questionnaire and EHR documentation tool.

Multifaceted Implementation Strategy to Improve the Comprehensive Assessment of Penicillin Allergies in Perioperative Patient

Background: The CDC recommends that nurses improve the evaluation of penicillin allergies as part of antimicrobial stewardship programs. We evaluated the feasibility of a multifaceted implementation strategy to improve nurses’ documentation of penicillin allergy histories and to encourage nurses to notify prescribers of patients with low-risk symptoms of reported penicillin allergy. The implementation strategy was guided by the COM-B model of behavior change and addressed nurses’ capability, opportunity, and motivation to implement practices (Figure 1). The implementation strategy included education on the STORY mnemonic that details the questions of a penicillin allergy history, education on low-risk symptoms of penicillin allergy, dot phrases in EPIC to facilitate nurses’ documentation of STORY and communication of patients with low-risk penicillin allergy symptoms, and educational pocket cards and flyers. We define feasibility as the implementation and acceptability of practices. Methods: This was a six-month feasibility study conducted in an outpatient perioperative area. We compared penicillin allergy documentation pre- and post- implementation strategy and report on nurses’ notification of prescribers regarding patients with low-risk penicillin allergies in the post-implementation period. We engaged nurses in a focus group to assess factors that facilitated or hindered practice adoption. Results: A total of 426 unique patients with 482 penicillin allergy records were included in our study (n= 207 records pre-implementation, n = 275 records post-implementation). We found little to no change in the percentage of records that included symptom information post vs. pre-implementation (88.36% vs 88.41%). A greater percentage of allergy records in the post vs. pre-implementation periods included information on: timing/years since reaction (25.6% vs. 8.2%), onset of reaction (20.7% vs. 0%), resolution of symptoms (20.4% vs. 0%), and penicillin re-exposure (21.1% vs. 2.4%). There were 24 documented instances of nurses’ notifying prescribers of patients with a low-risk penicillin allergy. Focus group data revealed nurses perceived their comprehensive documentation of penicillin allergies highly acceptable and likely to improve patient care and outcomes. Whereas nurses’ notification of prescribers concerning patients meeting low-risk penicillin allergy criteria had little appeal. Nurses described the STORY mnemonic, pocket cards describing the penicillin allergy assessment mnemonic, and the associated dot phrase in EPIC as particularly helpful. Conclusions: A multifaceted implementation strategy showed promise in improving the comprehensive documentation of penicillin allergy histories. Future studies are needed to determine the efficacy of the multifaceted implementation strategy on penicillin allergy documentation, the selection of antibiotic prophylactic treatment, and clinical outcomes among surgical patients.

Redefining the Nurses’ Role in Antimicrobial Stewardship Practices

Antimicrobial stewardship program aims to optimize the use of antimicrobials. Through the present narrative review, we sought to identify the nurse’s role in antimicrobial stewardship (AMS) practices at various healthcare facilities around the globe. Infection control, microbiology culture, intravenous (IV) to oral switch, antimicrobial de-escalation, documentation of allergy, questioning the prescription, and education were the few roles of nurses in AMS practices that emerged from documented literature published in the last ten years. The present review also showcased the best available guidelines on the prompt switch from IV to oral antibiotics, nurses’ AMS checklist based on the model, and Key factors to enhance the involvement of nurses in AMS practices.

Antibiotic allergy prevalence and documentation quality in Massachusetts long-term care facilities: A cross-sectional survey

BackgroundAntimicrobial resistance poses a significant global health challenge, particularly affecting older adults who are more susceptible to infections and their complications. Accurate diagnosis and documentation of antibiotic allergies are essential for effective antimicrobial stewardship. Despite the recognized overdiagnosis of antibiotic allergies, comprehensive studies on this subject in long-term care (LTC) settings are limited. ObjectiveTo determine the point prevalence of antibiotic allergies and documentation quality in Massachusetts LTC facilities. MethodsWe conducted a cross-sectional, 1-day point prevalence survey from July 1, 2023, to March 31, 2024, across 20 participating LTC facilities in Massachusetts in partnership with the Massachusetts Department of Public Health. The survey assessed the prevalence and documentation of antibiotic allergies among 2345 residents. Multivariable logistic regression was used to explore associations between documented penicillin allergy and demographic factors, including non-penicillin antibiotic allergies. ResultsThe overall point prevalence of documented antibiotic allergies was 39.1%, with the most frequently reported classes being penicillins at 23.1%, sulfonamides at 15.4%, and cephalosporins at 5.2%. Significant documentation gaps were identified, with up to 92.8% of the allergy records found to be incomplete. Factors associated with documented penicillin allergies included female sex (adjusted odds ratio [aOR], 1.50; 95% CI, 1.16-1.94), White race (aOR, 1.92; 95% CI, 1.25-2.94), having allergies to non-penicillin antibiotics (aOR, 2.89; 95% CI, 2.33-3.59), and receipt of antibiotic (aOR, 2.13; 95% CI, 1.68-2.71). ConclusionThe high prevalence of documented antibiotic allergies and the notable deficiencies in their documentation underscore the urgent need for enhanced antibiotic evaluation, documentation practices, and penicillin delabeling in LTC facilities.

HSD44 Association of Penicillin Allergy Documentation and First-Line Penicillin Prescribing for Common Infections in Primary Healthcare Facilities in Beijing

HSD44 Association of Penicillin Allergy Documentation and First-Line Penicillin Prescribing for Common Infections in Primary Healthcare Facilities in Beijing

Long-Term Outcomes Associated With β-Lactam Allergies

β-lactam (BL) allergies are the most common drug allergy worldwide, but most are reported in error. BL allergies are also well-established risk factors for adverse drug events and antibiotic-resistant infections during inpatient health care encounters, but the understanding of the long-term outcomes of patients with BL allergies remains limited. To evaluate the long-term clinical outcomes of patients with BL allergies. This longitudinal retrospective cohort study was conducted at a single regional health care system in western Pennsylvania. Electronic health records were analyzed for patients who had an index encounter with a diagnosis of sepsis, pneumonia, or urinary tract infection between 2007 and 2008. Patients were followed-up until death or the end of 2018. Data analysis was performed from January 2022 to January 2024. The presence of any BL class antibiotic in the allergy section of a patient's electronic health record, evaluated at the earliest occurring observed health care encounter. The primary outcome was all-cause mortality, derived from the Social Security Death Index. Secondary outcomes were defined using laboratory and microbiology results and included infection with methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or vancomycin-resistant Enterococcus (VRE) and severity and occurrence of acute kidney injury (AKI). Generalized estimating equations with a patient-level panel variable and time exposure offset were used to evaluate the odds of occurrence of each outcome between allergy groups. A total of 20 092 patients (mean [SD] age, 62.9 [19.7] years; 12 231 female [60.9%]), of whom 4211 (21.0%) had BL documented allergy and 15 881 (79.0%) did not, met the inclusion criteria. A total of 3513 patients (17.5%) were Black, 15 358 (76.4%) were White, and 1221 (6.0%) were another race. Using generalized estimating equations, documented BL allergies were not significantly associated with the odds of mortality (odds ratio [OR], 1.02; 95% CI, 0.96-1.09). BL allergies were associated with increased odds of MRSA infection (OR, 1.44; 95% CI, 1.36-1.53), VRE infection (OR, 1.18; 95% CI, 1.05-1.32), and the pooled rate of the 3 evaluated antibiotic-resistant infections (OR, 1.33; 95% CI, 1.30-1.36) but were not associated with C difficile infection (OR, 1.04; 95% CI, 0.94-1.16), stage 2 and 3 AKI (OR, 1.02; 95% CI, 0.96-1.10), or stage 3 AKI (OR, 1.06; 95% CI, 0.98-1.14). Documented BL allergies were not associated with the long-term odds of mortality but were associated with antibiotic-resistant infections. Health systems should emphasize accurate allergy documentation and reduce unnecessary BL avoidance.

Beta-lactam allergy risk stratification in a maternity population in Australia: Scope for allergy de-labelling.

Unconfirmed beta-lactam allergy in pregnant people has been associated with higher morbidity, unnecessary exposure to broad-spectrum antibiotics and prolonged hospitalisation. There are no published data on beta-lactam allergies in pregnant people in Australia. The aim was to describe patient-reported beta-lactam allergies and appropriateness for antibiotic allergy de-labelling in a maternity cohort in Australia. Maternity patients aged ≥18 years admitted to our institution between March 2021 and June 2021 with a beta-lactam allergy documented in their electronic medical record were interviewed for details of their allergy. The documented allergies were compared to the allergy history obtained from the interview. Severity of the allergy was rated, and appropriateness for allergy de-labelling was assessed using the Victorian Therapeutics Advisory Group beta-lactam antibiotic allergy assessment tool. One hundred and fifty-three beta-lactam allergies (182 reactions) were reported by 145 patients. Penicillin class antibiotics were the most frequently implicated, including unspecified penicillins (95/153, 62%), amoxicillin (19/153, 13%) and amoxicillin-clavulanate (8/153, 5%). Allergy documentation required amending in 52 of 145 patients (36%); 85 of 153 (56%) of the beta-lactam allergies were considered low risk and potentially appropriate for direct oral re-challenge. Beta-lactam allergies were inaccurately documented in more than one third of the maternity patients included in our study. As such, education of maternity care providers about the importance of accurate allergy history taking remains an urgent unmet need. Furthermore, allergy assessment and de-labelling during pregnancy should be considered in maternity patients to optimise antibiotic prescribing and to improve maternal and neonatal health outcomes.

Food Allergy Documentation Patterns in Children in the Era of Early Food Introduction

Food Allergy Documentation Patterns in Children in the Era of Early Food Introduction

Audit of ‘true’ penicillin allergies and their documentation in Milton Keynes University Hospital (MKUH)

Abstract Introduction 2.7 million people are estimated to have a penicillin allergy in United Kingdom but 90% of these people are not allergic.1 In reality, only 1 in 100 patients have a ‘true’ penicillin allergy.2 These patients end up receiving alternative, less effective broad-spectrum antibiotics. This leads to a higher risk of antibiotic resistance, prolonged hospital stays, and increased healthcare costs.3 The root of this issue lies in the confusion between an allergic reaction and side effects. Findings from this audit could be used to inspire substantial cost savings, reduction in unnecessary antibiotic use, improved patient outcomes, and proper antimicrobial stewardship. Aim To undertake an audit with the following criteria and standards, to establish the percentage of patients that have a ‘true’ penicillin allergy as well as checking the accuracy of documentation for penicillin allergies: At least 70% of penicillin-allergic patients will have the nature of allergy documented on the trust’s electronic prescribing (eCare) system; At least 90% of penicillin allergies that are documented on the eCare system will also be documented on the Summary Care Record (SCR) system; 100% of penicillin-allergic patients will not have had penicillin therapy during their current or most recent hospital stay; A penicillin allergy label will be justified by the nature of allergy in at least 90% of patients. Methods This study did not require ethics approval. Data was extracted from the eCare system, consisting of penicillin-allergic patients admitted between 25/1/2023-30/1/2023. Extracted data featured the nature of allergy, reaction status and class, and antibiotic prescribed. A pilot study was undertaken using a day’s worth of data (25/1/2023). The pilot study was successful; therefore, no adjustments were made to the data collection tool. Results 90 patients were included in the study. 63.3% (n=57) of patients had their nature of allergy documented on eCare system. 85.6% (n=77) of patients also had their penicillin allergy documented on SCR. Of the patients taking inpatient antibiotics (n=30), 93.3% (n=28) were not prescribed a penicillin during their hospital stay. 50% (n=45) of patients had a justified penicillin allergy based on the nature of allergy. Discussion/Conclusion None of the four objectives were achieved. This audit study proved that there are fewer patients with a ‘true’ penicillin allergy than expected. More improvement is needed for documenting the nature of allergy on the eCare system as well as justifying penicillin allergy based on the nature of allergy and other relevant factors. This can be actioned by giving training sessions to clinicians, teaching the importance of proper penicillin allergy documentation, creating a new hospital guideline to help deliver a penicillin allergy de-labelling service, and performing a re-audit after 6 months. One limitation of this study was not being able to speak to patients due to time and logistical constraints.

A review of the quality and completeness of the allergy status documented during the transfer of care

Abstract Introduction The implementation of NICE Clinical Guidance, Drug Allergy: Diagnosis and Management across all care settings is crucial to improve prescribing practices and ensure safer care throughout the NHS. This study is of great significance as incorrect allergy status leading to treatment delay and adverse drug reactions (ADRs) is a cause for hospital admission. Aim This study aimed to ascertain whether the allergy status of patients admitted to three community hospitals was consistent with NICE recommendations. Additionally, the study explored the advice and information provided to patients regarding their allergies. Methods The First Community research team and the Health Research Authority (HRA) online decision tool were used to determine if ethical approval was required. It was concluded that no approval was necessary. A retrospective analysis of the discharge summaries, GP summaries, and Drug Charts was conducted to determine consistency in allergy recording across the interface. Medical records of 61 patients admitted to three community hospitals were reviewed over three days in December 2022. Four patients with missing records or non-drug allergies were excluded. The information about allergy status was categorized using a data collection form based on NICE guidelines. 22 patients were administered a questionnaire to explore if they had a consultation regarding their allergy and if any written information was provided. All results were analysed using Microsoft Excel. Results The analysis covered 57 patient discharge summaries, GP summaries, and drug charts. The results indicated that 98.3% of patients had their allergy status documented. However, to comply fully with NICE guidance, all elements of allergy documentation must be recorded, which was not the case for any of the patients. The lowest compliance rate was for "the need to state the class of medicines" (0%). 86.4% (19) of the 22 patients who completed the questionnaire acknowledged that their doctor did not address their drug allergy with them at the time it occurred. 95.5% (21) of patients did not receive structured written information while 72.7% (16) of patients are not aware of the drug(s) or drug classes to avoid. Only 27.2% (5) of patients discussed the information offered with pertinent healthcare personnel, and none of the patients carried the information given with them. Discussion/Conclusion This study highlighted that NICE guidance is not always followed in its entirety during the transfer of care. The sample size is a limitation of this study; therefore, more research is needed in a community hospital environment with a larger sample size. Caterham Dene Community Hospital has responded to this study by changing its drug chart to include a distinct box for allergy, side effects, and intolerance. Prescribers must evaluate allergy lists and classify medications as either allergy, side effects, or intolerance upon admission. The study's results were shared in the Surrey Heartlands Newsletter to remind prescribers of the requirement to document allergy status accurately and encourage healthcare professionals to improve communication with patients about their allergies to minimize adverse drug reactions.

1182. Impact of Penicillin Allergy Focused Antimicrobial Stewardship Interventions on Antimicrobial Use and Allergy Documentation - Optimizing Allergy Prescribing Alerts and Pharmacy Allergy Assessments

Abstract Background The discrepancy between true prevalence and reported penicillin (PCN) allergies results in suboptimal antimicrobial use, which is associated with increased adverse drug reactions, antimicrobial resistance, increased hospital length of stay, and poor outcomes. Many patients with mild-moderate reactions tolerate other beta-lactams, but allergy records are often inaccurate or missing information. In 2021, our institution began suppressing prescriber-facing PCN allergy alerts when ordering cephalosporins for patients with mild-moderate PCN reactions. More recently, a pharmacist-driven allergy assessment via chart review +/- patient interview was piloted to clarify PCN allergy documentation. This quasi-experimental study evaluated the effect of PCN allergy interventions on antimicrobial use. Methods Days of broad-spectrum antimicrobials in patients with PCN allergies was compared between groups [pre-intervention (G1, n=100), post-alert suppression (G2, n=100), and allergy assessment (G3, n=50)]. Patients were excluded for cephalosporin allergy, MRSA or ESBL history, surgical prophylaxis or UTI indication, or antibiotics within 48 hours of mechanical ventilation. Groups were matched 2:2:1 based on length of stay and antibiotic indication. Additional outcomes included cephalosporin use, allergy clarifications, and time spent per allergy assessment. Results The most common antibiotic indications were pneumonia (54%) and intra-abdominal infection (28%). No differences were noted in median duration of broad-spectrum therapy (2 vs 1 vs 1 days, p=0.52) or cephalosporin therapy (1 vs 2 vs 3 days, p=0.39). However, more patients received cephalosporins as initial therapy post-alert suppression, G1 40 (40%) vs G2 57 (57%), p=0.02 vs G3 26 (52%). A pharmacist completed 50 allergy assessments (50 chart review with 19 interviews) and clarified 43 (86%) records to include previous beta-lactam tolerance. Average time of chart review and interview was 4 minutes each. Conclusion PCN allergy alert suppression significantly increased initial cephalosporin use and decreased broad-spectrum use. Pharmacist allergy assessment improved allergy documentation accuracy, but future study is required to assess the clinical impact on antimicrobial use. Disclosures All Authors: No reported disclosures

2191. An Assessment of Penicillin Allergy Documentation among Patients undergoing Elective Surgeries and Ambulatory Procedures

Abstract Background A documented allergy to a penicillin class antibiotic can have a significant impact on perioperative antibiotic prescribing and is associated with an increased risk of post-operative adverse events. Comprehensive penicillin allergy histories enable risk stratification to influence future antibiotic prescribing. We evaluated the documentation of penicillin allergies among patients undergoing elective surgeries and ambulatory procedures to identify opportunities to improve allergy assessments and documentation in these settings. Methods This was a retrospective chart review of unique records of patients who underwent elective surgeries and ambulatory procedures at UConn Health from December 2, 2022 – January 24, 2023, and had a documented allergy to a penicillin class antibiotic at the time of the surgery or procedure. Information on the documented details of the allergy, including type and timing of the reaction and who documented the allergy was recorded and analyzed. Results Among 233 unique records reviewed, most penicillin allergies were initially documented by a medical assistant (n=135, 58%), and not subsequently updated after initial documentation (n=211, 91%). Symptoms of allergy were documented for 177 (76%) of records, with the most common symptoms being hives/rash (n=106, 46%), gastrointestinal symptoms (n=27, 12%) and anaphylaxis (n=26, 11%). Symptoms of allergy were unknown or missing for 56 (24%) of records. In 5 (3%) of records, clinicians documented when the patient’s reaction occurred (childhood) and in 2 (1%) of records, clinicians indicated the patient tolerates cephalexin or amoxicillin. Conclusion Among patients undergoing elective surgeries and ambulatory procedures, we found medical assistants documented most penicillin allergy records. Penicillin allergy records were rarely updated and contained scant information for risk stratification. Efforts are needed to improve the documentation of penicillin allergies in outpatient pre-operative and pre-procedural settings. Disclosures All Authors: No reported disclosures

Impact of a Pharmacist-Conducted Preoperative Beta-Lactam Allergy Assessment on Perioperative Cefazolin Prescribing

Background: Cefazolin is guideline recommended for perioperative prophylaxis in orthopedic surgery. Despite its unique R1 side chain, cefazolin is often avoided in patients with beta-lactam allergy with concern for cross reactivity. Objectives: The primary outcome was the percentage of patients who received cefazolin perioperatively. Secondary outcomes included the percentage of patients with a beta-lactam allergy clarified following the telephone interview and clinical outcomes including acute kidney injury, surgical site infection, Clostridioides difficile infection, and re-admission at 30 and 90 days. Methods: This single-center, quasi-experimental study evaluated a pilot program in which a pharmacist phoned patients > 18 years of age with a scheduled orthopedic surgery and a documented beta-lactam allergy to assess their allergy preoperatively. Recommendations to use cefazolin were based on an algorithm. Patients were divided into pre- and post-intervention cohorts. Results: A total of 832 patients were screened for inclusion with 135 and 66 patients included in the pre- and post-intervention cohorts. No significant difference was identified in the primary outcome. In the post-intervention cohort, 62% had a beta-lactam reaction updated in the electronic medical record. Those with a beta-lactam allergy delabeled or made less severe were numerically more likely to receive cefazolin than those with an unchanged reaction or a reaction made more severe (95.2% vs 68% vs 65%). There were no differences in clinical outcomes between groups. Conclusion: A pharmacist-conducted preoperative beta-lactam allergy interview in adult patients undergoing elective orthopedic surgery improved beta-lactam allergy documentation but, did not result in increased utilization of cefazolin.

Implementation of 4T Score Documentation on PF4 Testing in Patients with Suspected Heparin-Induced Thrombocytopenia

Purpose: Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin therapy. Diagnosis requires clinical evaluation and laboratory testing. The 4T score is a pretest clinical scoring tool used to determine the probability of HIT. A non-profit health system implemented mandatory documentation of 4T score calculation prior to ordering PF4 tests for suspected HIT patients. The purpose of this performance improvement project is to evaluate the implementation of 4T score documentation on PF4 testing and argatroban utilization. Methods: This was a retrospective, multi-site chart review of patients conducted to assess the impact of mandatory 4T score documentation prior to a PF4 order. The study included adult patients who were admitted to one of the practice sites between January 2020 and November 2022 with a suspicion of HIT and a PF4 order. The primary outcomes included the number of PF4 tests ordered and the percentage of positive PF4 results. Secondary outcomes included number of SRA orders and percentage of positive SRA results, turnaround time for SRA, and the utilization of argatroban. Data collection included baseline demographics, documentation of 4T score, PF4 results, SRA results, documentation of heparin allergy, initial anticoagulant prescribed, platelet trend, ordering provider, and duration of argatroban therapy in patients with a positive PF4 result. The analysis involved using χ2 test and Fisher's exact test for the primary outcomes. Results: Mandatory 4T score documentation significantly reduced PF4 orders by 68% over a two-year period (p&amp;lt;0.0001). It also improved the percentage of positive PF4 results from 12% to 24% (p=0.60) and positive SRA results from 19% to 44% (p=0.35). Notably, after documentation of the mandatory 4T score tool, only 21% of the patients had a PF4 order placed. A total of 42 patients with a positive PF4 test were included to assess argatroban utilization. The turnaround time for SRA in these patients was 3.6 days while duration of argatroban therapy was 6.8 days. Conclusion: Implementation of mandatory 4T score documentation significantly reduced PF4 orders and improved HIT diagnostic testing in a non-profit health system. Challenges remain with SRA turnaround time and corresponding duration of argatroban therapy. The results of this project have demonstrated that standardized documentation is essential for optimizing HIT diagnosis and management protocols. Future efforts will focus on optimizing confirmatory HIT testing and non-heparin anticoagulation therapy.

Impact of targeted education on adverse drug reaction documentation in cancer center sites.

395 Background: Allergic and infusion-related reactions represent a significant portion of reported adverse drug reactions (ADRs) at The University of Kansas Health System (TUKHS) Cancer Center sites. According to the TUKHS Allergy Documentation policy, all observed reactions are required to be documented in the electronic health record (EHR) and reported to the responsible provider. Insufficient documentation may result in preventable patient harm due to continued exposure to medications after known ADRs. An audit of patient EHRs demonstrated notable variability in documentation practices, which served as the impetus to implement a standardized ADR documentation workflow at Cancer Center sites. Methods: This multi-center, retrospective study included patients with ADRs submitted via safety reports from July 1st, 2022 to April 1st, 2023. Categorical data was analyzed using the chi-squared test. Duplicate reports and ADRs identified as side-effects were not included in the final analysis. Targeted education was provided via two online video modules, a workflow tips sheet, and an educational infographic. The primary outcome was frequency of allergy lists updated following submission of a safety event report. Secondary outcomes included frequency of standardized progress note writing, note routing, and accurate reaction type differentiation. Results: Targeted education significantly improved allergy list updating from 34.2% to 84.0% (P &lt; 0.001), use of a standardized progress note from 47.4% to 64.2% (P = .008), and correct differentiation of reaction type from 57.7% to 76.4% (P = .02). Progress notes were routed to the responsible provider 58.5% of the time. Smaller community-based Cancer Center sites were significantly less likely to update allergy lists (7.5% vs. 24.5%, P = .017) and more likely to document incorrect reaction types (35.0% vs. 14.3%, P = .022). Conclusions: Targeted education for a standardized documentation workflow increased adherence to ADR documentation, ensuring future treatment plans are updated for patients with a history of reaction and the EHR accurately reflects ADR history. There is an opportunity to strengthen targeted education surrounding ADR documentation workflows for smaller community-based sites.

A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies

Background/purposeCephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. MethodsA multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. Results578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. ConclusionsCompliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. Level of EvidenceIII. Type of StudyProspective.