Implementation of Electronic Medical Record Hard Stop Alerts for Inappropriate Clostridium difficile Tests in Academic and Community Hospital Setting; Impact on Testing Rates and Clinical Outcomes

Abstract

BackgroundEnsuring appropriate C. diff nucleic acid amplification testing is increasingly important. We implemented electronic medical record (EMR) hard stop alerts across our health-system to reduce inappropriate tests. We review the impact on testing rates and outcome of those where testing was not pursed.Methods C. diff order in a patient with previous test (14 or 7 days for positive or negative), or receipt of laxative in past 48 hours triggered an EMR alert; test could only proceed with micro lab approved test code. The initiative was rolled out at an academic (October 2016) and two community hospitals (December 2016, January 2017). Statistical control charts (SPC) tracked changes in number of tests over time. Wilcoxon rank-sum tests were used to examine pre-post changes. Forward stepwise logistic regression models was used to explore factors associated pursuit of testing post EMR alert. Clinical outcomes of patients at the academic hospital whose testing attempt triggered an alert and testing was not pursued were reviewed.ResultsFor the 3 hospitals, mean weekly C. diff testing rate pre and post-intervention was 146 (SD 12.5) and 119 (SD 12.9), P <0.001. Average number of weekly EMR alerts was 51; 26 for laxative, 14 for previous negative, 3 for previous positive est, 8 for undetermined reason. Figure shows SPC chart weekly testing rate for each hospital.Table shows factors associated with C. diff test pursuit at the academic hospital.OR95% CI P value≥3 unformed stools within 24 hours5.55(2.84 − 10.81)<0.001ID consult team following No1.00 Yes, agreed/recommended test11.33(2.73 − 47.01)0.001 Yes, disagreed/did not recommend test3.42(1.36 − 8.61)0.009Order reason: leukocytosis3.14(1.45 − 6.80)0.004Alert reason: laxatives3.15(1.41 − 7.03)0.005Comorbidity: cirrhosis2.32(1.15 − 4.67)0.019Outcome review of 83 patients who had EMR alert and did not pursue testing was as follows: 36 diarrhea resolved, 21 an alternate cause found, 3 died from non CDI related etiology, 11 had subsequent c diff testing later in the admission (6 negative, 5 positive results), 12 patients were discharged home.ConclusionIn academic and community hospital setting, EMR hard stop alerts educed inappropriate C. diff test, without impact on patient outcomes.Disclosures K. C. Carroll, GenePOC, Inc.: Grant Investigator, Grant recipient