The appropriateness of penicillin allergy de-labelling by non-allergist clinical ward teams.

OBJECTIVES: We aimed to assess the appropriateness of penicillin allergy (PenA) assessment conducted by clinical teams and to review the safety of subsequent exposure of these patients to penicillin. METHODS: Opportunistic, prospective observational study of usual clinical care, between 16 May 2023 and 14 August 2023, of inpatients with a PenA and requiring antibiotics, in a 750-bed hospital in England. To assess the appropriateness of management, PenA patients prescribed penicillins were grouped into risk categories using a validated antibiotic allergy assessment tool: eligible for de-label on history alone (direct de-label; DDL), eligible for direct oral challenge (DOC), high risk or unable to obtain history. RESULTS: Of the 123 patients admitted with a PenA (or sensitivity record) and exposed to a penicillin, data were collected for 50. Their PenA records were grouped follows: eligible for DDL 34 (68%), eligible for DOC 11 (22%), high risk 4 (8%) and unable to obtain history 1 (2%). In 14/50 (28%) patients there was no evidence of a current PenA assessment in the medical notes. CONCLUSIONS: Using the allergy risk tool, most patients with PenA records were exposed to penicillin appropriately. However, patients meeting high-risk criteria were also exposed to penicillin when the tool excluded them. PenA assessment needs to be carried out with appropriate training and governance structures in place.

Community pharmacy discharge medicines service activity as recorded in PharmOutcomes: a retrospective exploration and analysis.

OBJECTIVES: Transition of care when a patient moves between healthcare locations is a risk factor for medication errors and medicines-related preventable harm. The aims of this retrospective service evaluation were to understand, by classifying and quantifying, the nature of interventions made by community pharmacy when receiving a discharge medicines service referral from a secondary care hospital, with a focus on two groups of high-risk medicines supplied at discharge-oral anticoagulants and weak opioids following hip or knee surgery. METHODS: Records made on the PharmOutcomes™ platform by community pharmacists in response to referral for the NHS England discharge medicines service were analysed and summarized. This analysis was exploratory and interpretative in nature and used a convenience sample of patients who had consented for the service over 12 months from May 2022 to April 2023. KEY FINDINGS: During 12 months, 6811 referrals occurred, of which 71% were recorded as having different stages of the service completed on PharmOutcomes™. Medicines reconciliation, first-prescription review, and consultation stages decreased as patients progressed through the service. Slightly greater rates of completion were observed for patients receiving oral anticoagulants and for codeine or dihydrocodeine following hip and knee surgery, although overall referrals were low for this latter cohort. CONCLUSIONS: Through this service, community pharmacists are well placed to support the safe and effective use of medicines including oral anticoagulants and weak opioids posthospital discharge and potentially reduce incidents of avoidable harm. The variations in recorded completion rates across the three stages of the service and the apparent greater finalization rates for the high-risk medicines studied require further investigation.

Removal of incorrect penicillin allergy labels in a UK hospital.

OBJECTIVES: Penicillin allergy records are common, often incorrect and are associated with broad spectrum antibiotic use. We piloted a pharmacist-led multidisciplinary penicillin allergy de-labelling daily ward round to determine the opportunity for penicillin allergy de-labelling in a UK hospital. METHODS: A daily ward round, delivered by antibiotic pharmacists or junior doctors, identified adult medical and surgical patients between 7 November 2022 and 31 January 2023 with a penicillin allergy record that was preventing first-line penicillin use. An allergy history was taken before risk stratifying likelihood of future harm from penicillin re-exposure and an allergy testing method was determined (direct de-label on history alone or after direct drug provocation testing). After successful allergy de-label, the antibiotic was switched to a penicillin antibiotic. RESULTS: Of 7214 inpatients during the study period, 1133 (15.7%) had a penicillin allergy record. Of 285 allergy histories taken, 105 (36.8%) met high-risk criteria, 45 (15.8%) met low-risk criteria eligible for direct de-label and 73 (25.6%) met criteria eligible for direct drug provocation testing. We were unable to obtain a history for 61 (21.4%) patients. Of 45 low-risk patients eligible for direct de-label, 40 (88.9%) were de-labelled of whom 24 (53.3%) were switched to a penicillin antibiotic. Of 73 patients with a low-risk allergy history eligible for direct drug provocation testing, 16 (21.9%) received direct drug provocation testing, of whom 9 were switched to a penicillin antibiotic. Two direct de-label patients experienced harm (thrush within 5 days and delayed skin reaction after day 5); none of the direct drug provocation testing patients had a reaction by day 5. The switches resulted in reduced alternative antibiotic use by 173 Daily Defined Doses (DDDs). DISCUSSION: Penicillin allergy de-labelling patient pathway delivered by pharmacists and junior doctors was safe and effective and well accepted by patients and the wider clinical teams.

Newer generation antidepressants and withdrawal effects: reconsidering the role of antidepressants and helping patients to stop.

In England, the prescribing of antidepressants, primarily the newer generation antidepressant classes, has steadily increased over recent years. There is ongoing debate about how the efficacy of these drugs is viewed, their place in therapy and the harms associated with stopping them. Much of the evidence of their efficacy comes from short-term placebo-controlled trials which tend not to include outcomes that are of greatest relevance to patients, such as social functioning or quality of life, but rather restrict outcomes narrowly to symptom measures. On such measures these studies do not demonstrate clinically significant differences from placebo for depression. A range of adverse effects are also recognised, often greater in naturalistic studies of long-term antidepressants users than those measured in short-term efficacy studies, including emotional numbing, sexual difficulties, fatigue and weight gain. There is increasing recognition that withdrawal symptoms from antidepressants are common and that these symptoms can be severe and long-lasting in some patients. Recent guidance on how to stop antidepressants in a tolerable way has been presented by the Royal College of Psychiatrists. We believe that increasing awareness about the difficulty that some patients have in stopping antidepressants should lead to more cautious prescribing practice, with antidepressants given to fewer patients and for shorter periods of time. This article discusses the perceived benefits and harms of antidepressant use.

Exploring pharmacist involvement in the discharge medicines reconciliation process and information transfer to primary care: an observational study.

Background Medication errors can occur because of incomplete or poorly communicated information at the transition from hospital to community. Following an audit in 2016, a project was undertaken to determine if pharmacists could improve the quality of medication information in discharge summaries by introducing a discharge medication reconciliation process. Pharmacists recorded any changes to the patient's medication in the electronic prescribing system during their inpatient stay and summarised these changes on discharge. Objective To compare medication information in discharge summaries with recognised standards for the clinical structure and content of patient records, and to assess the impact of the pharmacist process on compliance with certain elements of these standards. Setting A 750 bed teaching district general hospital in England. Method A retrospective observational study examining all patient discharge summaries over a 1 week period for compliance to national standards. Main outcome measure The main outcome measures were compliance with standards for medication started, stopped or changed in hospital and any differences between extent of recording this information by doctors and pharmacists. Results Data were collected and analysed for 243 patients, of whom 94 (38.7%) attracted a discharge medicines reconciliation process by a pharmacist. Discharge summaries were compliant with basic standards for changed medication in 42% of patients or 51.4% with the input of a pharmacist. This increase of 9.4% was statistically significant (p = 0.0365). At an enhanced level, pharmacists increased compliance from 39.1 to 46.5%, this did not represent a significant increase (p = 0.0989). Conclusion Pharmacists undertaking a discharge medication reconciliation process significantly improves the quality of discharge summaries.

Focus group study exploring the issues and the solutions to incorrect penicillin allergy-labelled patients: an antibiotic stewardship patient safety initiative.

OBJECTIVES: Approximately 10% of the general population are reported to have a penicillin allergy, but more than 90% of these patients are able to tolerate penicillins after formal assessment. Patients with penicillin allergy labels have poorer health outcomes and incorrect labels impact negatively on healthcare systems. Identifying patients with incorrect penicillin allergy labels (those who can safely take penicillin) has the potential to benefit patients and healthcare systems. This study explores barriers and enablers towards identifying and removing incorrect penicillin allergy labels in inpatients ('delabelling'). METHODS: Two focus groups were completed with a total of 17 doctors, nurses and pharmacists at a 750-bed district general hospital in England. RESULTS: Thematic analysis identified four main themes: managing penicillin allergic patients, environmental barriers, education for patients and staff and a future delabelling process. Staff reported that identifying and delabelling incorrect penicillin allergy records was a complex task and not a priority during the acute presentation. Participants felt confident removing erroneous allergy records if the patient was able to describe the reaction. Balancing time to confirm and delabel with competing duties was felt to be a challenge. Revisiting the discussion with the patient when time was less pressured was offered as a solution to the problem. The lack of provision to translate uncertainty about allergy status in the electronic health record was mentioned as a barrier to accurate documentation of allergy history. Ensuring all patient records were amended to reflect the new allergy status was identified as a challenge. A delabelling process involving nurses, doctors and pharmacist was discussed. CONCLUSIONS: Delabelling patients with erroneous penicillin allergy labels was recognised as a complex problem. A patient pathway involving nurses, doctors and pharmacist is likely to be the optimal method to safely delabel patients.

Involving community pharmacists in transfer of care from hospital: Indications of reduced 30-day hospital readmission rates for patients in Cornwall.

OBJECTIVES: The purpose of this study was to determine any benefit from a discharge transfer of care service from hospital to community pharmacy. METHOD: A cross-sectional cohort design was used to compare actioned and non-actioned transfers of care. KEY FINDINGS: Of the 1130 transfers of care referrals to pharmacies in 2017, 365 patients received an actioned community pharmacy service after discharge. The 30-day readmission rate was 8.5% (31/365) in those who received an actioned community pharmacist service compared to 23.3% (178/765) in those who did not. Odds ratio for readmission at 30 days was 3.26 (95% CI 2.04 to 4.59, P < 0.0001), significantly higher in those not receiving an actioned transfer of care service. CONCLUSION: Involving community pharmacy at patient discharge appears to contribute to lower rates of readmission.

A UK hospital survey to explore healthcare professional views and attitudes to patients incorrectly labelled as penicillin allergic: an antibiotic stewardship patient safety project.

OBJECTIVES: To ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic stewardship intervention at the study hospital. METHODS: An electronic questionnaire (SurveyMonkey) was distributed to medical, nursing and pharmacy staff at a 750-bed teaching district general hospital with no specialist allergy service. RESULTS: 193 staff responded (58% medical, 31% nursing and 11% pharmacy). Virtually all staff had encountered patients who believed themselves to be penicillin allergic, but felt the patient's belief to be erroneous. The potential negative consequences of an incorrectly assigned penicillin allergy label were acknowledged by the majority of respondents. In total, 188/190 (99%) of staff thought patients having an incorrect allergy status to penicillin was a problem and required a solution. Staff reported they would feel confident using a validated evidence-based question tool to de-label patients incorrectly labelled as penicillin allergic if the process was supported by Trust management, although many still felt apprehensive about de-labelling patients for fear of patient harm through inappropriate de-labelling. CONCLUSIONS: A penicillin allergy de-labelling intervention would be well supported by healthcare workers at the study hospital, demonstrating a receptive environment for this behavioural change intervention. Further exploration of the barriers and levers to introducing an intervention is required using behavioural change methodology in order to design a successful de-labelling intervention.