clostridiumdifficile order set 1205
system across inpatient settings in a multihospital academic health system.
methods The Intervention
We defined an inappropriate C. difficile test as a stool specimen tested for C. difficile from a patient who received laxatives in the 36 hours prior to the ordering of the test. All other C. difficile tests were considered appropriate. We created a computerized clinical decision support (CCDS) tool in the form of a C. difficile order set in the inpatient electronic health record. Providers were required to use the order set to order testing for C. difficile in all inpatient settings. The order set automatically identified patients receiving laxativeswithin the previous 36 hours and displayed the following message: “In patients who do not have severe illness, stop laxatives and reassess diarrhea in 24 hours before sending a C. difficile test.” In such cases, the names, doses, frequency, and route of each laxative administered to the patient in the previous 36 hours were displayed, along with the last date and time of administration. Users had the following options: (1) discontinue the laxatives directly from the order set without ordering C. difficile testing, (2) discontinue the laxatives and proceed with ordering C. difficile testing, or (3) proceed with ordering C. difficile testing without discontinuing any laxatives (Supplement Figure 1). If a patient received a laxative within the previous 36 hours, the order set defaulted to option 1. If a patient did not receive laxatives within the previous 36 hours, then the order set only displayed the C. difficile test order (Supplement Figure 2). The order set went live on March 11, 2014.
Clostridium difficile Testing
Our C. difficile testing algorithm includes enzyme immunoassay (EIA) for glutamate dehydrogenase and toxins A/B (Techlab C. Diff Chek Complete; Alere, Orlando, FL), followed by a nucleic acid amplification test (NAAT) (Illumigene, Meridian Bioscience, Cincinnati, OH; changed to BDMax, Becton-Dickinson, Sparks, MD, in August 2013) for discordant EIA results (glutamate dehydrogenase positive but toxin A/B negative).10 Clostridium difficile testing is restricted to stool specimens that are semiformed to liquid (Bristol score of ≥5), and testing cannot be repeated for 9 days to reduce inappropriate C. difficile testing. Cases of C. difficile were documented in the surveillance
program Theradoc (Hospira, Salt Lake City, UT), as well as Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) database formandatory state public reporting requirements. For positive C. difficile assays sent ≥48 h after hospital admission and from patients readmitted within 14 days of a previous discharge, we determined whether NHSN criteria were met for each event.11 Adjudicated C. difficile infections (CDI) were classified as complicated if associated with ICU transfer, colectomy, or death attributed to CDI within 30 days.12
Setting
The CCDS intervention was developed, implemented, and evaluated in an academic healthcare system comprised of 3 acute-care teaching hospitals—Hospital of the University of Pennsylvania (HUP), Penn PresbyterianMedical Center (PPMC) and Pennsylvania Hospital (PAH)—with a combined capacity of more than 1,500 beds and 70,000 annual admissions. In the preintervention period, 224 encounters with hospital-acquired CDI and 407 encounters with non–hospital-acquired CDI occurred, for a total baseline CDI rate of 0.91% (631 of 69,362 encounters). The tool was used across all adult inpatient units, where resident physicians are responsible for most orders placed. All hospitals within the healthcare system used Sunrise Clinical Manager version 5.5 (Allscripts, Chicago, IL) as the inpatient EHR for order entry. An e-mail message communicating the implementation of the tool was distributed to all faculty and staff across the healthcare system, including attendings, trainees, nurses, and administrators. In addition, broadcast screensavers communicating the implementation of the tool were displayed on all computer workstations on all units across the healthcare system, excluding patient rooms.
Study Population
The study population included all adult patients who were hospitalized at the 3 health system hospitals during the study period. The preintervention period spanned 12 months prior to implementation of the CCDS tool (March 1, 2013–February 28, 2014). The postintervention period spanned a 12-month period after the implementation of the CCDS tool (April 1, 2014–March 31, 2015). Patients hospitalized between March 1, 2014, and April 1, 2014, were excluded to allow for a wash-in period.
Primary and Secondary Outcomes Measures
The primary outcome measure of this study was the change in proportion of inappropriate C. difficile tests sent, defined as any C. difficile stool assay ordered on a patient receiving laxatives in the preceding 36 hours. Additional outcome measures included the number of patients who had laxatives discontinued within 15 minutes from the time the order was placed, and proportion of patients with C. difficile tests sent, positive C. difficile tests, positive tests in patients receiving laxatives (which we classified as false-positive C. difficile tests), and C. difficile related complica- tions (ICU transfer, colectomy, or CDI-related death) for those with adjudicated hospital-acquired infections. For those with complications associated with hospital-acquired CDI, we also examined whether C. difficile testing was “delayed” more than 24 hours as a result of the CCDS tool (ie, C. difficile testing was delayed because the patient was receiving a laxative). The delay duration was measured as the difference between the first instance of a C. difficile order placed but not performed because of active laxative use and the first instancewhere the C. difficile order was placed and performed.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144
