Original Title: Avis sur la standardisation des pratiques relatives aux allergies aux bêta-lactamines

Authors' objectives: In Québec, the small number of allergy specialists limits access to diagnostic tests. This is especially true for patients in remote areas. This problem is in addition to that of the heterogeneity associated with the different healthcare software programs used across Québec, which is responsible for suboptimal documentation and sharing of information throughout the entire care continuum. The objectives of this project were, therefore, to prepare a report with recommendations addressed to decision-makers for standardizing the practice regarding diagnosis, the documentation and sharing of health information on drug allergies, and furthermore to create a set of practices support tools to assist health professionals who are not specialized in the area of allergy.

Authors' results and conclusions: RESULTS: After completing its work, INESSS developed several practical tools containing, among other things, definitions, essential components of the history, profitable questions, and a list of severity criteria that can guide and assist the different professionals in adopting a more focused and more effective diagnostic approach when there is a suspected drug allergy. The resemblance analyses and the results obtained in the meta-analysis led to the identification of BLs with a higher moderate risk of cross-reactivity with penicillins and those with a much lower risk. Clinical recommendations for the different professionals who are not specialized in allergy and a decision algorithm summarizing the main key criteria for managing the risk associated with reintroducing a BL based on the severity of the initially observed allergic reaction were therefore proposed. Until health information on drug allergies is centralized in the Québec Health Record (QHR), INESSS is also proposing the use of a standardized form for reporting a new allergic drug reaction in order to standardize the documentation methods and to ensure sustained communication between the different professionals, which is necessary for achieving the patient’s therapeutic objectives. In light of its work, and following a public consultation and numerous discussions with different stakeholders, INESSS is also proposing implementation recommendations intended for the MSSS, healthcare software providers, healthcare facility administrators and other key players that will promote the implementation of such a form throughout the province. CONCLUSION: Within these tools, INESSS wishes to support health professionals in the diagnostic approach to be used with a patient with symptoms suggestive of an allergy after taking penicillin or whose medical record indicates a suspected or confirmed drug allergy. Based on the different information gathered during the clinical interview, and following an analysis of the risks for the patient, the different professionals will therefore be better equipped and will be able to recommend discontinuing the drug, reintroducing it or, if there is some diagnostic doubt, turning to an allergist. Until the QHR becomes efficient and functional, the standardized form proposed by INESSS could be a good alternative for quickly improving the processes for documenting and reporting drug allergies and at the same time promoting more sustained communication between the different health professionals, which is necessary for patient safety.

Authors' recommendations: FOR MSSS: Create favourable conditions for the large-scale dissemination and appropriation of the “ New allergic drug reaction reporting form ” (AH-707A DT-9309) standardized and proposed by INESSS by establishing collaborative initiatives with the partners in the healthcare system.  Improve the allergy/adverse effects module developed in Cristal Net, the province wide electronic health record system (EHR), according to INESSS’s terminology and best practices, as recommended in INESSS’s information brief and tools, such as the new allergic drug reaction reporting form. Ensure that the information in the “new allergic drug reaction reporting form” proposed by INESSS is usable by the different healthcare software programs in the form of indexed/digitized/interoperable data to make exporting them to the Québec Health Record (QHR) easier, if applicable. One of the avenues to explore consists in modifying the certification criteria (technical and functional standards) for the different healthcare software programs (e.g., electronic medical file [DMÉ], EHR, pharmacy software) and in making the allergy and intolerance aspect a priority in Bill 59 (QHR). Take steps to ensure that the allergy/intolerance modules in the different healthcare software programs enable the user to provide greater detail on observed reactions with free text. (FOR PROFESSIONAL ORDERS, FEDERATIONS AND ASSOCIATIONS): Promote the appropriation and use of the practice aid tools developed by INESSS and the “new allergic drug reaction reporting form” through the usual means of dissemination and as part of continuing education activities. (FOR FACULTIES OF MEDICINE, PHARMACY, NURSING AND DENTISTRY):  Encourage the professors in charge of courses on drug allergies or the treatment and prevention of infections requiring the use of BL in the faculties of medicine, pharmacy, nursing and dentistry to integrate into the course plans the practice aid tools developed by INESSS. (FOR SUPPLIERS OF HEALTHCARE SOFTWARE PROGRAMS):  Host the different practice aid tools developed by INESSS and ensure that they are easily accessible to the different healthcare professionals.

Authors' methods: This information brief is based on an explicit methodology that includes systematic literature searches, a critical evaluation of the relevant publications, and a presentation and systematic summary of the conclusions, which included the triangulation of several sources of experiential, contextual and scientific data. The search for scientific information for all the research questions was conducted in several databases and was limited to certain types of publications (e.g., clinical practice guidelines, consensus conferences and systematic reviews) published between 2010 and 2016 in French or English. The documents identified were selected independently by two examiners according to pre-established selection criteria. The quality of each publication selected was assessed with recognized standard evaluation checklists. Only good-quality publications were selected. Contextual and experiential data were gathered qualitatively throughout the project during consultations with the different stakeholders (e.g., monitoring committee, advisory committee, key informers, external experts and future users) by different means, namely, face-to-face and telephone encounters and email exchanges. The data concerning the physiological (e.g., definitions of the different types of allergic and nonallergic reactions) and clinical (e.g., process leading to a diagnosis, the most common clinical allergic manifestations associated with BLs, important elements of the history, and criteria for referring patients to a specialist) were extracted from the different selected publications, worked on and improved with the Advisory Committee’s members and adapted according to the needs of professionals who are not specialized in allergy and according to the context of Québec healthcare. The recommendations concerning the choice of antibiotic therapy in a penicillin-allergic patient were developed on the basis of 1) the data gathered during the analyses of chemical structure similarities between the penicillins and cephalosporins following a special collaboration with the medical chemistry laboratory of the Centre de recherche du CHU de Québec  Université Laval, 2) the data obtained from a systematic review with a meta-analysis based on individual and pooled data on the risk of cross-reactivity between the different BLs, 3) the experiential knowledge on the part of the Advisory Committee’s allergists, and 4) the needs of primary care professionals when an allergist cannot be consulted. The recommendations and strategies for documenting, sharing and sending data on allergic drug reactions across the different health professionals (e.g., pharmacists, physicians and nurses) and across the different levels of service (e.g., private or hospital pharmacy, medical clinic and emergency room) were developed on the basis of the recommendations extracted from the different publications selected with a view to contextualizing the practice in Québec, mainly on the basis of experiential data and following consultations with the different stakeholders. The feedback gathered during a province-wide online survey for assessing the relevance, user-friendliness, versatility and contents of a standardized form for reporting a new allergic reaction were used to improve the recommendations and better identify field needs.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/avis-sur-la-standardisation-des-pratiques-relatives-aux-allergies-aux-beta-lactamines-modifications-apportees-au-rapport-du-20-fevrier-2017.html

Year Published: 2017

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/avis-sur-la-standardisation-des-pratiques-relatives-aux-allergies-aux-beta-lactamines-modifications-apportees-au-rapport-du-20-fevrier-2017.html

Requestor: Minister of Health

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec