Computerized clinical decision support may help reduce unnecessary C. diff testing
A two-year cohort study of nine academic and six community hospitals in the U.S. found that testing for Clostridioides difficile decreased when the electronic health record stopped a clinician from proceeding with a test order if the patient had already been tested or had recently received laxatives.
Hospital clinicians may be less likely to order unnecessary tests for Clostridioides difficile if hard-stop and soft-stop computerized clinical decision supports (CCDS) are included in the electronic health record (EHR), a recent study found.
Researchers performed a two-year cohort study of nine academic and six community hospitals in the U.S. to determine the difference in C. diff testing rates before and after CCDS interventions were implemented. A hard- or soft-stop CCDS was triggered when clinicians attempted to order a duplicate C. diff test or when laxatives had recently been received. For hard stops, clinicians needed to obtain approval, such as a signature from another clinician, to continue with the order, while for soft stops, they could continue without approval. The primary outcome was the monthly number of C. diff test orders processed, while secondary outcomes included the quarterly hospital-onset C. diff infection rate, as defined by the CDC-National Healthcare Safety Network (NHSN), and prescription of oral vancomycin or fidaxomicin. The researchers also assessed user experience with the CCDS through contextual inquiries, focus groups, and semi-structured interviews. The study results were published Feb. 1 by Clinical Infectious Diseases.
Nine hospitals implemented hard-stop CCDS, four implemented soft-stop CCDS, and two implemented a human intervention that did not involve the EHR. The testing order rate per 1,000 patient-days decreased from 13.1 to 9.9 at the hard-stop sites, 10.5 to 7.6 at the soft-stop sites, and 12.6 to 9.9 at the human intervention sites. The researchers adjusted for NHSN-predicted C. diff counts and C. diff testing strategies versus no CCDS at baseline and found a reduction in incident rate ratio of 33% (95% CI, 30% to 36%) and 23% (95% CI, 21% to 25%) at the hard-stop and soft-stop sites, respectively, and of 21% (95% CI, 15% to 28%) at sites with the non-EHR intervention.
The researchers conducted focus groups and interviews with 24 attending physicians/hospitalists, five residents, 12 nurse practitioners, five physician assistants, and one infection prevention clinician at five academic and two community hospitals. Clinicians reported generally favorable experiences with the CCDS and noted that they improved efficiency by, for example, including information on patients' most recent laxative administration. Organizational factors that affected the acceptance and integration of the CCDS included hierarchical cultures and communication among clinicians caring for the same patient, participants reported.
The researchers noted that they were unable to travel to study sites for in-person visits and that facility recruitment was voluntary, among other limitations. They concluded that CCDS reduced unnecessary testing for C. diff in the hospital and were generally considered a positive intervention by clinicians when they were integrated into the workflow and displayed relevant, patient-specific information that helped decision making. They called for additional studies on optimal CCDS design to improve care while avoiding alert fatigue, as well as more research on how to encourage use of CCDS at different types of hospitals with different organizational structures.