The Association of Antibiotic Stewardship With Fluoroquinolone Prescribing in Michigan Hospitals: A Multi-hospital Cohort Study.

BACKGROUND: Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown. METHODS: This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015-September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship. RESULTS: There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003). CONCLUSIONS: Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing.

Development of Biodegradable Injectable In situ Forming Implants for Sustained Release of Lornoxicam.

OBJECTIVE: The focus of this study was to develop in situ injectable implants of Lornoxicam which could provide sustained drug release. METHODS: Biodegradable in situ injectable implants were prepared by polymer precipitation method using polylactide-co-glycolide (PLGA). An optimized formulation was obtained on the basis of drug entrapment efficiency, gelling behavior and in vitro drug release. The compatibility of the formulation ingredients were tested by Fourier transform infrared (FT-IR) spectroscopy, and differential scanning colorimetry (DSC). SEM study was performed to characterize in vivo behavior of in situ implant. Pharmacokinetic study and in vivo gelling study of the optimized formulation were performed on Sprague-Dawley rats. Stability testing of optimized formulation was also performed. RESULTS: The drug entrapment efficiency increased and burst release decreased with an increase in the polymer concentration. Sustained drug release was obtained up to five days. SEM photomicrographs indicated uniform gel formation. Chemical interaction between the components of the formulation was not observed by FT-IR and DSC study. Pharmacokinetic studies of the optimized formulation revealed that the maximum plasma concentration (Cmax), time to achieve Cmax (Tmax) and area under plasma concentration curve (AUC) were significantly higher than the marketed intramuscular injection of lornoxicam. Stability study of optimized batch showed no change in physical and chemical characteristics. CONCLUSION: Lornoxicam can be successfully formulated as in situ injectable implant that provides long-term management of inflammatory disorders with improved patient compliance.

Development and characterization of novel hydrogel containing antimicrobial drug for treatment of burns.

INTRODUCTION: The aim of burn management and therapy is fast healing and epithelisation to prevent infection. The present study is concerned with the development and characterization of a novel nanaoparticulate system; cubosomes, loaded with silver sulfadiazine (SSD) and Aloe vera for topical treatment of infected burns. METHODS: Cubosome dispersions were formulated by an emulsification technique using different concentrations of a lipid phase Glyceryl Monooleate (GMO) and Poloxamer 407. The optimum formulae were incorporated in an aloe vera gel containing carbopol 934, to form cubosomal hydrogels (cubogels). The cubogels were characterized by in vitro release of SSD, rheological properties, pH, bioadhesion, Transmission Electron Microscopy and in-vivo Wound Healing Study. RESULTS: The results show that the different concentration of GMO had significant effect on particle size, % EE and in vitro drug release. From the in-vitro drug release pattern and similarity factor (f2), it was concluded that batch CG3 (15% GMO and 1% P407) exhibited complete and controlled drug release within 12 hour (i.e. 98.25%), better bio adhesion and superior burn healing as compared to the marketed product. CONCLUSION: The in vivo burns healing study in rats revealed that the prepared optimized cubogel containing SSD and aloe vera has superior burns healing rate than cubogel with only SSD and marketed preparation so, it may be successfully used in the treatment of deep second degree burn.

Impact of an antimicrobial stewardship-led intervention for Staphylococcus aureus bacteraemia: a quasi-experimental study.

BACKGROUND: Staphylococcus aureus bacteraemia (SAB) carries high rates of morbidity and mortality. Antimicrobial stewardship programmes (ASPs) are well situated to promote adherence to quality performance measures in order to optimize the management of SAB and associated clinical outcomes. METHODS: This uncontrolled pre-post quasi-experimental study evaluated compliance with an ASP-driven comprehensive care bundle and associated clinical outcomes for patients with SAB. The ASP provided recommendations to prescribers to promote adherence with quality performance measures, which included: initiate effective antibiotics within 24 h of Gram's stain; achieve therapeutic vancomycin trough concentration; provide ß-lactam therapy if MSSA; obtain repeat blood cultures every 48 h until clearance; complete appropriate treatment duration; eliminate or debride foci of infection; and obtain an echocardiogram for complicated bacteraemia. RESULTS: One hundred and seventy patients with SAB were included: 82 patients in the pre-intervention group and 88 patients in the ASP-intervention group. Overall bundle adherence to quality performance measures improved from 56.1% (46/82) in the pre-intervention group to 84.1% (74/88) in the ASP-intervention group (P < 0.001), which was associated with a reduction in 30 day readmission with SAB [9 patients (11.0%) versus 1 patient (1.1%), P = 0.008]. The 30 day mortality was numerically lower in the ASP-intervention group, but the difference was not statistically significant [16 patients (19.5%) versus 10 patients (11.4%), P = 0.2]. CONCLUSIONS: Implementation of an ASP-driven comprehensive care bundle for SAB improved adherence with performance measures and was associated with a decrease in hospital readmission for SAB.

Antihyperglycemic activity of Albizzia lebbeck bark extract in streptozotocin-nicotinamide induced type II diabetes mellitus rats.

INTRODUCTION: Albizzia lebbeck (L.) Benth. (Family - Leguminosae) extract is a proven mast cell stabilizing agent. Mast cells are involved in the inflammatory processes leading to the diabetes mellitus. AIM: To evaluate the effect of A. lebbeck against experimentally induced type 2 diabetes mellitus in rats. MATERIALS AND METHOD: Female Sprague-Dawley rats were randomly allocated to six groups (n = 6). Diabetes was induced by single intraperitoneal injection of streptozotocin (50 mg/kg) given after 15 min of nicotinamide administration (110 mg/kg). Treatment with methanolic extract of A. lebbeck bark (MEAL) and metformin drug as standard was given for 21 days. Serum glucose (GLU) levels were measured on the 0 day and on 1(st), 7(th), 14(th) and 21(st) day after diabetes induction. After completion of study period, various biochemical parameters in serum such as - GLU, lipid profile, urea and creatinine were estimated. One-way analysis of variance followed with post-hoc Dunnett's test was used to analyse the data. Statistical significance for the values was set at P< 0.05. RESULTS: MEAL significantly decreased the level of serum GLU, creatinine, urea, cholesterol, triglycerides, low-density lipoprotein-cholesterol, very low-density lipoprotein-cholesterol and increased high-density lipoprotein levels. CONCLUSION: A. lebbeck bark extract showed antihyperglycaemic activity along with antihyperlipidemic effect.

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial.

BACKGROUND AND OBJECTIVE: Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results. METHODS: We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction. RESULTS: We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention. CONCLUSIONS: Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01153451).

Impact of an antimicrobial stewardship program comprehensive care bundle on management of candidemia.

STUDY OBJECTIVE: To analyze the impact of a comprehensive care bundle directed by an antimicrobial stewardship team (AST) on the management of candidemia. DESIGN: Single-center, quasi-experimental study. SETTING: A 930-bed academic hospital. PATIENTS: Seventy-eight patients with candidemia were evaluated; 41 patients received the candidemia care bundle (AST group), and 37 did not (historical control group). MEASUREMENTS AND MAIN RESULTS: A candidemia care bundle was developed by an interdisciplinary AST, incorporating key elements from the Infectious Diseases Society of America's Clinical Practice Guidelines for the Management of Candidemia. The AST made prospective recommendations in accordance with the care bundle. Bundle elements were utilization of appropriate antifungal agents with appropriate duration of use, removal of intravenous catheters, repeat blood cultures, monitoring of time until clearance of candidemia, and performance of ophthalmologic examinations. Compliance with all candidemia care bundle elements was significantly higher in the AST group versus the control group (78.0% vs 40.5%, p=0.0016). Implementation of the care bundle significantly improved rates of ophthalmologic examination (97.6% vs 75.7%, p=0.0108), selection of appropriate antifungal therapy (100% vs 86.5%, p=0.0488), and compliance with an appropriate duration of therapy (97.6% vs 67.7%, p=0.0012). In addition, the AST group had fewer excess total days of therapy beyond the recommended duration than the control group (5 vs 83 total antifungal days). Length of hospitalization (20 vs 21 days, p=0.9184), time until clearance of candidemia (3 vs 3 days p=0.610), rate of persistent candidemia (22% vs 40.5%, p=0.126), and rate of recurrent candidemia (4.9% vs 5.4%, p=0.916) were similar in the AST group versus the control group. CONCLUSION: A comprehensive candidemia care bundle directed by our institution's AST improved the management of patients with candidemia. We encourage further exploration into the use of care bundles by ASTs as part of their multifaceted approach to promoting appropriate antimicrobial utilization and optimizing the management of patients with infectious diseases.

Antiurolithiatic activity of saponin rich fraction from the fruits of Solanum xanthocarpum Schrad. & Wendl. (Solanaceae) against ethylene glycol induced urolithiasis in rats.

ETHNOPHARMACOLOGICAL RELEVANCE: A well-known traditional herb Solanum xanthocarpum is widely used in India for the management of different ailments including urolithiasis. This study was designed to rationalize the use of Solanum xanthocarpum in kidney stone and to investigate its mechanism of action. MATERIALS AND METHODS: The saponin rich fraction prepared from fruits of Solanum xanthocarpum (SXS) was evaluated for antiurolithiatic activity by in vitro and in vivo studies. In ethylene glycol (EG, 0.75% in drinking water for 28 days) induced urolithiasis model, two different experimental doses (20 mg/kg and 40 mg/kg, p.o., for 28 days) of saponin rich fraction were selected by dose fixation study. After 28 days, various biochemical parameters were measured in urine, serum and kidney homogenate. Kidneys were also subjected to histopathological analysis. RESULTS: In vitro calcium oxalate crystal (CaOx) nucleation as well as aggregation was inhibited in artificial urine solution by SXS. The lithogenic treatment caused polyuria, damage renal function and oxidative stress, manifested as increased malondialdehyde, depleted reduced glutathione and decreased antioxidant enzyme catalase activities of the kidneys, which were prevented by simultaneous administration with SXS. Lithogenic treatment also caused crystalluria, hyperoxaluria, hypercalciuria, hypocitrauria, and hypomagnesaemia. Deposition of CaOx in renal tissue and cellular injury were seen in histopathology. Co-administration of SXS had potential to prevent these pathological changes due to lithogenic treatment. Moreover, SXS raised level of glycosaminoglycan, a stone inhibitor macromolecule found in urine which decreased. CONCLUSION: The antiurolithiatic activity in Solanum xanthocarpum is mediated possibly through the inhibition of CaOx crystal formation and its effect on the urinary concentration of stone-forming constituents and nephrolithiasis inducing factors and this study rationalizes its medicinal use in urolithiasis.

Evaluation of bronchodilator and anti-anaphylactic activity of Myrica sapida.

BACKGROUND: Asthma is a chronic inflammatory disorder of the airways. The available treatment options have major limitations owing to low efficacy, associated adverse events and compliance issues. Therefore, the health burden of bronchial asthma is increasing globally at an alarming rate, providing a strong impetus for the development of new therapeutics. Myrica sapida is known traditionally in Ayurveda to possess anti-asthmatic activity. Hence, the present investigation was undertaken to evaluate the bronchodilator and anti-anaphylactic activity of the stem bark of Myrica sapida. METHODS: Experimental models studied were acetylcholine induced bronchospasm in guinea pigs, egg albumin induced anaphylaxis in guinea pigs, in vitro studies on tracheal strip of egg albumin sensitized guinea pigs. RESULTS: Treatment with ethanolic extract of M. sapida, 75 mg/kg, orally resulted in significant protection against acetylcholine aerosol induced bronchospasm and allergen induced anaphylaxis in guinea pigs. Ethanolic extract of M. sapida (75 mg/kg, p.o.) prevented the potentiation of responses and also produced a decrease in pD2 value of histamine and acetylcholine in guinea pig tracheal strip. CONCLUSION: These results suggest that M. sapida possesses bronchodilator activity, has potent inhibitory effect on immediate hyper-sensitivity reactions and decreases bronchial hyper-responsiveness.

Design and implementation of a web-based patient portal linked to an electronic health record designed to improve medication safety: the Patient Gateway medications module.

In this article we describe the background, design, and preliminary results of a medications module within Patient Gateway (PG), a patient portal linked to an electronic health record (EHR). The medications module is designed to improve the accuracy of medication lists within the EHR, reduce adverse drug events and improve patient-provider communication regarding medications and allergies in several primary care practices within a large integrated healthcare delivery network. This module allows patients to view and modify the list of medications and allergies from the EHR, report non-adherence, side effects and other medication-related problems and easily communicate this information to providers, who can verify the information and update the EHR as needed. Usage and satisfaction data indicate that patients found the module easy to use, felt that it led to their providers having more accurate information about them and enabled them to feel more prepared for their forthcoming visits. Further analyses will determine the effects of this module on important medication-related outcomes and identify further enhancements needed to improve on this approach.

A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.

OBJECTIVE: Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring. DESIGN: We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels. MEASUREMENTS: Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics. RESULTS: Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring. CONCLUSION: We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.

Empowering patients to improve the quality of their care: design and implementation of a shared health maintenance module in a US integrated healthcare delivery network.

We describe a health maintenance module within a personal health record designed to improve the quality of routine preventive care for patients in a large integrated healthcare delivery network. This module allows patients and their providers to share an online medical record and decision support tools. Our preliminary results indicate that this approach is well-accepted by patients and their providers and has significant potential to facilitate patient-provider communication and improve the quality of routine health maintenance care. Further research will determine the long term impact and sustainability of this approach.

Physicians value patient review of their electronic health record data as a means to improve accuracy of medication list documentation.

Providers place great value on their patients as sources of clinical information. Patient access to and review of their medication list from their electronic health record prior to a visit may improve the accuracy of medication documentation.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.

Design and implementation of a web-based patient portal linked to an ambulatory care electronic health record: patient gateway for diabetes collaborative care.

BACKGROUND: Despite the availability of expert guidelines and widespread diabetes quality improvement efforts, care of patients with diabetes remains suboptimal. Two key barriers to care that may be amenable to informatics-based interventions include (1) lack of patient engagement with therapeutic care plans and (2) lack of medication adjustment by physicians ("clinical inertia") during clinical encounters. METHODS: The authors describe the conceptual framework, design, implementation, and analysis plan for a diabetes patient web-portal linked directly to the electronic health record (EHR) of a large academic medical center via secure Internet access designed to overcome barriers to effective diabetes care. RESULTS: Partners HealthCare System (Boston, MA), a multi-hospital health care network comprising several thousand physicians caring for over 1 million individual patients, has developed a comprehensive patient web-portal called Patient Gateway that allows patients to interact directly with their EHR via secure Internet access. Using this portal, a specific diabetes interface was designed to maximize patient engagement by importing the patient's current clinical data in an educational format, providing patient-tailored decision support, and enabling the patient to author a "Diabetes Care Plan." The physician view of the patient's Diabetes Care Plan was designed to be concise and to fit into typical EHR clinical workflow. CONCLUSIONS: We successfully designed and implemented a Diabetes Patient portal that allows direct interaction with our system's EHR. We are assessing the impact of this advanced informatics tool for collaborative diabetes care in a clinic-randomized controlled trial among 14 primary care practices within our integrated health care system.

Clinicians recognize value of patient review of their electronic health record data.

Increasing patient demands for convenient access to their own health care information has led to the development of "patient portals" that allow limited patient access to ambulatory electronic health records (EHR). Little is known about clinicians attitudes towards this new model of health care. In our study, we collected baseline information about primary care providers (PCP) usage of a secure, web-based patient portal linked to the ambulatory EHR. We also assessed providers initial perceptions of these technologies as facilitators of patient-provider communications and the potential for these tools to improve quality of outpatient care.

Improving patient safety across a large integrated health care delivery system.

OBJECTIVE: Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare system, a large, integrated, non-profit health care delivery system in the United States. DESIGN: Partners identified a central Patient Safety Officer, who then formed a Patient Safety Advisory Group with local expert members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implementation. There was broad consensus that interventions should include the areas of culture change, process change, and process measurement. SETTING: A large, integrated health care delivery system in the Boston, Massachusetts, area. RESULTS: Key milestones to date include implementation of Executive WalkRounds, development of accountability principles, agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physician order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network. Most influenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient safety initiatives. CONCLUSIONS: This loosely integrated delivery system represents a daunting landscape for the development and institution of patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for significant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging. Moreover, with many potential interventions, and limited resources, prioritization and selection is difficult. Nonetheless, consensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the net result will be substantial improvement in patient safety.

Patient Safety Leadership WalkRounds.

BACKGROUND: In the WalkRounds concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events. ANALYSIS OF EVENTS: Events in the Walkrounds are entered into a database and classified according to the contributing factors. The data are aggregated by contributing factors and priority scores to highlight the root issues. The priority scores are used to determine QI pilots and make best use of limited resources. Executives are surveyed quarterly about actions they have taken as a direct result of WalkRounds and are asked what they have learned from the rounds. RESULTS: As of September 2002, 47 Patient Safety Leadership WalkRounds visited a total of 48 different areas of the hospital, with 432 individual comments. DISCUSSION: The WalkRounds require not only knowledgeable and invested senior leadership but also a well-organized support structure. Quality and safety personnel are needed to collect data and maintain a database of confidential information, evaluate the data from a systems approach, and delineate systems-based actions to improve care delivery. Comments of frontline clinicians and executives suggested that WalkRounds helps educate leadership and frontline staff in patient safety concepts and will lead to cultural changes, as manifested in more open discussion of adverse events and an improved rate of safety-based changes.

Creating an enterprise-wide allergy repository at Partners HealthCare System.

A significant fraction of medication errors and preventable adverse drug events are related to drug-allergy interactions (DAIs). Computerized prescribing can help prevent DAIs, but an accurate record of the patient's allergies is required. At Partners HealthCare System in Boston, the patient's allergy list is distributed across several applications including computer physician order entry (CPOE), the outpatient medical record, pharmacy applications, and nurse charting applications. Currently, each application has access only to its own allergy data. This paper presents details of a project designed to integrate the various allergy repositories at Partners. We present data documenting that patients have allergy data stored in multiple repositories. We give detail about issues we are encountering such as which applications should participate in the repository, whether "NKA" or "NKDA" should be used to document known absence of allergies, and which personnel should be allowed to enter allergies. The issues described in this paper may well be faced by other initiatives intended to create comprehensive allergy repositories.