Table 2 Representative quotes demonstrating perspectives of inpatient and outpatient clinicians

Knowledge

Knowledge (scientific rationale)

I think a lot of people would be convinced by the data out there about long term benefits to doing this. And people are probably not super aware of the data. So I think the data would be a good selling point overall (Resident 1)

Probably the majority of providers don't know that de-labeling of something that is actually a viable thing that we can do a lot of times historically or otherwise. (PCP 4)

Procedural knowledge

I think a big barrier is just that we have SharePoint, we have all these other folders, there’s different sites. I'm sure I could find [the CDST] if I went to go look for it, but we have so many different places to start looking that it's just hard to find where everything is, and how updated it is, because we have old versions of stuff and new versions. Our file organization system isn't the best. (Pharm 4)

I am aware that there are kind of protocols to look at history and things like that to delabel and then a paradigm or an algorithm to go through. But I don't think the majority of primary care doctors are. (PCP 4)

Skills

Skills

In terms of evaluating their risk for an actual activation of the allergy, I wouldn't feel extremely comfortable, especially doing that on my own. I feel like it's always been a discussion with the team and then if ID needs to get involved in evaluating from that standpoint of group collaboration of what do we think, when was this reaction? …But in terms of actually assigning a risk to it, I don't feel too comfortable at this point doing that on my own. (Pharm 5)

I think I'd be somewhat worried about the volume. I could just see getting trained initially and then we do this for one patient a month and no one has a reaction for 2 years. And then someone does have a reaction and we don't feel as comfortable anymore. (PCP 3)

Beliefs about capabilities

Perceived competence

We rarely do antibiotic test doses. So there may be a lot of concerns about doing that inpatient. So I think familiarity and comfort level across the disciplines is probably one of the barriers. Again, if we do this maybe four times a year, that's really quite infrequent that we're challenging patients. (Hospitalist 2)

Without having been there in the initial moment when they had the reaction, I think it's hard sometimes to be able to, to sort of distinguish and feel confident and questioning whether it was a true allergy. PCP#?

Beliefs about consequences

Outcome expectancies

I feel like if they had penicillin allergy on their chart, but maybe you didn't think it was all that severe, so you give penicillin anyway and having them have an anaphylactic reaction and possibly bad outcome. I think that's probably my biggest fear or barrier to removing the label or giving someone penicillin when they have a documented allergy. (Resident 2)

I haven't done the direct or, the ordering provider, the administrator, the monitoring provider. So I think without experience in that, it would be relatively unsafe and then we don't have any protocols for monitoring after things outside of a few minutes after a vaccination in clinic, we don't have a structure in place to have somebody actively monitor for longer. (PCP 2)

Professional role and identity

Professional role

It’d be nice to know who is ultimately going to lead the charge, because I feel like a lot of times, we might see it first, because the pharmacy technician put it in med rec. And then if we reach out to the team, I feel like, then sometimes it gets bounced from the team to ID. And if ID recommends getting allergy involved, and it kind of seems like it's always the next person who will be looking into it. And a lot of times I feel like that's where it falls through the cracks. So, if we knew who is going to take charge of it from the beginning, because by the time all those things have happened, the patient might be ready for discharge and then this falls through the cracks anyways, they've already selected a different antibiotic and are being discharged on something else. So, just kind of knowing who ultimately is in charge of that follow up. (Pharm5)

I guess historically part of the problem has been sort of ownership of that and kind of a belief that once it's on the chart, it's gold and we're not going to re diagnose a patient or kind of delve too much into that…so unless someone is prompting us to do that, it’s not something we're necessarily going to go into. (PCP 4)

I guess we would wonder what standard of care is, if it's standard for primary care to be doing this or if it's standard for allergy to be doing it…. I would just wonder if it's kind of outside the typical realm of what primary care would be doing to actually administer the trials…. I think there's a lot of very specific primary care things like healthcare maintenance type things that we don't have time to complete all of that. And so I would wonder if adding something that was more specialty driven is the best use of primary care resources but, but not impossible. (PCP 2)

Environmental context and resources

Environmental stressors

You get done with a long day at the hospital and it's like 6 pm and you're ready to go home. You could always ask yourself, could I go talk to this patient some more about penicillin allergy de-labeling? The answer is yes, there's always time there, but is there time within reasonably normal working hours that isn't going to burn the inpatient team out? (Hospitalist 1)

It's hard right now, the way the model is, when you're a pharmacist, you have two medical teams essentially that you're covering. And so usually they round at the same times and so you can't be in two places at once. (Pharmacist 2)

If primary care does all the preventative care that it’s supposed to do for each patient that comes in, that's going to take seven hours out of the day. Plus all the acute care needs that patients are bringing up and things they have to address and paperwork and other things. And so eventually the day just kind of runs out of time and, you know, we kind of struggle to do the things that typically fall under the umbrella of primary care in the way the system is currently set up. (PCP 4)

A lot of times when I'm seeing a new patient, there's so much to get done. There's so much medical history that when I'm entering the allergies, I'm kind of trying to go as fast as I can and it does ask, what the reaction was, but sometimes they're just like, ‘oh, I don't know.’ And I'm just like, okay ‘unknown, next.’ [Laughs] So, I think probably just general primary care time constraints is the big one. (PCP 3)

Resources/material resources

Eventually a lot of these patients need to be sent to the allergy clinic for testing or could get tested in the hospital. And we don't have FTE either here or in the allergy clinic to do that… But we have limited ability to do that because of [Allergy’s] space, their FTE and then our FTE. So that that's probably the biggest barrier. (AMSPh1)

At our community based outpatient clinics, I don't know if I would want to do this if a patient had a reaction, so if this would be done at the main hospital where, if something did happen, we've got the emergency department, we've got inpatient services right there… I could see some hesitancy with doing this procedure in some of our community based outpatient clinics or clinics that just aren't as well supported to navigate an issue if it arose. (Outpatient Pharm 2)

Organizational culture /climate

I think a lot of conversations now happen by Microsoft Teams. I think the lack of an in-person communication probably impacts that, like you don't want to bother them as much by sending them yet another Teams message, or your point might not necessarily get across in the electronic communication. I think a lot of times, often it’s just easier to have that face to face conversation, and really not having that with the physician teams, like I almost never see the physicians in person anymore, when I'm staffing on the floors, I guess I should say. (AMS Ph2)

For a procedure that takes 90 min, I feel like that might be a tough sell to have the team available…. that could be overwhelming if there's a lot of those coming through…. we're in a workforce shortage right now within primary care providers, LPNs, nurses… That, I think is something else to note, work availability of personnel to be able to implement it. (Outpatient Pharm 1)