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The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection

  • Jessica R. Howard-Anderson (a1), Mary Elizabeth Sexton (a1), Chad Robichaux (a2), Zanthia Wiley (a1), Jay B. Varkey (a1), Sujit Suchindran (a1), Benjamin Albrecht (a3), K. Ashley Jones (a3), Scott K. Fridkin (a1) and Jesse T. Jacob (a1)...

Abstract

Objective:

To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).

Design:

An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.

Setting:

Four hospitals in an academic healthcare network.

Patients:

All patients with a C. difficile order after hospital day 3.

Intervention:

Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).

Results:

Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).

Conclusion:

An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.

Copyright

Corresponding author

Author for correspondence: Jessica R. Howard-Anderson, E-mail: Jrhowa4@emory.edu

Footnotes

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PREVIOUS PRESENTATION: A preliminary version of this work was presented at the Society for Healthcare Epidemiology of America Spring Conference on April 26, 2019, in Boston, Massachusetts.

Footnotes

References

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1.2015 Annual report for the Emerging Infections Program for Clostridium difficile infection. Centers for Disease Control and Prevention website. https://www. Cdc.Gov/Hai/Eip/Annual-CDI-Report-2015.Html. Accessed March 25, 2018.
2.Lessa, FC, Mu, Y, Bamberg, WM, et al.Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825834.
3.McDonald, LC, Gerding, DN, Johnson, S, et al.Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66(7):e1–e48.
4.Magill, SS, O’Leary, E, Janelle, SJ, et al.Changes in prevalence of health care–associated infections in US hospitals. N Engl J Med 2018;379:17321744.
5.Zacharioudakis, IM, Zervou, FN, Pliakos, EE, Ziakas, PD, Mylonakis, E. Colonization with toxinogenic C. difficile upon hospital admission, and risk of infection: a systematic review and meta-analysis. Am J Gastroenterol 2015;110:381390.
6.Alasmari, F, Seiler, SM, Hink, T, Burnham, C-AD, Dubberke, ER. Prevalence and risk factors for asymptomatic Clostridium difficile carriage. Clin Infect Dis 2014;59:216222.
7.White, DR, Hamilton, KW, Pegues, DA, Hanish, A, Umscheid, CA. the impact of a computerized clinical decision support tool on inappropriate Clostridium difficile testing. Infect Control Hosp Epidemiol 2017;38:12041208.
8.Buckel, WR, Avdic, E, Carroll, KC, Gunaseelan, V, Hadhazy, E, Cosgrove, SE. Gut check: Clostridium difficile testing and treatment in the molecular testing era. Infect Control Hosp Epidemiol 2015;36:217221.
9.Rock, C, Pana, Z, Leekha, S, et al.National Healthcare Safety Network laboratory-identified Clostridium difficile event reporting: a need for diagnostic stewardship. Am J Infect Control 2018;46:456458.
10.Dubberke, ER, Han, Z, Bobo, L, et al.Impact of clinical symptoms on interpretation of diagnostic assays for Clostridium difficile infections. J Clin Microbiol 2011;49:28872893.
11.Thaler, RH, Sunstein Cass, R. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press; 2008.
12.Vaughn, VM, Linder, JA. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf 2018;27:583586.
13.Sunstein, CR. Nudging smokers. N Engl J Med 2015;372:21502151.
14.Meeker, D, Knight, TK, Friedberg, MW, et al.Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014;174:425431.
15.Caris, MG, Labuschagne, HA, Dekker, M, Kramer, MHH, van Agtmael, MA, Vandenbroucke-Grauls, CMJE. Nudging to improve hand hygiene. J Hosp Infect 2018;98:352358.
16.Penfold, RB, Zhang, F. Use of interrupted time series analysis in evaluating healthcare quality improvements. Acad Pediatr 2013;13(6):S38–S44.
17.Truong, CY, Gombar, S, Wilson, R, et al.Real-Time electronic tracking of diarrheal episodes and laxative therapy enables verification of Clostridium difficile clinical testing criteria and reduction of Clostridium difficile infection rates. J Clin Microbiol 2017;55:12761284.
18.Sharp, SE, Ruden, LO, Pohl, JC, Hatcher, PA, Jayne, LM, Ivie, WM. Evaluation of the C.Diff Quik Chek complete assay, a new glutamate dehydrogenase and A/B toxin combination lateral flow assay for use in rapid, simple diagnosis of Clostridium difficile disease. J Clin Microbiol 2010;48:20822086.
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The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection

  • Jessica R. Howard-Anderson (a1), Mary Elizabeth Sexton (a1), Chad Robichaux (a2), Zanthia Wiley (a1), Jay B. Varkey (a1), Sujit Suchindran (a1), Benjamin Albrecht (a3), K. Ashley Jones (a3), Scott K. Fridkin (a1) and Jesse T. Jacob (a1)...

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