Conference Coverage

How to stop penicillin allergy relabeling


 

– About a third to half of patients who test negative for penicillin allergies and have the label removed from their charts will, somewhere down the line, be relabeled as penicillin allergic.

It’s a vexing problem for the increasing number of patients who undergo confirmatory skin testing for penicillin sensitivity while in hospital. It’s become clear in recent years that at least 90% of people who say they have a penicillin allergy don’t really have one. Without confirmatory testing, they end up on expensive, second-line antibiotics, and don’t do well.

It’s unclear why people are relabeled after negative tests. Maybe patients don’t trust the results. Maybe doctors don’t hear about them or err on the side of caution despite negative testing. “I suspect it’s a combination of patient and provider factors,” said Sheenal Patel, MD, an allergy and immunology fellow at the University of Texas Southwestern Medical Center, Dallas.

Dr. Sheenal Patel

Dr. Sheenal Patel

Whatever the reason, UT Southwestern has taken steps over the past few years to make sure negative test results stick in patients’ records, he said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

First, the time and place of negative tests were documented in the EHR, primary care providers were notified of the results, and pharmacists counseled patients at the time of negative testing to make sure they understood the results.

Next, pharmacists began to counsel patients after discharge to reaffirm the message, either face to face or over the phone. The center added an alert to the EHR that pops up if someone tries to relabel a patient and it notifies the pharmacists running the penicillin allergy testing program that an attempt was made. They call the patient’s primary care provider to find out what’s going on.

As of late, patients go home with a wallet card that documents their negative test results, to show providers who aren’t on the UT Southwestern EHR system, and family members.

It’s all made a difference. Only 31 of 225 (13.8%) were relabeled in a review presented by Dr. Patel. All 225 patients had at least 90 days of postdischarge follow-up in the UT Southwestern EHR system.

Rates of relabeling varied according to the specific intervention. Five of 27 (18.5%) who had only pharmacist counseling at the time of negative testing, documentation of negative results in the EHR, and the alert added to their electronic record were relabeled, versus just 1 of 15 patients (6.7%) who received all of the interventions, including pre- and postdischarge counseling and the wallet card. The relabel rate was 14.3% (14) among the 98 patients counseled by a pharmacist when they tested negative, with the results documented in their electronic record – the largest patient subset in the study.

Given the small numbers, it’s hard to know which intervention gave the most bang for the buck, but “pharmacist counseling and EHR documentation had clear benefit.” Postdischarge counseling, EHR alerts, and the wallet cards probably helped, too, Dr. Patel said.

Older patients were more likely to be relabeled, but the trend didn’t reach significance (P = .07). The risk of relabeling was unrelated to race, gender, infection risk factors, number of drug allergies, allergy symptoms, or how long ago the alleged penicillin reaction occurred; most patients reported it was more than 20 years ago. About half of the relabels were on the outpatient side, almost a third in the ED, and the rest in a hospital.

The study didn’t address why they occurred. “Some patients who have had this label for 20 or 30 years will just say they are penicillin allergic despite all our counseling efforts, and whoever is reviewing their allergy list has to decide what to do with that. [Often,] they put it back in the chart. There’s a fear of penicillin allergy histories not only among patients, but also among many providers, and that contributes a lot to this,” Dr. Patel said.

There was no external funding for the work. Dr. Patel had no disclosures.

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