2350. Electronic Interventions to Improve Clostridioides difficile Ordering Practices and Incidence: Impact of Soft Stops vs. Hard Stops

Abstract

BackgroundDistinguishing between Clostridioides difficile infection (CDI) and asymptomatic colonization with a PCR-based test can be difficult and can lead to unnecessary antibiotic use, longer lengths of stay and inflated hospital-onset (HO) CDI rates. Additionally, inappropriate testing for CDI complicates this challenge. The Infectious Disease Society of America’s (IDSA) 2018 guidelines discourage CDI testing for patients who received laxatives within 48 hours. Our hospital implemented a two-phase clinical decision support order set (DSOS) to improve appropriateness of CDI testing.MethodsThe DSOS was implemented at a hospital system in New York City (2 large academic medical centers, 2 community hospitals, 1 pediatric hospital: total 2,200 beds). The electronic health record is Allscripts SCM tm. The first iteration of the DSOS required providers to document the indication for CDI testing, as well as a soft stop (SS) pop-up message prompting providers to reconsider testing in patients who received laxatives within 24 hours. The second phase of the DSOS utilized a hard stop (HS) that prevented providers from ordering CDI testing for patients who received laxatives within 24 hours. Providers received a pop-up with IDSA recommendations for CDI testing and contact information for the Clinical Microbiology Laboratory. If testing was still desired, the ordering provider had to discuss the case with a Pathology resident or Infectious Disease specialist before the laboratory staff placed the order. The monthly number of orders and tests sent in the different time periods, pre-SS (April 2016–April 2017), post-SS (May 2017–2019, 2018), and post-HS (November 2018–March 2019), were compared using ANOVA. The National Healthcare Safety Network calculator was used to compare CDI incidence density ratios and SIRs between the three periods.ResultsSS implementation significantly reduced mean monthly orders (18%) and HO-CDI SIR (31%) but SIR remained above national benchmarks. Adding a HS further reduced orders (25%) and SIR (18%) (table).ConclusionA DSOS designed to reduce inappropriate CDI testing among patients who received laxatives within 24 hours was associated with a reduction in CDI testing and the CDI SIR. While use of a soft stop reduced CDI testing, the addition of a hard stop was associated with additional significant reductions in the CDI SIR. Disclosures All authors: No reported disclosures.