To address this issue, the Tiger Team launched a prospective performance improvement project using a new “hard stop” laxative alert. The alert, which would fire 36 hours after admission, “first assess[ed] for documentation of diarrhea—more than 2 episodes per 24 hours—and if that was present, we would then look for laxative use within the prior 24 hours,” Dr. Drees explained. “If neither of those criteria were met, the ordering provider could still proceed with the order but only by calling the lab and documenting the name of the person who was ordering from the lab.” No further justification for the test order was required.
A further breakdown of how the algorithm works is listed below:
- Assessment for the presence of diarrhea. If it’s not present, then the order for testing is discontinued, unless the provider calls for an override. If it is present, then the ordering provider will receive an alert.
- Alert prompts the provider to look for recent laxative use. If there is none, the order proceeds. If there is documented laxative use, then the provider is issued another alert which will prompt them to cancel the order to override.
How well did the hard stop alert work? After the alert went active, the team saw an “immediate drop in testing” from a mean of 12 C. difficile
testing orders per day when using the soft stop alert to 7. “Similarly, our hospital-onset CDI cases also declined [from a mean of 3.6 cases/week down to 2 cases/week],” Dr. Drees added. “Aside from a slight uptick in August, if we look at the time period of our intervention and compare it with the exact same time period a year before, or if we compare it to a longer time period starting in January 2016, we see statistically significant decreases in our rate ratio.”
In addition, Dr. Drees and her team have yet to identify any delayed diagnoses or empiric treatment with oral vancomycin without testing. However, a total of 18 override calls were reported.
Dr. Drees noted that the study was not without limitations. First, the project didn’t address or prevent true C. difficile
disease (“which is really what we want to do,” she said). Second, it was a single health care-system, pre-post study, and as a symptom, diarrhea is not always well-documented. Finally, Dr. Drees noted that even a hard stop approach can lose effectiveness over time as providers figure out ways around it.
“Testing stewardship is really critical to minimize false-positive CDI cases which could lead to inappropriate treatment, prolonging the stay and patient dissatisfaction. And, it does put you at risk for hospital penalties. Limiting testing using the hard stop method was certainly more effective than a suggestion to cancel the test and it was generally well-accepted,” Dr. Drees concluded.
What are the next steps for the health care system?
“Our next steps are to automate some of the processes in terms of detecting delays in testing,” said Dr. Drees. “We are also evaluating the C. difficile
scoring tool to identify other low-risk patients. We have some ongoing/increasing efforts to reduce our “true positive” CDIs, including the statewide ‘Choosing Wisely
,’ antibiotic stewardship campaign, ongoing environmental cleaning assessments, and we’re ramping up the patient hand hygiene and bathing efforts.”
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