To better understand clinicians’ rationale for ordering testing for C. difficile infection (CDI) for patients receiving laxatives and the impact of the implementation of a clinical decision support (CDS) intervention.

A mixed-methods, case series was performed from March 2, 2017 to December 31, 2018.

Yale New Haven Hospital, a 1,541 bed tertiary academic medical center.

Hospitalized patients ≥ 18 years old, and clinicians who were alerted by the CDS.

CDS was triggered in real-time when a clinician sought to order testing for CDI for a patient who received one or more doses of laxatives within the preceding 24 hours.

A total of 3,376 CDS alerts were triggered during the 21-month study period from 2,567 unique clinician interactions. Clinicians bypassed the CDS alert 74.5% of the time, more frequent among residents (48.3% bypass vs. 39.9% accept) and advanced practice providers (APPs) (34.9% bypass vs. 30.6% accept) than attendings (11.3% bypass vs. 22.5% accept). Ordering clinicians noted increased stool frequency/output (48%), current antibiotic exposure (34%), and instructions by an attending physician to test (28%) were among the most common reasons for overriding the alert and proceeding with testing for CDI.

Testing for CDI despite patient laxative use was associated with an increased clinician concern for CDI, patient risk for CDI, and attending physician instruction for testing. Attendings frequently accepted CDS guidance while residents and APPs often reinstated CDI test orders, suggesting a need for greater empowerment and discretion when ordering tests.

Methicillin-resistant Staphylococcus aureus (MRSA) nasal swabs are utilized to guide the discontinuation of empiric MRSA therapy. In multiple studies, MRSA nasal swabs have been shown to have a negative predictive value (NPV) of ~99% in non-oncology patients with pneumonia and other infections. We evaluated the performance characteristics of a negative MRSA nasal swab in the acute myeloid leukemia (AML) populaion to determine its NPV.

Retrospective chart review.

This study included adult AML patients with a suspected infection and a MRSA nasal swab collected between 2013 and 2018.

MRSA nasal swab and culture-documented infections were identified to determine the sensitivity, specificity, NPV, and positive predictive value of the MRSA nasal swabs.

In total, 194 patients were identified, and 484 discrete encounters were analyzed. Overall, 468 (97%) encounters had a negative MRSA nasal swab upon admission with no cultured documented MRSA infection during their hospitalization. However, 3 encounters (0.6%) had a negative MRSA nasal swab with a subsequent cultured documented MRSA infection during their admission. Identified infections were bacteremia (n = 2) and confirmed pneumonia (n = 1). MRSA nasal swab had a sensitivity of 62% (95% CI, 0.24–0.91), specificity of 98% (95% CI, 0.96–0.99), positive predictive value of 38% (95% CI, 0.21–0.6), and NPV of 99% (95% CI, 0.98–1).

A negative MRSA nasal swab has a 99% NPV for subsequent MRSA infections in AML patients with no prior history of MRSA colonization or infection. Based on these findings, a negative MRSA nasal swab can help guide de-escalation of empiric MRSA antibiotic therapy.

Influenza vaccine receipt by healthcare workers (HCWs) is important because HCWs are at risk for occupational exposure to influenza and may act as vectors in the nosocomial transmission of influenza. HCWs were surveyed to determine whether belief in commonly held influenza vaccine misconceptions was associated with influenza vaccine acceptance.

Cross-sectional study.

A large urban teaching hospital.

A self-administered survey was used to assess nursing and physician staff influenza vaccine knowledge, current vaccination status, and potential reasons for vaccine declination.

Two hundred twelve of 215 surveys were completed. The overall influenza vaccination rate was 73%. Physician staff were significantly more likely to have been vaccinated compared with nursing staff (82% vs 62%, respectively; P = .0009). HCWs answering the 5 influenza vaccine basic knowledge questions correctly were significantly more likely to have been vaccinated than those responding incorrectly to any question (84% vs 64%, respectively; P = .002). This association was present in the nursing group where 80% of those answering the knowledge questions correctly were vaccinated, but only 49% of those answering incorrectly were vaccinated (P = .000005). However, in the physician group, there was no significant difference in the influenza vaccination rates between those answering correctly and those answering incorrectly (P = .459).

Belief in commonly held influenza vaccine misconceptions was significantly associated with influenza vaccine declination among nursing staff and may act as a barrier to greater rates of influenza vaccination. Reasons for influenza vaccine nonreceipt may differ between nursing and physician staff.