Implementation of a Clinical Decision Support Tool for Stool Cultures and Parasitological Studies in Hospitalized Patients

Abstract

There is substantial evidence that stool culture and parasitological examinations are of minimal to no value after 3 days of hospitalization. We implemented and studied the impact of a clinical decision support tool (CDST) to decrease the number of unnecessary stool cultures (STCUL), ova/parasite (O&P) examinations, and Giardia/Cryptosporidium enzyme immunoassay screens (GC-EIA) performed for patients hospitalized Ͼ3 days. We studied the frequency of stool studies ordered before or on day 3 and after day 3 of hospitalization (i.e., categorical orders/total number of orders) before and after this intervention and denoted the numbers and types of microorganisms detected within those time frames. This intervention, which corresponded to a custom-programmed hard-stop alert tool in the Epic hospital information system, allowed providers to override the intervention by calling the laboratory, if testing was deemed medically necessary. Comparative statistics were employed to determine significance, and cost savings were estimated based on our internal costs. Before the intervention, 129/670 (19.25%) O&P examinations, 47/204 (23.04%) GC-EIA, and 249/1,229 (20.26%) STCUL were ordered after 3 days of hospitalization. After the intervention, 46/521 (8.83%) O&P examinations, 27/157 (17.20%) GC-EIA, and 106/1,028 (10.31%) STCUL were ordered after 3 days of hospitalization. The proportions of reductions in the number of tests performed after 3 days and the associated P values were 54.1% for O&P examinations (P Ͻ 0.0001), 22.58% for GC-EIA (P ϭ 0.2807), and 49.1% for STCUL (P Ͻ 0.0001). This was estimated to have resulted in $8,108.84 of cost savings. The electronic CDST resulted in a substantial reduction in the number of evaluations of stool cultures and the number of parasitological examinations for patients hospitalized for more than 3 days and in a cost savings while retaining the ability of the clinician to obtain these tests if clinically indicated.KEYWORDS O&P examinations, stewardship, stool culture, utilization T he current migration from volume-based reimbursement to value-based health care delivery encourages health care leaders to reexamine practices to optimize cost-effective care delivery (1, 2). There is a substantial literature that demonstrates that clinical laboratory tests are often overused by health care providers (3, 4). Unnecessary testing not only results in inflated health care costs but may also result in patient harm secondary to iatrogenic anemia and false-positive test results that require retesting and other follow-up procedures.Microbiologists have been among the earliest advocates for the appropriate use of laboratory studies (5). The value of cultures for bacterial enteric pathogens and parasitological examinations of the stool for patients who develop diarrhea after 3 days of hospitalization has been examined by many researchers over decades (6)(7)(8)(9). It has been shown that there is no to very low detection of community-acquired pathogens (e.g., Salmonella, Giardia, et cetera), i...

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