Background
Methods
Current clinic workflow of inpatient penicillin de-labeling
Developing and implementing the clinical decision-making support tool (CDST)
Theoretical framework
Design and setting
Data collection
TDF Domain (definition) | Constructs | Selected Interview Question(s) |
---|---|---|
Knowledge (An awareness of the existence of something) | Knowledge Procedural knowledge | • How do you think patients will benefit from de-labeling? • What are the key questions to ask when taking a history for patients with pcn allergy? • Once you take the clinical history, do you know the next steps of evaluating a patient with pcn allergy? |
Skills (An ability or proficiency acquired through practice) | Skills Practice | • Have you ever evaluated patients with pcn allergy? • How often do you evaluate patients with pcn allergy? |
Beliefs about capabilities (Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use) | Perceived competence | • How comfortable are you in determining a patient’s risk of future reaction? • How comfortable are you administering an oral drug challenge to a patient determined to be low risk? |
Beliefs about consequences (Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation) | Outcome expectancies | • What fears do you have about the consequences of recommending de-labeling (for patients)? • What fears do you have about the consequences of recommending de-labeling (for the healthcare team)? |
Professional role and identity (A coherent set of behaviors and displayed personal qualities of an individual in a work setting) | Professional role and identity | • Which services take the lead on pcn allergy de-labeling? • What does the workflow among the services look like? |
Environmental context and resources (Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, and adaptive behavior) | Organizational culture or climate Environmental stressors Resources or material resources | • How do communications [or communication gaps] between specialty services and primary services influence the de-labeling process? • How much does de-labeling have priority among your other clinical responsibilities? • What do you think is the most significant barrier to incorporating de-labeling into your work? • Since our allergy resources are limited, what do you think the system can manage without allergy’s involvement? • What technological constraints impede querying the record and documenting what you find? |
Ethical considerations
Data analysis
Results
Inpatient setting
Knowledge, skills, beliefs about capabilities and consequences
Professional role and identity
“There's sometimes a little bit of disagreement with the history taking and the one that comes up all the time is, did the patient really have hives or true urticaria? And then almost always in that situation, we default to the most conservative or safest option, [between] skin testing, getting allergy involved, or doing an oral test dose”. (Hospitalist 1)
“I guess it's a little unclear [who takes the lead on de-labeling]. Um, I think that, you know, teams, individual medical teams do try to do something. It is certainly not very systematic amongst the teams” (Hospitalist 2)
Domain | Constructs | Quotes from inpatient clinicians | Quotes from outpatient clinicians |
---|---|---|---|
Knowledge | Knowledge (scientific rationale) | I think a lot of people would be convinced by the data out there about long term benefits to doing this. And people are probably not super aware of the data. So I think the data would be a good selling point overall (Resident 1) | Probably the majority of providers don't know that de-labeling of something that is actually a viable thing that we can do a lot of times historically or otherwise. (PCP 4) |
Procedural knowledge | I think a big barrier is just that we have SharePoint, we have all these other folders, there’s different sites. I'm sure I could find [the CDST] if I went to go look for it, but we have so many different places to start looking that it's just hard to find where everything is, and how updated it is, because we have old versions of stuff and new versions. Our file organization system isn't the best. (Pharm 4) | I am aware that there are kind of protocols to look at history and things like that to delabel and then a paradigm or an algorithm to go through. But I don't think the majority of primary care doctors are. (PCP 4) | |
Skills | Skills | In terms of evaluating their risk for an actual activation of the allergy, I wouldn't feel extremely comfortable, especially doing that on my own. I feel like it's always been a discussion with the team and then if ID needs to get involved in evaluating from that standpoint of group collaboration of what do we think, when was this reaction? …But in terms of actually assigning a risk to it, I don't feel too comfortable at this point doing that on my own. (Pharm 5) | I think I'd be somewhat worried about the volume. I could just see getting trained initially and then we do this for one patient a month and no one has a reaction for 2 years. And then someone does have a reaction and we don't feel as comfortable anymore. (PCP 3) |
Beliefs about capabilities | Perceived competence | We rarely do antibiotic test doses. So there may be a lot of concerns about doing that inpatient. So I think familiarity and comfort level across the disciplines is probably one of the barriers. Again, if we do this maybe four times a year, that's really quite infrequent that we're challenging patients. (Hospitalist 2) | Without having been there in the initial moment when they had the reaction, I think it's hard sometimes to be able to, to sort of distinguish and feel confident and questioning whether it was a true allergy. PCP#? |
Beliefs about consequences | Outcome expectancies | I feel like if they had penicillin allergy on their chart, but maybe you didn't think it was all that severe, so you give penicillin anyway and having them have an anaphylactic reaction and possibly bad outcome. I think that's probably my biggest fear or barrier to removing the label or giving someone penicillin when they have a documented allergy. (Resident 2) | I haven't done the direct or, the ordering provider, the administrator, the monitoring provider. So I think without experience in that, it would be relatively unsafe and then we don't have any protocols for monitoring after things outside of a few minutes after a vaccination in clinic, we don't have a structure in place to have somebody actively monitor for longer. (PCP 2) |
Professional role and identity | Professional role | It’d be nice to know who is ultimately going to lead the charge, because I feel like a lot of times, we might see it first, because the pharmacy technician put it in med rec. And then if we reach out to the team, I feel like, then sometimes it gets bounced from the team to ID. And if ID recommends getting allergy involved, and it kind of seems like it's always the next person who will be looking into it. And a lot of times I feel like that's where it falls through the cracks. So, if we knew who is going to take charge of it from the beginning, because by the time all those things have happened, the patient might be ready for discharge and then this falls through the cracks anyways, they've already selected a different antibiotic and are being discharged on something else. So, just kind of knowing who ultimately is in charge of that follow up. (Pharm5) | I guess historically part of the problem has been sort of ownership of that and kind of a belief that once it's on the chart, it's gold and we're not going to re diagnose a patient or kind of delve too much into that…so unless someone is prompting us to do that, it’s not something we're necessarily going to go into. (PCP 4) I guess we would wonder what standard of care is, if it's standard for primary care to be doing this or if it's standard for allergy to be doing it…. I would just wonder if it's kind of outside the typical realm of what primary care would be doing to actually administer the trials…. I think there's a lot of very specific primary care things like healthcare maintenance type things that we don't have time to complete all of that. And so I would wonder if adding something that was more specialty driven is the best use of primary care resources but, but not impossible. (PCP 2) |
Environmental context and resources | Environmental stressors | You get done with a long day at the hospital and it's like 6 pm and you're ready to go home. You could always ask yourself, could I go talk to this patient some more about penicillin allergy de-labeling? The answer is yes, there's always time there, but is there time within reasonably normal working hours that isn't going to burn the inpatient team out? (Hospitalist 1) It's hard right now, the way the model is, when you're a pharmacist, you have two medical teams essentially that you're covering. And so usually they round at the same times and so you can't be in two places at once. (Pharmacist 2) | If primary care does all the preventative care that it’s supposed to do for each patient that comes in, that's going to take seven hours out of the day. Plus all the acute care needs that patients are bringing up and things they have to address and paperwork and other things. And so eventually the day just kind of runs out of time and, you know, we kind of struggle to do the things that typically fall under the umbrella of primary care in the way the system is currently set up. (PCP 4) A lot of times when I'm seeing a new patient, there's so much to get done. There's so much medical history that when I'm entering the allergies, I'm kind of trying to go as fast as I can and it does ask, what the reaction was, but sometimes they're just like, ‘oh, I don't know.’ And I'm just like, okay ‘unknown, next.’ [Laughs] So, I think probably just general primary care time constraints is the big one. (PCP 3) |
Resources/material resources | Eventually a lot of these patients need to be sent to the allergy clinic for testing or could get tested in the hospital. And we don't have FTE either here or in the allergy clinic to do that… But we have limited ability to do that because of [Allergy’s] space, their FTE and then our FTE. So that that's probably the biggest barrier. (AMSPh1) | At our community based outpatient clinics, I don't know if I would want to do this if a patient had a reaction, so if this would be done at the main hospital where, if something did happen, we've got the emergency department, we've got inpatient services right there… I could see some hesitancy with doing this procedure in some of our community based outpatient clinics or clinics that just aren't as well supported to navigate an issue if it arose. (Outpatient Pharm 2) | |
Organizational culture /climate | I think a lot of conversations now happen by Microsoft Teams. I think the lack of an in-person communication probably impacts that, like you don't want to bother them as much by sending them yet another Teams message, or your point might not necessarily get across in the electronic communication. I think a lot of times, often it’s just easier to have that face to face conversation, and really not having that with the physician teams, like I almost never see the physicians in person anymore, when I'm staffing on the floors, I guess I should say. (AMS Ph2) | For a procedure that takes 90 min, I feel like that might be a tough sell to have the team available…. that could be overwhelming if there's a lot of those coming through…. we're in a workforce shortage right now within primary care providers, LPNs, nurses… That, I think is something else to note, work availability of personnel to be able to implement it. (Outpatient Pharm 1) |
Environmental stressors, resources, and organizational culture
“I think from an inpatient perspective, it's probably the culture that ‘we need to address the things that need to be addressed as an inpatient, and the rest can be pushed to outpatient world.’ So that tends to be a general thought process. And it's sometimes appropriate, and sometimes it isn't, and penicillin allergy falls in that bucket. So, I think that is probably something in the organizational culture". (ID MD1)
“I think de-labeling is important but right now, the hospital is completely full every day. We are getting messages on the screen, ‘discharge your patients as fast as you can.’ So, everything becomes secondary to getting the inpatient work done and getting the patients out of the hospital as quickly as we can”. (Hospitalist 1)
“I think there's always an inherent time limitation, the admission pharmacy med rec isn't put on the chart sometimes for, like, 24 or 48 h after admission… By the time you hit 48 h, we're already planning to get [patients] out of the hospital at that point.” (Hospitalist 1)
“I think it is a much more passive form of communication of just assigning people to notes. It's very noncommittal by the signature that you've received that, whereas, you know, if you had a phone call, it may convey more importance”. (Hospitalist2)
Inpatient to outpatient transitions
Barriers to de-labeling in primary care settings
“We're also struggling with space concerns at the facility where I work. I just don't think the building management would like to have people sitting around for 2 h when we don't have enough rooms as it is”. (PCP 1)