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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:S0196-6553(24)00341-9. [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] [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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Starolis MW, Zaydman MA, Liesman RM. Working with the Electronic Health Record and Laboratory Information System to Maximize Ordering and Reporting of Molecular Microbiology Results. Clin Lab Med 2024; 44:95-107. [PMID: 38280801 DOI: 10.1016/j.cll.2023.10.009] [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] [Indexed: 01/29/2024]
Abstract
Molecular microbiology assays have a higher cost of testing compared to traditional methods and need to be utilized appropriately. Results from these assays may also require interpretation and appropriate follow-up. Electronic tools available in the electronic health record and laboratory information system can be deployed both preanalytically and postanalytically to influence ordering behaviors and positively impact diagnostic stewardship. Next generation technologies, such as machine learning and artificial intelligence, have the potential to expand upon the capabilities currently available and warrant additional study and development but also require regulation around their use in health care.
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Affiliation(s)
- Meghan W Starolis
- Molecular Infectious Disease, Quest Diagnostics, 14225 Newbrook Drive, Chantilly, VA 20151, USA.
| | - Mark A Zaydman
- Department of Pathology & Immunology, Washington University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Rachael M Liesman
- Clinical Microbiology and Molecular Diagnostics Pathology, Department of Pathology, Medical College of Wisconsin, 9200 West Wisconsin, Milwaukee, WI 53226, USA
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3
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Lev V, Anbarchian T, Yao H, Bhat A, Britt P, Shieh L. Health care-associated Clostridioides difficile infection: Learning the perspectives of health care workers to build successful strategies. Am J Infect Control 2024; 52:284-292. [PMID: 37579972 DOI: 10.1016/j.ajic.2023.08.008] [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: 05/01/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Clostridioides difficile (C difficile) is one of the most common health care-associated infections that negatively impact patient care and health care costs. This study takes a unique approach to C difficile infection (CDI) control by investigating key prevention obstacles through the perspectives of Stanford health care (SHC) frontline health care personnel. METHODS An anonymous qualitative survey was distributed at SHC, focusing on knowledge and practice of CDI prevention guidelines, as well as education, communication, and perspectives regarding CDI at SHC. RESULTS 112 survey responses were analyzed. Our findings unveiled gaps in personnel's knowledge of C difficile diagnostic guidelines and revealed a need for targeted communication and guideline-focused education. Health care staff shared preferences and recommendations, with the majority recommending enhanced communication of guidelines and information as a strategy for reducing CDI rates. The findings were then used to design and propose internal recommendations for SHC to mitigate the gaps found. DISCUSSION Many guidelines and improvement strategies are based on strong scientific and medical foundations; however, it is important to ask whether these guidelines are effectively translated into practice. Frontline health care workers hold empirical perspectives that could be key in infection control. CONCLUSIONS Our findings emphasize the importance of including frontline health care personnel in infection prevention decision-making processes and the strategies presented here can be applied to mitigating infections in different health care settings.
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Affiliation(s)
- Vered Lev
- Stanford University School of Medicine, Stanford, CA.
| | | | - Hanqi Yao
- Stanford University School of Medicine, Stanford, CA
| | | | | | - Lisa Shieh
- Stanford University School of Medicine, Stanford, CA
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4
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Saif NT, Dooley C, Baghdadi JD, Morgan DJ, Coffey KC. Clinical decision support for gastrointestinal panel testing. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e22. [PMID: 38415090 PMCID: PMC10897720 DOI: 10.1017/ash.2024.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 02/29/2024]
Abstract
Objective This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel ("GI panel"). Design Single-center, retrospective, before-after study. Setting Tertiary care Veteran's Affairs (VA) Medical Center provides inpatient, outpatient, and residential care. Patients All patients tested with a GI panel between June 22, 2022 and April 20, 2023. Intervention We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A "soft stop" reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022. Results Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention. Conclusions Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.
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Affiliation(s)
- Nadia T. Saif
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cara Dooley
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan D. Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Veteran’s Affairs (VA) Maryland Healthcare System, Baltimore, MD, USA
| | - KC Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Veteran’s Affairs (VA) Maryland Healthcare System, Baltimore, MD, USA
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Advani SD, Claeys K. Behavioral Strategies in Diagnostic Stewardship. Infect Dis Clin North Am 2023; 37:729-747. [PMID: 37537001 DOI: 10.1016/j.idc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Fridkin SK, Onwubiko UN, Dube W, Robichaux C, Traenkner J, Goodenough D, Angulo FJ, Zamparo JM, Gonzalez E, Khanna S, Myers C, Dumyati G. Determinates of Clostridioides difficile infection (CDI) testing practices among inpatients with diarrhea at selected acute-care hospitals in Rochester, New York, and Atlanta, Georgia, 2020-2021. Infect Control Hosp Epidemiol 2023; 44:1085-1092. [PMID: 36102331 PMCID: PMC10369210 DOI: 10.1017/ice.2022.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We evaluated the impact of test-order frequency per diarrheal episodes on Clostridioides difficile infection (CDI) incidence estimates in a sample of hospitals at 2 CDC Emerging Infections Program (EIP) sites. DESIGN Observational survey. SETTING Inpatients at 5 acute-care hospitals in Rochester, New York, and Atlanta, Georgia, during two 10-workday periods in 2020 and 2021. OUTCOMES We calculated diarrhea incidence, testing frequency, and CDI positivity (defined as any positive NAAT test) across strata. Predictors of CDI testing and positivity were assessed using modified Poisson regression. Population estimates of incidence using modified Emerging Infections Program methodology were compared between sites using the Mantel-Hanzel summary rate ratio. RESULTS Surveillance of 38,365 patient days identified 860 diarrhea cases from 107 patient-care units mapped to 26 unique NHSN defined location types. Incidence of diarrhea was 22.4 of 1,000 patient days (medians, 25.8 for Rochester and 16.2 for Atlanta; P < .01). Similar proportions of diarrhea cases were hospital onset (66%) at both sites. Overall, 35% of patients with diarrhea were tested for CDI, but this differed by site: 21% in Rochester and 49% in Atlanta (P < .01). Regression models identified location type (ie, oncology or critical care) and laxative use predictive of CDI test ordering. Adjusting for these factors, CDI testing was 49% less likely in Rochester than Atlanta (adjusted rate ratio, 0.51; 95% confidence interval [CI], 0.40-0.63). Population estimates in Rochester had a 38% lower incidence of CDI than Atlanta (summary rate ratio, 0.62; 95% CI, 0.54-0.71). CONCLUSION Accounting for patient-specific factors that influence CDI test ordering, differences in testing practices between sites remain and likely contribute to regional differences in surveillance estimates.
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Affiliation(s)
- Scott K. Fridkin
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, AtlantaGeorgia
| | | | - William Dube
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
| | - Chad Robichaux
- Division of Biomedical Informatics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Jessica Traenkner
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
| | - Dana Goodenough
- Foundation for Atlanta Veterans’ Education and Research, Decatur, Georgia
- Atlanta Veterans’ Affairs Medical Center, Decatur, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Frederick J. Angulo
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, Collegeville, Pennsylvania
| | - Joann M. Zamparo
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, Collegeville, Pennsylvania
| | - Elisa Gonzalez
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, Collegeville, Pennsylvania
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Christopher Myers
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
- Infectious Diseases Division, University of Rochester Medical Center, Rochester, New York
| | - Ghinwa Dumyati
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
- Infectious Diseases Division, University of Rochester Medical Center, Rochester, New York
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Trirattanapikul A, Pasomsub E, Siriyotha S, Pattanaprateep O, Phuphuakrat A. Diagnostic stewardship to limit repeat plasma cytomegalovirus viral load testing. BMC Infect Dis 2023; 23:387. [PMID: 37296377 DOI: 10.1186/s12879-023-08355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Frequent serial monitoring of plasma cytomegalovirus (CMV) viral load caused unnecessary budgets for laboratory testing without changes in treatment. We aimed to implement diagnostic stewardship to limit CMV viral load testing at appropriate intervals. METHODS A quasi-experimental study was performed. To avoid unnecessary plasma CMV viral load testing, the inpatient electronic pop-up reminder was launched in 2021. In cases with plasma CMV viral load testing was ordered in intervals of less than five days, telephone interview and feedback were performed. Pre-post intervention data was compared in terms of clinical and monetary outcomes. The rate of plasma CMV viral load testing performed in intervals of less than five days was compared between 2021 and 2019 using the Poisson regression model. RESULTS After the protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test orders in intervals of less than five days from 17.5% to 8.0% [incidence rate ratio 0.40, p < 0.001]. There was no statistically significant difference in the incidence of CMV DNAemia and CMV disease (p = 0.407 and 0.602, respectively). As a result, the hospital could save the costs of plasma CMV viral load testing per 1,000 patients performed with intervals of less than five days from 2,646,048.11 to 1,360,062.89 Thai Baht. CONCLUSIONS The diagnostic stewardship program is safe and helpful in reducing unnecessary plasma CMV viral load testing and costs.
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Affiliation(s)
- Akeatit Trirattanapikul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Angsana Phuphuakrat
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Krouss M, Israilov S, Alaiev D, Tsega S, Talledo J, Chandra K, Zaurova M, Manchego PA, Cho HJ. SEE the DIFFerence: Reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system. Am J Infect Control 2022:S0196-6553(22)00783-0. [PMID: 36370868 DOI: 10.1016/j.ajic.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C. difficile leads to false positive results due to a high rate of asymptomatic colonization, resulting in unnecessary and harmful treatment for patients. METHODS This was a quality improvement initiative to decrease the rate of inappropriate C. difficile testing across 11 hospitals in an urban, safety-net setting. Three best practice advisories were created, alerting providers of recent laxative administration within 48 hours, a recent positive test within 14 days, and a recent negative test within 7 days. The outcome measures were the number of C. difficile tests per 1,000 patient days, as well as the rate of hospital onset C. difficile infection was compared pre- and post-intervention. The process measures included the rate of removal of the C. difficile test from the best practice advisory, as well as the subsequent 24-hour re-order rate. RESULTS The number of C. difficile tests decreased by 27.3% from 1.1 per 1,000 patient days preintervention (May 25, 2020-May 24, 2021) to 0.8 per 1,000 patient days postintervention, (May 25, 2021-March 25, 2022), P < .001. When stratified by hospital, changes in testing ranged from an increase of 12.5% to a decrease of 60%. Analysis among provider type showed higher behavior change among attendings than compared to trainees or advanced practice providers. There was a 12.1%, nonsignificant decrease in C. difficile rates from preintervention, 0.33 per 1,000 patient days compared to postintervention, 0.29 per 1,000 patient days, P=.32. CONCLUSIONS Using only an electronic health record intervention, we successfully decreased C. difficile orders after 72 hours of admission in a large, safety-net system. Variation existed among hospitals and by provider type.
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Affiliation(s)
- Mona Krouss
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Sigal Israilov
- Department of Anesthesia, Icahn School of Medicine, New York, NY
| | - Daniel Alaiev
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY
| | - Surafel Tsega
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, NYC Health + Hospitals/Kings County, New York, NY
| | - Joseph Talledo
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY
| | - Komal Chandra
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY
| | - Milana Zaurova
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Alacron Manchego
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Pediatrics, NYC Health + Hospitals/Kings County, New York, NY
| | - Hyung J Cho
- Department of Quality & Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, NYU School of Medicine, New York, NY
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9
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Wolf A, Sant'Anna A, Vilhelmsson A. Using nudges to promote clinical decision making of healthcare professionals: A scoping review. Prev Med 2022; 164:107320. [PMID: 36283484 DOI: 10.1016/j.ypmed.2022.107320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2022]
Abstract
Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.
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Affiliation(s)
- Axel Wolf
- University of Gothenburg, Centre for Person-Centred Care (GPCC), Sweden; University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Sweden
| | | | - Andreas Vilhelmsson
- Lund University, Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Sweden.
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10
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Katzman M, Cohrs AC, Hnatuck PE, Greene WH, Reed SM, Ward MA, Glasser FD, Loser MF, Hale CM. Impact of a Multipronged Approach to Reduce the Incidence of Clostridioides difficile Infections in Hospitalized Patients. Am J Infect Control 2022; 51:668-674. [PMID: 36075295 DOI: 10.1016/j.ajic.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Effective approaches to reduce Clostridioides difficile infections (CDI) in hospitalized patients are needed. We report data from 3 years preceding and 3 years following interventions that proved successful, with detailed analysis of all cases the first year after implementation. METHODS Interventions included a nursing protocol to identify cases present on admission by asking if the patient had 1 or more liquid stools in the last 24 hours, and a 2-step testing algorithm with samples positive by polymerase chain reaction (PCR) for the C. difficile toxin gene reflexing to an enzyme immunoassay (EIA) for the toxin antigen. RESULTS Healthcare-associated infections due to CDI fell from ∼160 in each of the preceding 3 years to <65 in each of the subsequent 3 years (P<0.001), while the ratio of observed-to-expected hospital-onset cases diminished to ∼0.50 (P<0.02). In the first year, 395 samples were PCR(+), but only 118 (29.9%) of these were EIA(+). 55 (46.6%) of the PCR(+)/EIA(+) samples were from hospital day 1 or 2 and classified as present on admission. The mean time from stool collection to report of PCR results was ∼7.5 hours, and the EIA took on average only 68 additional minutes to be reported. CONCLUSIONS The number of incident CDI cases can be dramatically decreased by implementing an admission screening question and a 2-step testing algorithm.
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Affiliation(s)
- Michael Katzman
- Department of Medicine and Department of Microbiology and Immunology, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA.
| | - Austin C Cohrs
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Patricia E Hnatuck
- Department of Quality and Infection Prevention, Milton S. Hershey Medical Center, Hershey, PA
| | - Wallace H Greene
- Department of Clinical Pathology, Milton S. Hershey Medical Center, Hershey, PA
| | - Stephanie M Reed
- Department of Nursing, Milton S. Hershey Medical Center, Hershey, PA
| | | | | | | | - Cory M Hale
- Department of Pharmacy, Milton S. Hershey Medical Center, Hershey, PA
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11
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Khanal S, Schmidtke KA, Talat U, Sarwar A, Vlaev I. Implementation and Evaluation of Two Nudges in a Hospital’s Electronic Prescribing System to Optimise Cost-Effective Prescribing. Healthcare (Basel) 2022; 10:healthcare10071233. [PMID: 35885760 PMCID: PMC9316495 DOI: 10.3390/healthcare10071233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
Providing healthcare workers with cost information about the medications they prescribe can influence their decisions. The current study aimed to analyse the impact of two nudges that presented cost information to prescribers through a hospital’s electronic prescribing system. The nudges were co-created by the research team: four behavioural scientists and the lead hospital pharmacist. The nudges were rolled out sequentially. The first nudge provided simple cost information (percentage cost-difference between two brands of mesalazine: Asacol® and Octasa®). The second nudge provided information about the potential annual cost savings if the cheaper medication were selected across the National Health Service. Neither nudge influenced prescribing. Prescribing of Asacol® and Octasa® at baseline and during the implementation of the first nudge did not differ (at p ≥ 0.05), nor was there a difference between the first nudge and second (at p ≥ 0.05). Although these nudges were not effective, notable administrative barriers were overcome, which may inform future research. For example, although for legal reasons the cost of medicine cannot be displayed, we were able to present aggregated cost information to the prescribers. Future research could reveal more behavioural factors that facilitate medication optimisation.
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Affiliation(s)
- Saval Khanal
- Warwick Business School, University of Warwick, Scarman Road, Coventry CV4 7AL, UK
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK;
- Correspondence: (S.K.); (I.V.)
| | - Kelly Ann Schmidtke
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK;
- Behavioral Science, University of Health Science and Pharmacy, St. Louis, MO 63110, USA
| | - Usman Talat
- Alliance Manchester Business School, University of Manchester, Manchester M13 9PL, UK;
| | - Asif Sarwar
- Pharmacy Department, Queen Elizabeth II Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK;
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Scarman Road, Coventry CV4 7AL, UK
- Correspondence: (S.K.); (I.V.)
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Sullivan KV. Diagnostic Stewardship in Clinical Microbiology, Essential Partner to Antimicrobial Stewardship. Clin Chem 2021; 68:75-82. [DOI: 10.1093/clinchem/hvab206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 12/26/2022]
Abstract
Abstract
Background
Diagnostic stewardship is an important partner to antimicrobial stewardship.
Content
Diagnostic stewardship focuses on ensuring correct diagnosis of infectious diseases while antimicrobial stewardship aims to optimize antimicrobial treatment. Both aim to improve patient outcomes. Diagnostic stewardship involves interventions that reduce testing in patients with low pretest probability, optimize a test’s likelihood ratio, and seek to warn providers when suboptimal test results might have been reported.
Conclusion
Diagnostic stewardship interventions have been described primarily in the areas of urinary tract infection, Clostridioides difficile infection, and bloodstream infection diagnosis. However, emerging areas include pneumonia and wound infections in addition to optimization of multiplexed panel-based testing.
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Affiliation(s)
- Kaede V Sullivan
- Department of Pathology & Laboratory Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Krishna A, Chopra T. Prevention of Infection due to Clostridium (Clostridioides) difficile. Infect Dis Clin North Am 2021; 35:995-1011. [PMID: 34752229 DOI: 10.1016/j.idc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.
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Affiliation(s)
- Amar Krishna
- Internal Medicine, Norther Light AR Gould Hospital, 140 Academy Street, Presque Isle, ME 04769, USA.
| | - Teena Chopra
- Infectious Diseases, Wayne State University/Detroit Medical Center, UHC-2B, 4201 St Antoine, Detroit, MI 48201, USA
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Jones KA, Onwubiko UN, Kubes J, Albrecht B, Paciullo K, Howard-Anderson J, Suchindran S, Trible R, Jacob JT, Yi SH, Goodenough D, Fridkin SK, Sexton ME, Wiley Z. Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2021; 1:e32. [PMID: 36168449 PMCID: PMC9495417 DOI: 10.1017/ash.2021.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
Objective To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI). Design We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention. Setting An academic healthcare system with 4 hospitals. Patients All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients. Intervention Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing. Results Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01). Conclusions Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.
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Affiliation(s)
| | - Udodirim N. Onwubiko
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | - Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Sujit Suchindran
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ronald Trible
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jesse T. Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Sarah H. Yi
- Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dana Goodenough
- Georgia Emerging Infections Program, Atlanta, Georgia
- Foundation for Atlanta Veterans’ Education & Research, Decatur, Georgia
- Atlanta Veterans’ Affairs Medical Center, Decatur, Georgia
| | - Scott K. Fridkin
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Mary Elizabeth Sexton
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zanthia Wiley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Green SB, Stover KR, Barber K, Bouchard JL, Brown ML, Deri CR, Francis BJ, Gauthier TP, Hayes JE, Marx AH, McGee EU, Mediwala K, Musgrove RJ, Slain D, Stramel SA, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020. Open Forum Infect Dis 2021; 8:ofab422. [PMID: 34557559 PMCID: PMC8454524 DOI: 10.1093/ofid/ofab422] [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: 07/28/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
The number of articles related to antimicrobial stewardship published each year has increased significantly over the last decade. Keeping up with the literature, particularly the most innovative, well-designed, or applicable to one’s own practice area, can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network reviewed antimicrobial stewardship–related, peer-reviewed literature from 2020 that detailed actionable interventions. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for teaching and training, and to identify novel or optimized stewardship opportunities within one’s institution.
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Affiliation(s)
- Sarah B Green
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Katie Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Matthew L Brown
- Department of Pharmacy, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Bailey J Francis
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Timothy P Gauthier
- Baptist Health South Florida, Clinical Pharmacy Enterprise, Miami, Florida, USA
| | - Jillian E Hayes
- Department of Pharmacy AdventHealth Orlando, Orlando, Florida, USA
| | - Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Edoabasi U McGee
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine-Georgia Campus, School of Pharmacy, Suwanee, Georgia, USA
| | - Krutika Mediwala
- Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Rachel J Musgrove
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Douglas Slain
- Department of Clinical Pharmacy and Section of Infectious Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Stefanie A Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, Texas, USA
| | - Christopher M Bland
- Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia, USA
| | - P Brandon Bookstaver
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
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16
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Burden and risk factors for inappropriate Clostridioides Difficile infection testing among hospitalized patients. Diagn Microbiol Infect Dis 2020; 99:115283. [PMID: 33360514 DOI: 10.1016/j.diagmicrobio.2020.115283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/17/2020] [Accepted: 11/28/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to identify the burden and risk factors for inappropriate Clostridioides difficile infection (CDI) testing. METHODS This was a retrospective cohort study among adults hospitalized between 2010 and 2019. Inappropriate CDI testing was defined as a formed stool specimen, an order within 7 days of a previously negative test, or an order within 24 hours of laxative administration. RESULTS A total of 51,302 CDI orders were placed for 29,840 unique patients. 59% were appropriate and 41% were inappropriate. An additional 24% of the appropriate orders never resulted. Risk factors for inappropriate testing included orders placed by a nurse practitioner, orders placed by high-ordering providers, specific hospital units, fever, and leukocytosis. CONCLUSIONS Nearly half of all CDI orders were inappropriate among hospitalized patients, and an additional 24% of test results never returned. Provider- and patient-level risk factors included type of provider, specific hospital units, and signs of sepsis.
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Bai L, Gao S, Burstein F, Kerr D, Buntine P, Law N. A systematic literature review on unnecessary diagnostic testing: The role of ICT use. Int J Med Inform 2020; 143:104269. [PMID: 32927268 DOI: 10.1016/j.ijmedinf.2020.104269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests. METHOD A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol. RESULTS 92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies. CONCLUSIONS This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.
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Affiliation(s)
- Lu Bai
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Donald Kerr
- USC Business School, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, VIC, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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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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