P-1123. Optimizing use of Cefazolin for Surgical Prophylaxis in Patients with Penicillin Allergy Labels

TL;DR

This study shows how improving communication and workflow design can increase appropriate use of cefazolin in patients with penicillin allergy labels during surgery.

Contribution

A novel approach combining workflow optimization and provider feedback to improve cefazolin prescribing in patients with penicillin allergy labels.

Findings

Cefazolin prescribing rates increased from 63% to 75% after optimizing order set verbiage.

Further increase to 80% was achieved after distributing provider prescribing summaries.

Engaging end users and refining CPOE alerts improved adherence to best practices.

Abstract

Cefazolin (CFZ), a common antibiotic used in surgical prophylaxis, is not always utilized when appropriate in patients with a penicillin (PCN) allergy due to concerns regarding potential cross-reactivity. Use of alternative antibiotics has been associated with increased risk of surgical site infections and delays in start of surgery due to longer infusions.Figure 1:WorkflowFigure 2:Antimicrobial prophylaxis recommendations

Workflow

Antimicrobial prophylaxis recommendations

Our team completed a multi-step evaluation including contextual inquiry to identify potential opportunities for optimization within the current workflow and collaborated with key stakeholders to identify areas for intervention.Table 1:Cefazolin prescribing rates in individuals with documented penicillin allergies

Cefazolin prescribing rates in individuals with documented penicillin allergies

Contextual inquiry demonstrated several key barriers including various workflows for ordering of perioperative antibiotics, identification of a CPOE alert regarding potential of cross-allergenicity, and lack of clarity for who is ultimately responsible for decision as to which antibiotic to use.

As an initial intervention, the Antimicrobial Stewardship team collaborated with orthopedics and allergy clinicians to provide guidance on risk of cross-reactivity with CFZ/common PCN-based antibiotics and the importance of updating the medical record with accurate allergy information. This educational initiative demonstrated increased CFZ prescribing which was sustained for the following two quarters, however, still left room for optimization.

Several strategies were developed and proposed to key stakeholders including integrated pathways detailing workflow and antibiotic recommendations (figures 1 and 2). After discussion, the decision was made to continue with utilization of the current order set with optimized verbiage to nudge providers to use CFZ in individuals with documented PCN allergies. In addition, individual provider ordering summaries were distributed to the individual orthopedic and anesthesiology providers detailing the rate of CFZ prescribing in these individuals as compared to their top quartile peers. Prescribing rates of CFZ increased from a baseline of 63% to 75% after optimization of the order sets and 80% post distribution of the provider summaries (table 1).

This collaboration demonstrated the importance of engaging end users in strategy meetings as well optimizing the verbiage in CPOE systems to support recommendations.

Amanda Binkley, PharmD, BCIDP, AAHIVP, Shionogi: Advisor/Consultant

Figures