clostridiumdifficile order set 1207
increase in the proportion of patients with C. difficile related complications between the preintervention and postintervention periods (5.0% vs 8.9%; P=.11) (Table 2). Among those with complications associated with hospital-acquired CDI in the post period, we observed only 1 case in which C. difficile testing was “delayed” more than 24 hours because of the CCDS tool.
discussion
In this large quality-improvement study, we examined the impact of a CCDS tool on the testing of Clostridium difficile across a heterogeneous patient population in diverse inpatient clinical settings. This intervention resulted in a statistically significant decrease in inappropriate C. difficile testing. The CCDS tool led to a substantial increase in discontinuation
of laxatives both in patients with diarrhea who had C. difficile testing sent and in patients with diarrhea who did not have C. difficile testing sent. As a result, patients with diarrhea were less likely to continue receiving laxatives, potentially preventing patient discomfort and dissatisfaction. Additionally, the
proportion of patients who had C. difficile testing was identical during the 2 study periods, suggesting that overall the tool did not discourage appropriate and timely testing. Notably, we observed a small but nonsignificant increase in the overall proportion of patients who experienced a C. difficile–related complication (eg, ICU transfer, colectomy, or death) for those with hospital-acquired C. difficile in the postintervention period. Possible explanations for this increase include an increase in virulent strains of C. difficile or improved documentation of complications by infection preventionists responsible for C. difficile surveillance activities. The order set seems to be a less likely cause, as only 1 of the cases with complications had C. difficile testing delayed more than 24 hours. The strengths of this study include the size and diversity
of the patient population included. Many examinations of quality-improvement initiatives are limited to single units or service lines and by study population and duration. These restrictions can limit generalizability. By contrast, this study population was comprised of all inpatients hospitalized across a multientity academic hospital system over a multiyear period. Nonetheless, this study has several limitations. First, our
figure 1. Pre-post Analysis of Impact of Tool on ProcessMeasures NOTE: Cdiff, C. difficile;D/c,discontinue;Lax,laxative; Pre, 12-month preintervention period; Post, 12-month postintervention period.
pre- and postintervention design does not control for cultural changes in testing and does not employ a control group. Second, we were not able to capture providers who viewed the order set and as a result did not order testing but did, in viewing the order set, benefit from the decision support provided. Third, we were unable to separate patients who received laxatives and had C. difficile testing ordered but also met other clinical criteria concerning for C. difficile infections andwould thus be considered high-risk patients. Fourth, other inappropriate indications for C. difficile testing could theore- tically be addressed by a CCDS tool that our current tool did not address, including repeated testing for C. difficile within a limited period and testing for cure. Adding such features could increase the impact of a CCDS tool on inappropriate testing for C. difficile. Future studies should explore the generalizability of
this intervention to nonacademic centers. A similar tool could also have an impact in long-term-care facilities where
table 2. ComplicationsofPatientswithHospital-Acquired Clostridium difficile Infection (CDI) in the Two Study Periods Complication
Perioda
1–ICU transfer for CDI complication 2–Surgery for CDI complication 3–CDI contributed to death 1 or 2 or 3
Preintervention Postintervention Preintervention Postintervention Preintervention Postintervention Preintervention Postintervention
NOTE: ICU, intensive care unit. aPreintervention and postintervention periods each spanned 12 months.
Proportion of CDI patients with complication, No. (%)
9/218 (4.2) 15/212 (7.1) 2/218 (0.9) 5/212 (2.3) 3/218 (1.4) 5/212 (2.4) 11/218 (5.0) 19/212 (8.9)
.24 .45 .11
P Value .18
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