Assessment of a Stepwise Intervention to Improve Nurse-administered Penicillin Allergy Screening and De-labeling in Pediatric Inpatients.

Introduction: Penicillins are first-line treatments for many childhood infections, but providers avoid them when patients report a penicillin allergy, although approximately 94% of these patients may tolerate penicillin. Patients with penicillin allergy labels often receive second-line antibiotics, which increases the risk of treatment failure and adverse events. To address this, programs to implement penicillin allergy de-labeling have increased; however, strategies to accomplish de-labeling most efficiently through guideline dissemination have not been well-studied. Methods: A multidisciplinary team created an evidence-based screening algorithm and standard protocol to screen eligible pediatric inpatients and de-label documented penicillin allergies. Plan-do-study-act cycles identified opportunities for improvement to the standard protocol. Results: We developed a screening tool to assess the risk of penicillin allergy and integrated it into the electronic health record for administration by clinical nurses. Follow-up actions, including de-labeling or further testing, are automatically communicated to the provider. Nurse-initiated screening increased from 3.8% to 28.1% after adding an electronic "worklist task" reminder. Allergy de-labeling demonstrated special cause variation following the dissemination of a standardized amoxicillin challenge order set and then again after a brief period of audit and feedback; however, the increases were not sustained. Conclusions: A nurse-administered screening questionnaire and protocolized follow-up actions can help achieve safe de-labeling at hospitals without a dedicated penicillin allergy service.