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

Norah S. Karlovich, Suchita Shah Sata, Brian Griffith, Ashley Coop, Ibukunoluwa C. Kalu, John J. Engemann, Jessica Seidelman, Nicholas A. Turner, Christopher R. Polage, Becky A. Smith, Sarah S. Lewis

Research output: Contribution to journalArticlepeer-review

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.

Original languageEnglish (US)
JournalInfection Control and Hospital Epidemiology
DOIs
StateAccepted/In press - 2021
Externally publishedYes

ASJC Scopus subject areas

  • Epidemiology
  • Microbiology (medical)
  • Infectious Diseases

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