S1252 Can a Single Decision-Making Support Tool Spare Inpatients From Inappropriate Testing for Nosocomial Diarrhea?

Abstract

INTRODUCTION: The incidence of nosocomial diarrhea occurs in 12-32% of generalized hospitalized patients with infectious causes accounting for 10–30% of these nosocomial cases. Appropriate testing in healthcare settings is important as colonization is 5–10 times more common than C. diff infection. However, concomitant laxative use was extremely common when positive testing for C. diff infection was examined, raising concern that patients testing positive may have been asymptomatic carrier with iatrogenic diarrhea due to laxative use. To assess whether a hard stop in the electronic health record for patients receiving laxatives in the previous 48 hours would decrease ordering of gastrointestinal pathogen panel (GIPP), decrease use of laxatives in the preceding 48 hours before testing, change rates of test positivity or reduce length of stay (LOS). METHODS: A retrospective cohort study at Houston Methodist Hospital was performed using the electronic database for any patient undergoing GIPP or C. diff toxin testing (CDT). Data was collected on age, sex, length of stay, infectious testing result, and laxative use in three groups, Period A: baseline time period; Period B: implementation of hard-stop where test could not be ordered electronically if patient received laxatives in the previous 48 hours with a bypass to order granted by manual requisition; Period C: continuation of hard-stop with manual requisition bypass only if approved by microbiologist. RESULTS: There were 8,725 admissions, 1,412 total tests, and 211 positive GIPP during the study period. 73 patients were on laxatives in the 48 hours prior to testing. There was a significant effect (P < 0.05) on decreasing percentage of patients receiving diarrhea infectious workup for the three time periods [F(2 35) = 4.2953, P = 0.021504]. There was a significant effect (P < 0.05) on decreasing percentage of patients who were on laxatives in the preceding 48 hours prior to GIPP testing for the three conditions [F(2 35) = 4.184 P = 0.0235]. There was not a significant effect on the rate of positive GIPP tests results for the three conditions [F(2 35) = 1.25 P = 0.299]. CONCLUSION: Implementation of a single hard stop can reduce the number of overall stool tests ordered and reduce the number of inappropriate stool testing on patients receiving laxatives without altering the rate of positive C. diff infection testing and without an additional requirement of a microbiology review to bypass the hard-stop. While testing number was decreased, LOS was not affected.Figure 1.: Description of each Intervention Period.Figure 2.: Number of GIPP, Positive GIPP and GIPP on Laxative Per Period.Figure 3.: Length of Stay, Percentage of GIPP, Percentage of Positive GIPP on Laxatives, and Percentage of GIPP due to C. difficile per Period.