Beta Lactam Allergies at UChicago Medical Center

Using a human centered design approach to educate patients about beta-lactam (penicillin) allergies

Healthcare Design

2024

Background

Surgical site infections (SSIs) occur approximately 157,000 times per year in the United States, are associated with excess hospital lengths of stay, and account for $3.2 billion in attributable costs annually in acute care hospitals. The first choice for antibiotics used during surgery are drugs in the beta-lactam family. Since it's discovery in 1928, penicillin and the 15 related drugs in the beta-lactam family have been among the most important, effective and widely used antibiotics.

10% of the population report having a penicillin allergy; however, when evaluated, more than 95% of patients labeled as allergic can tolerate beta-lactam antibiotics. Because alternative antibiotics are less effective, patients with a reported penicillin allergy are 50% more likely to develop a Surgical Site Infection.

About

This project involved the creation of a new patient education tool to help patients understand the basics of penicillin allergies, the importance of getting the penicillin allergy tag removed from their medical records, and how an allergist/immunologist can test for a penicillin allergy.

This project was part of a larger “beta-lactam allergy history program” proposed at the University of Chicago Medical Center. The program aims to reduce the number of surgical site infections in the hospital, and optimize the prescription of antibiotics prior to surgery. A pharmacist identifies surgical patients with a reported beta-lactam allergy 0-3 months prior to their scheduled procedure. The pharmacist reviews the patient’s medical record, calls the patient to obtain additional history, deletes the allergy label or updates the allergy documentation, makes a referral to Allergy & Immunology (if required), and recommends preoperative antibiotics prior to surgery. The program was implemented by a multi-disciplinary team (Pharmacy, Allergy and Immunology, Infectious Diseases, and multiple Surgery Sub-Specialties) led by Clinical Pharmacy Specialist Cynthia T. Nguyen and Allergy & Immunology professor Dr. Ruchi Singla.

The Patient’s Journey

A patient is referred to a surgeon, who recommends surgery as part of the treatment plan

A patient is referred to a surgeon, who recommends surgery as part of the treatment plan

During the pre-operative assessment, the nurse or medical team reviews the patient's medical history, including checking for any allergies.

During the pre-operative assessment, the nurse or medical team reviews the patient's medical history, including checking for any allergies.

While the medical team has attempted to train nurses to identify allergy tags during pre-operative assessments in the past, the system doesn't always capture this critical detail.

While the medical team has attempted to train nurses to identify allergy tags during pre-operative assessments in the past, the system doesn't always capture this critical detail.

When the pharmacy is notified of the upcoming surgery, the pharmacist sees that the patient may have an allergy, which triggers a follow-up call to the patient for more information

When the pharmacy is notified of the upcoming surgery, the pharmacist sees that the patient may have an allergy, which triggers a follow-up call to the patient for more information

The pharmacist takes time to carefully assess the situation, and asks the patient about any previous reactions to antibiotics. The goal is to determine if there is a true allergy.

The pharmacist takes time to carefully assess the situation, and asks the patient about any previous reactions to antibiotics. The goal is to determine if there is a true allergy.

The pharmacist works with the patient to assess the situation. The pharmacist ensures that the patient is comfortable and educated about the safety of using different types of antibiotics.

The pharmacist works with the patient to assess the situation. The pharmacist ensures that the patient is comfortable and educated about the safety of using different types of antibiotics.

If the patient's history suggests a higher risk of an allergic reaction, the patient is referred to an allergist/ immunologist for further evaluation, including skin testing, or test dosing.

If the patient's history suggests a higher risk of an allergic reaction, the patient is referred to an allergist/ immunologist for further evaluation, including skin testing, or test dosing.

The penicillin skin test involves pricking the skin with a small amount of penicillin and, monitoring the result. If these tests are negative, it's unlikely that the patient is allergic.

The penicillin skin test involves pricking the skin with a small amount of penicillin and, monitoring the result. If these tests are negative, it's unlikely that the patient is allergic.

In some cases, a test dose is given to rule out an immediate allergic reaction. For patients at high risk or with a known severe reaction, the allergist will recommend alternative treatments

In some cases, a test dose is given to rule out an immediate allergic reaction. For patients at high risk or with a known severe reaction, the allergist will recommend alternative treatments

Once the allergy status is confirmed, the pharmacist and surgeon discuss the safest and most effective antibiotics for the surgery.

Once the allergy status is confirmed, the pharmacist and surgeon discuss the safest and most effective antibiotics for the surgery.

After surgery, the patient is monitored for any signs of an allergic reaction. If there were any concerns about antibiotic use, the healthcare team and prepared to address any issues that may arise.

After surgery, the patient is monitored for any signs of an allergic reaction. If there were any concerns about antibiotic use, the healthcare team and prepared to address any issues that may arise.

Requirements for a new patient educational tool

Versatile

The tool must be adaptable for use in different healthcare settings (e.g., clinics, hospitals, or virtual environments).

Standalone

The tool should be able to function independently, i.e., it can be sent directly to patients without prior interaction with a pharmacist or healthcare provider.

Patient-Friendly Format

The document should be user-friendly, with a clear, legible layout, that ensures the message is accessible and easy for patients to read and understand.

Single-Page, Letter-Sized Document

The document must be a one-page, letter-sized document (8.5" x 11") for easy printing.

Inexpensive & Easy to Print

The tool must be designed in black and white to minimize printing costs. It should be easy to print without requiring special equipment or materials (e.g., no cutting, folding, or binding).

Delivery Methods

The tool must be compatible with multiple delivery channels:
Digital version (e.g., a PDF) to be sent via MyChart or other electronic health platforms.
Physical version (printed flyer) for distribution in the clinic.

Patient Friendly Formatting

Based on prior healthcare design projects at UChicago Medical Center, I followed these steps to ensure the tool would be patient friendly:

First the flyer was divided up into sections. The sections were split with the questions on the left, and answers/details on the right. This allows patients to quickly scroll through the page. It also keeps the line length to 60 characters, making it easier to read.

The font size was kept at 12 point to ensure legibility, and used the Gotham typeface from UChicago Medical Center’s brand guidelines.

Final Design

Flyer

Web Page

Citations

Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA 2015; 313:483–495.

Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating healthcare-associated infections and deaths in US hospitals, 2002. Public Health Repts 2007;122:160–166.

Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US healthcare system. JAMA Intern Med 2013;173:2039–2046.

Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198–1208

Sacco KA, Bates A, Brigham TJ, Imam JS, Burton MC. Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis. Allergy. 2017 Sep;72(9):1288-1296. doi: 10.1111/all.13168. Epub 2017 Apr 26. PMID: 28370003.

Blumenthal KG, Ryan EE, Li Y et al. The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk. Clin Infect Dis. 2018 Jan 18;66(3):329-336.