Check Again Collaborative

Antibiotic allergy de-labelling has become a focus of international antimicrobial stewardship programs. In Australia, over two million people report an antibiotic allergy, with one in ten in hospitals reporting an allergy to penicillin. As many as 85% of these allergies can be safely tested and de-labelled.³ As outlined in the Antimicrobial Stewardship Clinical Care Standard, antibiotic allergies should be accurately assessed and documented to allow for optimal antimicrobial prescribing. It is known that patients labelled with a penicillin allergy have increased prevalence of Clostridioides difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), and have longer hospital stays.¹ Inaccurate penicillin allergy labels have been associated with increased use of broad-spectrum antibiotic use and inappropriate prescribing.² Due to the success of the Better Care Victoria project that implemented an inpatient antibiotic allergy assessment and de-labelling service at Austin Health and Peter MacCallum Cancer Centre, Safer Care Victoria chose to expand the project to other health services in the state. 

A change package was developed to support other Victorian health services with the roll out of an inpatient penicillin allergy assessment and de-labelling program. 

The core activities undertaken during the planning phase of this project included:  

1. Encouraging health services to collect four weeks of baseline data prior to the project commencement
2. Implementing process mapping to identify key stakeholders for engagement and to determine stages in the patient’s journey where penicillin allergies could be identified, assessed and de-labelled
3. Establishing governance structures and stakeholder engagement mechanisms to enable project success
4. Development of local guidelines, including inclusion criteria for penicillin allergy testing
5. Education for clinicians. 

At the time, limited support and services were available to de-label low risk penicillin allergies in other health services in Victoria. 

Key measures for the project included percentage of patients with:

• No risk of a true penicillin allergy that have their allergy directly de-labelled
• Low risk of a true penicillin allergy that have their allergy de-labelled following an oral challenge
• A documented penicillin allergy in the medical record with the active ingredient, the date of the reaction, its nature and severity specified.

Safer Care Victoria found the following barriers in implementing allergy de-labelling services in Victorian hospitals: 

• Varying levels of clinician knowledge about penicillin allergy labels 
• Lack of expertise and confidence in implementing a penicillin allergy de-labelling service 
• Low priority to assess antibiotic allergies
• Overreporting of penicillin allergies by patients due to experiencing a side effect to a penicillin, childhood reactions, family history, miscommunication and overcaution. 

Safer Care Victoria collaborated with health services to use the Model for Improvement to implement penicillin allergy de-labelling at 12 health facilities including rural, regional and metropolitan hospitals. Safer Care Victoria ran three in-person learning sessions and three health service-based action periods, where changes were tested and adapted. The participating sites maintained contact with each other and Safer Care Victoria, and regularly shared wins, challenges and learnings.

Of the 12 sites, 11 have implemented a guideline to conduct inpatient penicillin de-labelling.

The program has: 

• Achieved a 25% increase in access to comprehensive allergy assessment for hospitalised patients 
• Developed a toolkit to share learnings. 

System benefits:
Safer Care Victoria is partnering with the international Network of Antibiotic Allergy Nations (iNAAN) to form the Check Again Network. The Check Again Network will scale and spread the work of the Collaborative to additional Victorian sites and create the opportunity for services to share wins, challenges, and learnings.