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Background Up to 15% of hospitalized patients report a penicillin allergy, but most can tolerate a β-lactam (BL). Use of second-line non-BL antibiotics poses untoward health consequences. Assessing for true penicillin allergies includes penicillin skin testing (PST) and a direct amoxicillin challenge, each with their own limitations in hospitalized patients. For inpatients, a graded challenge (GC) with the desired BL offers a streamlined approach for many who could benefit from a first-line BL agent. In 2019, a hospital-wide BL Allergy Assessment and Clinical Pathway was implemented, including a BL GC protocol for low-risk patients. This study aimed to assess the safety of the GC procedure in hospitalized patients. Methods A retrospective, observational cohort study of adult inpatients who completed a GC procedure between Sept 2019 – Sept 2021 was conducted. Primary objective: determine the incidence of a significant hypersensitivity reaction from a BL GC. Secondary objectives: 1) determine the incidence of a non-hypersensitivity reaction and 2) identify antimicrobial stewardship interventions in those tolerant to a BL GC (e.g. antibiotic switch to a BL with completion of treatment course and de-labeling of penicillin allergy). Results Fifty-one patients completed a GC procedure. Most (78%) had a reported allergy to penicillin vs. other BL antibiotics. Reported allergic reactions stratified by risk for a serious hypersensitivity episode were: low/reaction > 10 yrs ago – 33%; moderate-high/reaction > 10 yrs ago – 47%, and moderate-high/reaction < 5 yrs ago – 19.6%. A PST prior to a GC was performed in 75% of patients. Common GC agents included amoxicillin-clavulanate (16%), amoxicillin (12%) and ceftriaxone (12%). One patient experienced a hypersensitivity reaction managed with diphenhydramine and another patient had a non-hypersensitivity reaction. Both cases were non-life-threatening. Of the 49 patients who tolerated a GC, 76% were switched to a BL with completion of treatment course, and 84% of documented penicillin allergies were de-labeled or clarified in the electronic medical record. Conclusion The GC procedure in our hospitalized patients was generally well tolerated including those with an allergy history concerning for a moderate-high risk hypersensitivity reaction. Disclosures Nathaniel J. Rhodes, PharmD, MSc, American Academy of Colleges of Pharmacy: Grant/Research Support|Paratek: Grant/Research Support|Third Pole Therapeutics: Advisor/Consultant Marc H. Scheetz, PharmD, MSc, Abbvie: Advisor/Consultant|Allecra: Grant/Research Support|Merck: Advisor/Consultant|Nevakar: Advisor/Consultant|Nevakar: Grant/Research Support|Premier Healthcare Solutions: Honoraria|Spero: Advisor/Consultant|SuperTrans Medical: Advisor/Consultant|SuperTrans Medical: Grant/Research Support|Takeda: Advisor/Consultant|Third Pole Therapeutics: Advisor/Consultant.

To improve the timeliness and quality of discharge for patients by creating the role of the attending nurse.Discharge time affects hospital throughput and patient satisfaction. Bedside nurses and hospitalists have competing priorities that can hinder performing timely, high-quality discharges.This retrospective analysis evaluated the effect of an attending nurse paired with a hospital medicine physician on discharge time and quality. A total of 8329 patient discharges were eligible for the study, and propensity score matching yielded 2715 matched pairs.In the post-intervention matched cohort, the percentage of patients discharged before 2 PM increased from 34.4% to 45.9% (p .01), and the median discharge time moved 48 min earlier. In the unmatched cohort, patient satisfaction with the discharge process improved on several questions. While length of stay was not affected, the 30-day readmission rate did increase from 8.9% to 10.7% (p = .02).With the new attending nurse role, we positively impacted throughput by shifting discharge times earlier in the day while improving patient satisfaction. Length of stay stayed the same but the 30-day readmission rate increased.Our multidisciplinary approach to the problem of late discharge times led to the creation of a new role. This role made ownership of discharge tasks clear and reduced competing priorities, freeing up nurses and hospitalists to perform other care-related responsibilities without holding up discharges.

Background There is no known method for determining the minimum number of beds in hospital inpatient units (IPs) to achieve patient waiting-time targets. This study aims to determine the relationship between patient waiting time–related performance measures and bed utilization, so as to optimize IP capacity decisions. Methods The researchers simulated a novel queueing model specifically developed for the IPs. The model takes into account salient features of patient-flow dynamics and was validated against hospital census data. The team used the model to evaluate inpatient capacity decisions against multiple waiting time outcomes: (1) daily average, peak-hour average, and daily maximum waiting times; and (2) proportion of patients waiting strictly more than 0, 1, and 2 hours. The results were published in a simple Microsoft Excel toolbox to allow administrators to conduct sensitivity analysis. Results To achieve the hospital's goal of rooming patients within 30 to 60 minutes of IP bed requests, the model predicted that the optimal daily average occupancy levels should be 89%–92% (182–188 beds) in the Medicine cohort, 74%–79% (41–43 beds) in the Cardiology cohort, and 72%–78% (23–25 beds) in the Observation cohort. Larger IP cohorts can achieve the same queueing-related performance measure as smaller ones, while tolerating a higher occupancy level. Moreover, patient waiting time increases rapidly as the occupancy level approaches 100%. Conclusion No universal optimal IP occupancy level exists. Capacity decisions should therefore be made on a cohort-by-cohort basis, incorporating the comprehensive patient-flow characteristics of each cohort. To this end, patient-flow queueing models tailored to the IPs are needed.