Infectious Disease

Test restrictions more effective than EHR-based assistance in reducing C. difficile tests

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An intervention that required administrative approval of all Clostridioides difficile tests after hospital day 3 outperformed electronic health record-based support in reducing C. difficile tests, according to one study.

“We did this work as part of a larger quality improvement initiative with the aim of improving the accuracy of diagnosing C. difficile infection, improving the quality of care for patients, and improving the publicly reported C. difficile rates in our healthcare system to lower.” Sarah S. Lewis, MD, MPH, Associate professor of medicine in the Infectious Disease Department at Duke University Medical Center, Healio said.

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Test restriction was more effective than electronic health record-based clinical decision support to reduce Clostridioides difficile tests.
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“We made a number of changes to the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when a test was not clinically indicated, such as when patients with diarrhea did one had a more likely explanation such as recent laxative use, or ordering tests on patients who had no diarrhea or other symptoms of C. difficile infection, ”said Lewis. “In addition, a hospital independently implemented a medical ‘gatekeeper’ in our system to approve all C. difficile test arrangements for admitted patients.”

Lewis and colleagues tested the three EHR-based interventions in three hospitals. The first intervention, launched in January 2018, alerted clinicians who ordered a test if laxatives were administered within 24 hours. The second, initiated in October 2018, canceled test orders after 24 hours. The third intervention, implemented in July 2019, comprised “context-related rule-driven ordering questions” that had to be justified when administering laxatives or when there was no EHR documentation of diarrhea. In February 2019, one of the three hospitals then carried out the “gatekeeper intervention”, which required authorization, for all C. difficile tests after a 3-day hospital stay.

Sarah S. Lewis

Lewis and colleagues estimated the impact of the interventions on C. difficile testing and in-hospital C. difficile infection (HO-CDI) using an intermittent time series analysis. They found that the C. difficile tests were already in the prevention phase (annual change in the incidence rate [IR] = 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions.

However, the study showed that the laxative warning in two hospitals was temporally associated with a trend reduction in the HO-CDI (annual change in IR from baseline = 0.85; 95% CI 0.75-0.96). Meanwhile, the gatekeeper intervention in the third hospital was with a decrease in C. difficile test (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 the HO-CDI (annual change in IR = 0.68; 95% CI, 0.5-0.92) compared to the baseline period, the researchers reported.[IRR[=05;95%CI042-06)andtrendreductionsinCdifficiletesting(annualchangeinIR=091;95%CI085-098)andlevel(IRR=042;95%CI022-081)andtrendreductionsinHO-CDI(annualchangeinIR=068;95%CI05-092)relativetothebaselineperiodtheresearchersreported[IRR[=05;95%CI042-06)andtrendreductionsinCdifficiletesting(annualchangeinIR=091;95%CI085-098)andlevel(IRR=042;95%CI022-081)andtrendreductionsinHO-CDI(annualchangeinIR=068;95%CI05–092)relativetothebaselineperiodtheresearchersreported

“Diagnostic stewardship, or the appropriate use of diagnostic tests, is important to improve the quality of care. Electronic decision support in the form of alerts or background logic to reinforce the desired vendor behavior is attractive because it is relatively low in resources, easy to implement and relatively unobtrusively programmed for clinical workflow, ”said Lewis. “However, as we and others have seen, decision support often needs to be combined with both provider training and some form of administrative constraint in order to achieve the desired goals.”

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