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Eckardt P, Guran R, Jalal AT, Krishnaswamy S, Samuels S, Canavan K, Martinez EA, Desai A, Miller N, Cano Cevallos EJ. Impact of an electronic smart order-set for diagnostic stewardship of Clostridiodes difficile infection (CDI) in a community healthcare system in South Florida. Am J Infect Control 2024; 52:893-899. [PMID: 38935020 DOI: 10.1016/j.ajic.2024.04.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Inappropriate testing for Clostridiodes difficile infection (CDI) increases health care onset cases and contributes to overdiagnosis and overtreatment of patients in a community health care system. METHODS An electronic smart order set for the testing of CDI was created and implemented to improve the appropriateness of testing. A retrospective review of patients who were tested for CDI, pre and post, was conducted to determine if inappropriate stool testing for CDI decreased post-implementation of the order set. RESULTS 224 patients were tested for CDI during the study period with the post-implementation period having a higher proportion of patients who met appropriate testing criteria defined by presence of diarrhea (80.5% vs 61.3%; P = .002). The rate of inappropriate CDI stool testing decreased from 31.1% to 11.0% after implementation (P < .001). A higher proportion of CDI patients were readmitted within 30 days of discharge (54.2% vs 33.0%; P = 0.001) during the post-implementation period. CONCLUSIONS There was a significant reduction in inappropriate CDI testing following the implementation of the order set. There was an observed increase in the proportion of patients who underwent recent gastrointestinal surgery which may have contributed to the increase in 30-day readmission rates during the post-implementation period.
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Affiliation(s)
- Paula Eckardt
- Division of Infectious Disease, Medical Director of Antimicrobial Stewardship and Infection Control, Medical Director of MHS Ryan White Clinic, Memorial Healthcare System, Hollywood, FL
| | - Rachel Guran
- Director of Epidemiology and Infection Prevention, Memorial Healthcare System, Hollywood, FL.
| | - Ayesha T Jalal
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Shiv Krishnaswamy
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Shenae Samuels
- Office of Human Research, Memorial Healthcare System, Hollywood, FL
| | - Kelsi Canavan
- Office of Human Research, Memorial Healthcare System, Hollywood, FL
| | - Elsa A Martinez
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL
| | - Ajay Desai
- Florida Atlantic University, Boca Raton, FL
| | - Nancimae Miller
- Microbiology and Molecular Infectious Disease, Pathology Consultants of South Broward at Memorial Healthcare System, Hollywood, FL
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Shorten R, Pickering K, Goolden C, Harris C, Clegg A, J H. Diagnostic stewardship in infectious diseases: a scoping review. J Med Microbiol 2024; 73:001831. [PMID: 38722316 PMCID: PMC11165918 DOI: 10.1099/jmm.0.001831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/11/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction. The term 'diagnostic stewardship' is relatively new, with a recent surge in its use within the literature. Despite its increasing popularity, a precise definition remains elusive. Various attempts have been made to define it, with some viewing it as an integral part of antimicrobial stewardship. The World Health Organization offers a broad definition, emphasizing the importance of timely, accurate diagnostics. However, inconsistencies in the use of this term still persist, necessitating further clarification.Gap Statement. There are currently inconsistencies in the definition of diagnostic stewardship used within the academic literature.Aim. This scoping review aims to categorize the use of diagnostic stewardship approaches and define this approach by identifying common characteristics and factors of its use within the literature.Methodology. This scoping review undertook a multi-database search from date of inception until October 2022. Any observational or experimental study where the authors define the intervention to be diagnostic stewardship from any clinical area was included. Screening of all papers was undertaken by a single reviewer with 10% verification by a second reviewer. Data extraction was undertaken by a single reviewer using a pre-piloted form. Given the wide variation in study design and intervention outcomes, a narrative synthesis approach was applied. Studies were clustered around common diagnostic stewardship interventions where appropriate.Results. After duplicate removal, a total of 1310 citations were identified, of which, after full-paper screening, 105 studies were included in this scoping review. The classification of an intervention as taking a diagnostic stewardship approach is a relatively recent development, with the first publication in this field dating back to 2017. The majority of research in this area has been conducted within the USA, with very few studies undertaken outside this region. Visual inspection of the citation map reveals that the current evidence base is interconnected, with frequent references to each other's work. The interventions commonly adopt a restrictive approach, utilizing hard and soft stops within the pre-analytical phase to restrict access to testing. Upon closer examination of the outcomes, it becomes evident that there is a predominant focus on reducing the number of tests rather than enhancing the current test protocol. This is further reflected in the limited number of studies that report on test performance (including protocol improvements, specificity and sensitivity).Conclusion. Diagnostic stewardship seems to have deviated from its intended course, morphing into a rather rudimentary instrument wielded not to enhance but to constrict the scope of testing. Despite the World Health Organization's advocacy for an ideology that promotes a more comprehensive approach to quality improvement, it may be more appropriate to consider alternative regional narratives when categorizing these types of quality improvement interventions.
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Affiliation(s)
- Robert Shorten
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
- The University of Manchester, Manchester, UK
| | - Kate Pickering
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
| | - Callum Goolden
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
| | | | - Andrew Clegg
- University of Central Lancashire, Fylde Rd, Preston PR1 2HE, UK
| | - Hill J
- University of Central Lancashire, Fylde Rd, Preston PR1 2HE, UK
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3
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Ku TSN, Al Mohajer M, Newton JA, Wilson MH, Monsees E, Hayden MK, Messacar K, Kisgen JJ, Diekema DJ, Morgan DJ, Sifri CD, Vaughn VM. Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship. Infect Control Hosp Epidemiol 2023; 44:1901-1908. [PMID: 37665212 DOI: 10.1017/ice.2023.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.
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Affiliation(s)
- Tsun Sheng N Ku
- Billings Clinic, Billings, Montana
- Rocky Vista University Montana College of Osteopathic Medicine, Billings, Montana
| | - Mayar Al Mohajer
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Infectious Diseases Section, Baylor St. Luke's Medical Center, Houston, Texas
- Infection Prevention, Diagnostic Stewardship and Antibiotic Stewardship, CommonSpirit Health Texas Division, Houston, Texas
| | - James A Newton
- Department of Antibiotic Stewardship, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Marie H Wilson
- Infection Prevention & Control, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elizabeth Monsees
- Performance Excellence, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri School of Medicine, Kansas City, Missouri
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Kevin Messacar
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado/Children's Hospital Colorado, Aurora, Colorado
| | | | - Daniel J Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Maine Medical Center, Portland, Maine
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- VA Maryland Healthcare System, Baltimore, Maryland
| | - Costi D Sifri
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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4
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Ito H, Nakashima T, Oshida J, Fukui S, Kodama T, Kobayashi D. The incidence and factors of inappropriate rapid antigen test usage for group A streptococcus. J Infect Chemother 2023; 29:953-958. [PMID: 37343925 DOI: 10.1016/j.jiac.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/05/2023] [Accepted: 06/18/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Although rapid antigen tests (RADTs) for group A streptococcus (GAS) can help diagnose group A streptococcal pharyngitis, little is known about the inappropriate use of these RADTs. METHODS This retrospective observational study compared the appropriate vs. inappropriate use of RADTs in patients who had a RADT between January 2019 and August 2022. RADTs for patients with a low Centor score of 0-1 point were deemed inappropriate. RESULTS Of the 1015 patients, 380 (37.4%) had inappropriate RADTs. Patients with asthma were associated with an increased risk of inappropriate testing. In contrast, during the coronavirus 2019 pandemic, outpatients and residents were associated with a reduced risk of inappropriate testing. Consequent to the inappropriate use of RADTs, 162 (16.0%) patients received potentially inappropriate antibiotics. CONCLUSIONS Our results suggest that diagnostic stewardship for pharyngitis, including education for healthcare workers, is needed to reduce inappropriate test ordering and prevent unnecessary care.
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Affiliation(s)
- Hiroshi Ito
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan.
| | - Toshiya Nakashima
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan
| | - Jura Oshida
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan
| | - Sayato Fukui
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan
| | - Taisuke Kodama
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan
| | - Daiki Kobayashi
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan
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5
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Khuvis J, Alsoubani M, Mae Rodday A, Doron S. Impact of Diagnostic Stewardship Interventions on Clostridiodes difficile test ordering practices and results. Clin Biochem 2022; 117:23-29. [DOI: 10.1016/j.clinbiochem.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/24/2022]
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Ito H, Okamoto K, Yamamoto S, Yamashita M, Kanno Y, Jubishi D, Ikeda M, Harada S, Okugawa S, Moriya K. Incidence and Risk Factors for Inappropriate Use of Non-Culture-Based Fungal Assays: Implication for Diagnostic Stewardship. Open Forum Infect Dis 2022; 9:ofab601. [PMID: 35024373 PMCID: PMC8743121 DOI: 10.1093/ofid/ofab601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background Non-culture-based fungal assays (NCBFAs) have been used increasingly to help diagnose invasive fungal diseases. However, little is known about inappropriate use of NCBFAs. We aimed to investigate inappropriate use of NCBFAs in a tertiary academic hospital. Methods This retrospective cohort study included patients who underwent testing with beta-D glucan (BDG) between January and March 2018 or with galactomannan antigen (GMA) or cryptococcal antigen (CRAG) between January and June 2018. Testing was deemed appropriate if the clinical presentation was compatible with a fungal infection and there was a predisposing host factor at the time of ordering. We compared patients with appropriate and inappropriate use of NCBFAs using multivariate logistic regression analysis. Results Four hundred seventy patients (BDG, 394; GMA, 138; CRAG, 164) met inclusion criteria and were evaluated. About 80% of NCBFAs were deemed inappropriate. Ordering by transplant medicine physicians, repetitions of the test, the absence of predisposing factors for fungal infections, and the absence of recommendations from infectious diseases consultants were associated with an increased risk of inappropriate NCBFA use. Conclusions We found that a large proportion of NCBFAs were deemed inappropriate. There is an opportunity for diagnostic stewardship to reduce avoidable fungal testing among patients at low risk for fungal infection.
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Affiliation(s)
- Hiroshi Ito
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.,Division of Hospital Medicine, University of Tsukuba Hospital, Ibaraki, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Marie Yamashita
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshiaki Kanno
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Daisuke Jubishi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Mahoko Ikeda
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Sohei Harada
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.,Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
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Rock C, Perlmutter R, Blythe D, Bork J, Claeys K, Cosgrove SE, Dzintars K, Fabre V, Harris AD, Heil E, Hsu YJ, Keller S, Maragakis LL, Milstone AM, Morgan DJ, Dullabh P, Ubri PS, Rotondo C, Brooks R, Leekha S. Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health-academic collaborative: an evaluation of a quality improvement intervention. BMJ Qual Saf 2021; 31:153-162. [PMID: 34887357 PMCID: PMC8784990 DOI: 10.1136/bmjqs-2021-014014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/04/2021] [Indexed: 11/04/2022]
Abstract
To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health-academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals' experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health-academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.
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Affiliation(s)
- Clare Rock
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rebecca Perlmutter
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA
| | - David Blythe
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA
| | - Jacqueline Bork
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Dzintars
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sara Keller
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa L Maragakis
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA.,VA Maryland Health Care System, Baltimore, Maryland, USA
| | | | | | | | - Richard Brooks
- Emerging Infections Program, Maryland Department of Health, Baltimore, Maryland, USA.,Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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8
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In pursuit of the holy grail: Improving C. difficile testing appropriateness with iterative electronic health record clinical decision support and targeted test restriction. Infect Control Hosp Epidemiol 2021; 43:840-847. [PMID: 34085622 DOI: 10.1017/ice.2021.228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the impact of electronic health record (EHR)-based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI). DESIGN Quasi-experimental study in 3 hospitals. SETTING 957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals. INTERVENTIONS Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis. RESULTS C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75-0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85-0.98) and level (IRR 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50-0.92) relative to the baseline period. CONCLUSIONS Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.
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9
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Dunn AN, Radakovich N, Ancker JS, Donskey CJ, Deshpande A. The Impact of Clinical Decision Support Alerts on Clostridioides difficile Testing: A Systematic Review. Clin Infect Dis 2021; 72:987-994. [PMID: 32060501 DOI: 10.1093/cid/ciaa152] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Several studies have investigated the utility of electronic decision support alerts in diagnostic stewardship for Clostridioides difficile infection (CDI). However, it is unclear if alerts are effective in reducing inappropriate CDI testing and/or CDI rates. The aim of this systematic review was to determine if alerts related to CDI diagnostic stewardship are effective at reducing inappropriate CDI testing volume and CDI rates among hospitalized adult patients. METHODS We searched Ovid Medline and 5 other databases for original studies evaluating the association between alerts for CDI diagnosis and CDI testing volume and/or CDI rate. Two investigators independently extracted data on study characteristics, study design, alert triggers, cointerventions, and study outcomes. RESULTS Eleven studies met criteria for inclusion. Studies varied significantly in alert triggers and in study outcomes. Six of 11 studies demonstrated a statistically significant decrease in CDI testing volume, 6 of 6 studies evaluating appropriateness of CDI testing found a significant reduction in the proportion of inappropriate testing, and 4 of 7 studies measuring CDI rate demonstrated a significant decrease in the CDI rate in the postintervention vs preintervention period. The magnitude of the increase in appropriate CDI testing varied, with some studies reporting an increase with minimal clinical significance. CONCLUSIONS The use of electronic alerts for diagnostic stewardship for C. difficile was associated with reductions in CDI testing, the proportion of inappropriate CDI testing, and rates of CDI in most studies. However, broader concerns related to alerts remain understudied, including unintended adverse consequences and alert fatigue.
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Affiliation(s)
- Aaron N Dunn
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Nathan Radakovich
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Jessica S Ancker
- Division of Health Informatics, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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10
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Kang M, Abeles SR, El-Kareh R, Taplitz RA, Nyheim E, Reed SL, Jenkins IH, Seymann GB, Myers FE, Torriani FJ. The Effect of Clostridioides difficile Diagnostic Stewardship Interventions on the Diagnosis of Hospital-Onset Clostridioides difficile Infections. Jt Comm J Qual Patient Saf 2020; 46:457-463. [PMID: 32576438 DOI: 10.1016/j.jcjq.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Public reporting of Clostridioides difficile infection (CDI) using laboratory-identified events has led some institutions to revert from molecular-based tests to less sensitive testing modalities. At one academic medical center, researchers chose to use nucleic acid amplification test alone in CDI diagnosis with institutional protocols aimed at diagnostic stewardship. METHODS A single-center, quasi-experimental study was conducted to introduce and analyze the effects of various diagnostic stewardship interventions. In April 2017 an order report was created to inform providers of patients' recent bowel movements, laxative use, and prior Clostridioides difficile (CD) testing (Intervention 1). In November 2017 nursing staff were empowered to not send nondiarrheal stools for testing (Intervention 2). In February 2019, an interruptive alert was implemented to prevent testing that was not indicated (Intervention 3). CD testing rates and healthcare facility-onset CDI (HO-CDI) rates were compared before and after the interventions using one-way analysis of variance (ANOVA). RESULTS At baseline, testing for CD after 3 days of admission was performed at mean ± standard deviation of 15.9 ± 1.7 tests/1,000 patient-days. After Intervention 1, it decreased to 12.1 ± 1.1 tests. This further decreased to 10.6 ± 0.8 after Intervention 2 and to 8.1 ± 0.1 after Intervention 3 (p < 0.001). HO-CDI cases per 10,000 patient-days declined from 12.7 ± 1.4 cases at baseline to 10.7 ± 1.2 after Intervention 1, to 8.7 ± 2.4 after Intervention 2, and to 5.8 ± 0.2 after Intervention 3 (p = 0.03). CONCLUSION A multidisciplinary approach optimizing electronic health record support tools and leveraging nursing education can reduce both testing and HO-CDI rates while using the most sensitive testing modality.
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11
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Emberger J, Hitchcock MM, Markley JD. Diagnostic Stewardship Approaches to Clostridioides difficile Infection in the Era of Two-Step Testing: a Shifting Landscape. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Procop GW, Weathers AL, Reddy AJ. Operational Aspects of a Clinical Decision Support Program. Clin Lab Med 2020; 39:215-229. [PMID: 31036276 DOI: 10.1016/j.cll.2019.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Clinical decision support tools that involve improving test utilization should be jointly overseen by a laboratory stewardship committee and the hospital informatics team. The roles of these groups vary by institution and may overlap. This is a team effort and collaboration is a must. The effectiveness of these efforts in an institution depends on the receptiveness of leadership and providers, as well as the effectiveness of the associated committees. Examples of the challenges and successes of laboratory stewardship interventions that have been operationalized at the Cleveland Clinic that use clinical decision support tools, as well as associated literature, are reviewed.
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Affiliation(s)
- Gary W Procop
- Molecular Microbiology, Mycology, Parasitology and Virology Laboratories, Enterprise Laboratory Stewardship Committee, Department of Medical Operations, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue/ LL2-131, Cleveland, OH 44195, USA.
| | - Allison L Weathers
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 25900 Science Park Drive, AC220 Beechwood, OH 44122, USA
| | - Anita J Reddy
- Respiratory Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue/ G6-156, Cleveland, OH 44195, USA
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13
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Boly FJ, Reske KA, Kwon JH. The Role of Diagnostic Stewardship in Clostridioides difficile Testing: Challenges and Opportunities. Curr Infect Dis Rep 2020; 22:7. [PMID: 33762897 PMCID: PMC7987129 DOI: 10.1007/s11908-020-0715-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Accurate and timely diagnosis of Clostridioides difficile infection (CDI) is imperative to prevent C. difficile transmission and reduce morbidity and mortality due to CDI, but CDI laboratory diagnostics are complex. The purpose of this article is to review the role of laboratory tests in the diagnosis of CDI, and the role of diagnostic stewardship in optimization of C. difficile testing. RECENT FINDINGS Results from C. difficile diagnostic tests should be interpreted with an understanding of the strengths and limitations inherent in each testing approach. Use of highly sensitive molecular diagnostic tests without accounting for clinical signs and symptoms may lead to over-diagnosis of CDI and increased facility CDI rates. Current guidelines recommend a two-step, algorithmic approach for testing. Diagnostic stewardship interventions, such as education, order sets, order search menus, reflex orders, hard and soft stop alerts, electronic references, feedback and benchmarking, decision algorithms, and predictive analytics may help improve use of C. difficile laboratory tests and CDI diagnosis. The diagnostic stewardship approaches with the highest reported success rates include computerized clinical decision support (CCDS) interventions, face-to-face feedback, and real-time evaluations. SUMMARY CDI is a clinical diagnosis supported by laboratory findings. Together, clinical evaluation combined with diagnostic stewardship can optimize the accurate diagnosis of CDI.
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