Test stewardship, frequency and fidelity: Impact on reported hospital-onset Clostridioides difficile

Objective: To determine the impact of electronic health record (EHR)–based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI). Design: Quasi-experimental study in 3 hospitals. Setting: 957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals. Interventions: Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis. Results: C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72–0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75–0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85–0.98) and level (IRR 0.42; 95% CI, 0.22–0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50–0.92) relative to the baseline period. Conclusions: Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.

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confidence: 99%

In pursuit of the holy grail: Improving C. difficile testing appropriateness with iterative electronic health record clinical decision support and targeted test restriction

Karlovich

Sata

Griffith

et al. 2021

“…This intervention led to a 27% decrease in raw numbers of C. difficile tests as previously reported. 17 In this study, testing rates (to account for monthly patient volumes) similarly decreased with the EMR decision support. HO-CDI-rate models adjusted for testing rates demonstrated a lessening effect of intervention 5 compared with unadjusted models, suggesting that the decrease in reported HO rates is driven by lower testing volume rather than by tangible infection prevention benefit.…”

Section: Discussionmentioning

confidence: 53%

“…Fidelity to an evidence-based testing protocol did improve after intervention 5, as previously reported. 17…”

Section: Resultsmentioning

confidence: 99%

Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013–2018

Doll

Zhao

Kang

et al. 2020

Self Cite

Objective: To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period. Design: Interrupted time series. Setting: The study was conducted in an 865-bed academic medical center. Methods: Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018). Results: Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470). Conclusion: Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

“…A recent retrospective study demonstrated that an embedded electronic medical record decision-support matrix for ordering C. difficile testing resulted in a 27% reduction in total C. difficile testing, suggesting that electronic prompts are important in bolstering C. difficile diagnostic stewardship strategies. 30 Our study has several limitations, including potential shortcomings of the electronic health record (EHR) during the study periods. For example, documentation of CDI parameters, such as the number and consistency of stool (ie, Bristol stool type), was not consistently recorded and thus was not collected in this study.…”

Section: Discussionmentioning

confidence: 99%

The impact of changing reflexive to clinician-ordered Clostridioides difficile polymerase chain reaction (PCR) testing for indeterminate cases: Cost savings without associated adverse events

Sullivan

Majumdar

Ortiz

et al. 2020

Objective:To evaluate changing Clostridioides difficile infection (CDI) testing among inpatients with indeterminate enzyme immunoassay (EIA) results (antigen+/toxin−) from reflexive polymerase chain reaction (PCR) testing to clinician-ordered PCR testing.Design:Multicenter, before-and-after, quasi-experimental study.Setting:Four large urban tertiary-care hospitals.Methods:We evaluated two 6-month periods before and after an intervention. The primary study outcome was the change in the number of CDI diagnoses between periods. Secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings.Results:In total, 500 EIA-indeterminate C. difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 in the preintervention period versus 94 patients in the postintervention period (48% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281; 1 not performed due to an inhibitor) in the preintervention period versus 66% (144 of 219) in the postintervention period (34% reduction; P < .01). We observed no differences between study periods in 30-day all-cause (P = .96), GI-related (P = .93), or C. difficile (P = .47) readmissions, nor in 30-day C. difficile infections (P > .99). No patient without a PCR test in the postintervention period and not treated was later diagnosed with CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient.Conclusions:Applying diagnostic stewardship to C. difficile PCR testing in the inpatient setting led to significant reductions in both testing and cases. Changing the C. difficile PCR testing algorithm for EIA-indeterminate cases from reflexive to clinician-required ordering resulted in valuable cost savings without associated adverse events.