Reducing Inappropriate Selection of Penicillin Alternatives in Outpatient Surgery Patients

Abstract

Problems and Purpose: Current recommendations suggest cefazolin, a first-generation cephalosporin, as the first line choice for perioperative surgical prophylaxis. Providers refrain from its administration due to suspected cross sensitivity reactions in patients with penicillin allergies (Heuer & Kossick, 2017). Penicillin alternatives cause an increased risk of surgical site infection, an increase in adverse/anaphylactic reactions, and higher rates of patient complications (Blumenthal et al., 2017). The purpose of this project is to formulate strategies to reduce the rate of erroneous penicillin alternative administration. Methods: A retrospective quality improvement project was conducted at a large Level-1 Trauma Center in the Mid-Atlantic Region. The data elements collected were specifically focused on outpatients undergoing colorectal surgery over the course of a two-year period (2017-2019). Descriptive statistics were measured using frequencies and percentages regarding the patient’s comprehensive surgical information. One-on-one interviews were also conducted with staff members (n=9). The interviews were focused on obtaining the qualitative reports and perspectives of the staff regarding perceived barriers to protocol adherence. Results: Over the course of two years, 454 patients underwent (n=26) reporting an allergy to penicillin. There were 34% (n=9) of patients who had no allergic reactions appropriately charted in their EHR. Out of those patients, 69.2% (n=18) received some form of penicillin alternative for antibiotic prophylaxis prior to surgery. Finally, only 7% (n=2) of patients had a true indication for alternative antibiotic administration based on the institutions protocol. Common themes found in interviews included: lack of communication, lack of accountability, and relying on the “other” provider to document the allergy. Conclusion: Utilization of a standardized preoperative assessment, staff education, and increased pharmacy collaboration could lead to a significant decrease in the use of penicillin alternatives. The next steps of the project would be continued surveillance of recommendations by pharmacy and anesthesia staff and further analysis for possible areas of project sustainability and improvement.