Mandatory Pre-Authorization or “Hard Stop Order” to Decrease Inappropriate Testing for Clostridium difficile Infection. A Testing Stewardship at 2 Hospitals.

Abstract

BACKGROUND Despite implementation of the Clostridium difficile Infection (CDI) algorithm in 2016, inappropriate testing remains an issue. To further reduce this problem, Mandatory Pre-Authorization (MPrA) or Hard Stop Order (HSO) was implemented in March 2017. MPrA/HSO requires the ordering physician to apply the criteria set in the algorithm and obtain approval from an Infectious Disease (ID) physician. The test is stopped if the criteria are not met and without approval. The objective of this review is to examine the effectiveness of the MPrA/HSO in our hospitals. METHODS An order set was built in the electronic medical record (EMR) identifying the ordering physician and ID attending approving the test. Educational sessions, posters and pocket size algorithm were provided. Orders without ID approval were referred back to the ordering physician or escalated to the Chief of Service or to the Director of Infection Prevention. Exclusion for the MPrA/HSO were Emergency Room patients suspected with CDI. National Healthcare Safety Network (NHSN) data from February 2016 to March 2018 were retrospectively analyzed. RESULTS Comparison of Pre and Post implementation data showed a decline of 68% in CDI testing for Hospital A and 61% for Hospital B. The Hospital-Onset CDI dipped to 74% in Hospital A and 61% in Hospital B and inappropriate testing decreased by 75% and 100% respectively. >97% met testing criteria and ID approval. Pre and Post MPrA/HSO Standard Infection Ratio (SIR) were statistically significant. CONCLUSIONS Testing stewardship accomplished a reduction of CDI testing without a corresponding increase in CDI, and without evidence of missed cases. Our goal of reducing inappropriate testing is achieved, thereby improving patient outcome as unnecessary isolation and exposure to antibiotics are avoided. Administrative support, interdisciplinary teamwork and integration of the MPrA/HSO in the EMR are essential in the success of this initiative.