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

Published online by Cambridge University Press:  04 June 2021

Norah S. Karlovich ,
Suchita Shah Sata ,
Brian Griffith ,
Ashley Coop ,
Ibukunoluwa C. Kalu ,
John J. Engemann ,
Jessica Seidelman ,
Nicholas A. Turner ,
Christopher R. Polage  and
Becky A. Smith
...Show all authors
Norah S. Karlovich
Affiliation:
School of Medicine, Duke University, Durham, North Carolina
Suchita Shah Sata
Affiliation:
Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
Brian Griffith
Affiliation:
Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
Ashley Coop
Affiliation:
Duke Health Performance Services, Durham, North Carolina
Ibukunoluwa C. Kalu
Affiliation:
Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University, Durham, North Carolina
John J. Engemann
Affiliation:
Raleigh Infectious Diseases, RaleighNorth Carolina
Jessica Seidelman
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
Nicholas A. Turner
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
Christopher R. Polage
Affiliation:
Department of Pathology, Duke University, Durham, North Carolina
Becky A. Smith
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
Sarah S. Lewis*
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
*
Author for correspondence: Sarah S. Lewis, E-mail: Sarah.stamps@duke.edu
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Abstract

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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 7 , July 2022 , pp. 840 - 847
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Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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Footnotes

a

Authors of equal contribution.

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