Infection Control & Hospital Epidemiology (2019), 40, 467–469 doi:10.1017/ice.2019.18
Concise Communication
Use of a best practice alert linking Clostridioides difficile infection test results to a severity-based treatment order set Holly L. Reed PharmD1
, Trevor C. Van Schooneveld MD, FACP2, Craig G. Reha PharmD1 and
Scott J. Bergman PharmD, FIDSA, FCCP, BCPS1 1Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska and 2Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
Abstract
We evaluated provider adherence to practice guidelines for inpatients diagnosed with Clostridoides difficile infection (CDI) before and after implementation of a best practice alert (BPA) linking a positive test result to guideline-based orders. After implementation of the BPA, guideline-based prescribing increased from 39.4% in 2013 to 67.7% in 2016 (P = .014).
(Received 25 October 2018; accepted 13 January 2019)
Clostridoides difficile infection (CDI) practice guidelines published by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) and the American College of Gastroenterology (ACG) provide treatment recommendations based on severity of illness.1,2 Prior to the recent update in treatment recommendations from the IDSA, both guide- lines recommended the use of metronidazole for mild-to-moderate CDI and oral vancomycin for severe and complicated infections. Recent studies have found that only 49% of CDI patients were
treated appropriately with first-line treatment according to hospi- tal algorithms.3 With literature demonstrating improved outcomes and reduced complications with the use of guideline-based CDI treatment recommendations, antimicrobial stewardship programs (ASPs) have focused on methods to increase guideline-based prescribing.4–6 One tool to improve guideline-based prescribing is integrating clinical decision support systems (CDSS) into electronic medical records. Best practices with CDSS are to provide informa- tion in a formthat is most appropriate for those who are most likely to act on it, to anticipate workflows in design, and to provide mean- ingful data that is directly actionable.7 Although CDSS may take many forms, a common intervention is an electronic best practice alert (BPA) directed toward prescribers, which presents relevant clinical data linked to an action, such as an order set. In March 2014 our institution’s antimicrobial stewardship pro-
gram (ASP) implemented an electronic alert via a BPA linking a positive test result for CDI to guideline-based orders for those not currently on CDI therapy. We sought to evaluate the utility of this BPA and linked a CDI treatment order set while measuring guideline-based prescribing and CDI complications.
*The title has been updated since original publication. A corrigendum notice detailing
this change was also published (DOI: 10.1017/ice.2019.81) Author for correspondence: Holly L. Reed, Email:
Horeed@nebraskamed.com Cite this article: Reed HL, et al. (2019). Use of a best practice alert linking Clostridioides
difficile infection test results to a severity-based treatment order set. Infection Control & Hospital Epidemiology, 40: 467–469,
https://doi.org/10.1017/ice.2019.18
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
Methods Study design
This retrospective, single-center, quasi-experimental study utilized chart review to evaluate CDI guideline adherence before and after the implementation of aBPAand linked a severity-based treatment order set in March 2014. Adult inpatients (aged >19 years) with laboratory-confirmed CDI were included in the study. Patients were excluded if they had a documented vancomycin or metroni- dazole allergy or intolerance. Those diagnosed with CDI in 2013 served as controls before BPA implementation and patients from 2016 served as cases, allowing for a washout period after implementing the CDSS tool. Infection severity was defined by the 2010 IDSA guidelines for CDI diagnosed in 2013 and in 2016 using a modified algorithm of the IDSA and ACG guidelines (Supplementary Fig. 2).
Best practice alert and linked severity-based treatment order set
To improve CDI treatment and outcomes, we created a CDI clini- cal pathway, a severity-based treatment order set, and a BPA linked to this order set, which went live in March 2014. The clinical path- way was based on national guidelines and made available to pro- viders on the hospital’s website (
www.NebraskaMed.com/asp). The guidance included (1) a description of CDI symptoms that may prompt testing such as significant or persistent diarrhea with leukocytosis, fever, new-onset abdominal pain and/or distention; (2) C. difficile assay characteristics and interpretation; infection control requirements; and (3) severity-based treatment recom- mendations. In addition, recommendations for discontinuation of concomitant antimicrobials and acid suppressants, if possible, and appropriate consult services were included. No specific CDI education was provided to groups either before or after implemen- tation other than a short summary of the CDI treatment guideline with a link to the website, which was distributed via an institutional
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