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

• Published in: Transplantation and cellular therapy 2024-03, Vol.30 (3), p.322.e1-322.e10
• Main Authors: Merz, Lauren E., Huang, George X., Mehta, Geneva D., Lynch, Donna-Marie, Maliborski, Natalia, Besz, Kylie, Wickner, Paige, Cutler, Corey, Castells, Mariana
• Format: Article
• Language: English
• Subjects: Hematopoietic stem cell transplantation; PDSA; Penicillin allergy; Quality improvement
• ISSN: 2666-6367; 2666-6367
• DOI: 10.1016/j.jtct.2023.12.012

•A pipeline was developed to assess HSCT recipients with penicillin allergy labels.•Barriers to pipeline implementation were addressed through multiple PDSA cycles.•21.7% of screened patients with planned HSCT had an eligible penicillin allergy.•Nearly one-half of patients with eligible allergies were delabeled before the date of HSCT.•This is sustained by 4 hours from allergy clinic and under 1 hour from HSCT clinic. Penicillin allergy is reported by 10% to 20 % of patients, but when evaluated only 1% to 2% may have a true allergy. Patients undergoing hematopoietic stem cell transplantation (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 Clostridium difficile colitis. This group of patients already undergoes extensive pretreatment testing and would especially benefit from allergy delabeling. This study aimed to develop a self-sustaining, low-cost pipeline between an HSCT clinic and an allergy clinic to identify and successfully delabel 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 4 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 to 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, 89 (21.7%) were listed as having a penicillin and/or beta lactam allergy. All but 1 (66 of 67; 98.5%) of the participants completed the survey accurately when confirmed by an allergist, and the survey was 100% accurate in predicting delabeling success in low-risk patients. Of eligible patients, 43.8% (n = 39) were successfully delabeled before their transplant date, and 97.4% of these (n = 38) have undergone HSCT to date. This pipeline is maintained by approximately 5 hours of work per week (1 hour of allergy phy