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

Published online by Cambridge University Press:  10 February 2020

Jessica R. Howard-Anderson Open the ORCID record for Jessica R. Howard-Anderson [Opens in a new window] ,
Mary Elizabeth Sexton ,
Chad Robichaux ,
Zanthia Wiley ,
Jay B. Varkey ,
Sujit Suchindran ,
Benjamin Albrecht ,
K. Ashley Jones ,
Scott K. Fridkin  and
Jesse T. Jacob
Jessica R. Howard-Anderson*
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Mary Elizabeth Sexton
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Chad Robichaux
Affiliation:
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Zanthia Wiley
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Jay B. Varkey
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Sujit Suchindran
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Benjamin Albrecht
Affiliation:
Department of Pharmacy, Emory Healthcare, Atlanta, Georgia
K. Ashley Jones
Affiliation:
Department of Pharmacy, Emory Healthcare, Atlanta, Georgia
Scott K. Fridkin
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Jesse T. Jacob
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
*
Author for correspondence: Jessica R. Howard-Anderson, E-mail: Jrhowa4@emory.edu
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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.

Information

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 4 , April 2020 , pp. 411 - 417
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved

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Footnotes

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.

References

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.Google Scholar
Lessa, FC, Mu, Y, Bamberg, WM, et al.Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825–834.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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;379:1732–1744.CrossRefGoogle Scholar
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;110:381–390.CrossRefGoogle ScholarPubMed
Alasmari, F, Seiler, SM, Hink, T, Burnham, C-AD, Dubberke, ER. Prevalence and risk factors for asymptomatic Clostridium difficile carriage. Clin Infect Dis 2014;59:216–222.CrossRefGoogle ScholarPubMed
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;38:1204–1208.CrossRefGoogle ScholarPubMed
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;36:217–221.CrossRefGoogle ScholarPubMed
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;46:456–458.CrossRefGoogle ScholarPubMed
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;49:2887–2893.CrossRefGoogle ScholarPubMed
Thaler, RH, Sunstein Cass, R. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press; 2008.Google Scholar
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;27:583–586.CrossRefGoogle ScholarPubMed
Sunstein, CR. Nudging smokers. N Engl J Med 2015;372:2150–2151.CrossRefGoogle ScholarPubMed
Meeker, D, Knight, TK, Friedberg, MW, et al.Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014;174:425–431.CrossRefGoogle ScholarPubMed
Caris, MG, Labuschagne, HA, Dekker, M, Kramer, MHH, van Agtmael, MA, Vandenbroucke-Grauls, CMJE. Nudging to improve hand hygiene. J Hosp Infect 2018;98:352–358.CrossRefGoogle ScholarPubMed
Penfold, RB, Zhang, F. Use of interrupted time series analysis in evaluating healthcare quality improvements. Acad Pediatr 2013;13(6):S38–S44.CrossRefGoogle Scholar
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;55:1276–1284.CrossRefGoogle ScholarPubMed
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;48:2082–2086.CrossRefGoogle Scholar
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