Miller, Matthew M, DO

Rosentel, Joshua, BSn, RN

Slenker, Amy K, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine Reduction in Inappropriate C. difficile Testing through Just-in-Time Education upon Order Entry Amy K. Slenker MD Lehigh Valley Health Network, amy_k.slenker@lvhn.org Matthew M. Miller DO Lehigh Valley Health Network, Matthew_M.Miller@lvhn.org Joshua Rosentel BSn, RN Lehigh Valley Health Network, Joshua.Rosentel@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine Published In/Presented At Slenker, A. K., Miller, M. M., Rosentel, J. (2019, November 16). Reduction in Inappropriate C. difficile Testing through Just-in-Time Education upon Order Entry. Poster Presented at: (HVPAA) High Value Practice Academic Alliance- Architecture of High Value Health Care National conference organization, Baltimore, MD. This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. LVHN.org© 2019 Lehigh Valley Health NetworkReduction in Inappropriate C. difficile Testing through Just-in-Time Education upon Order EntryAmy K Slenker, MD, Matthew M. Miller, DO, Joshua Rosentel, BSN, RNLehigh Valley Health Network, Allentown, Pa.BACKGROUNDC. difficile infection is one of the most common health care-associated infections.1 Lehigh Valley Health Network (LVHN) uses  a C. difficile polymerase chain reaction (PCR) test to diagnose suspected C. difficile colitis. This test is highly sensitive but cannot distinguish between infection and asymptomatic colonization. Exclusive reliance on molecular testing without regard to clinical symptoms may result in overdiagnosis.2 There are multiple evidence-based interventions that can safely and effectively decrease inappropriate testing.3-4 OBJECTIVEWe aimed to provide education and implement changes in computerized-order entry to provide just-in-time feedback regarding the appropriateness of C. difficile testing.METHODSWe presented education to providers regarding C. difficile clinical criteria for appropriate testing beginning in February 2017. We implemented changes to our C. difficile testing computerized-order entry on Jan. 1, 2018 and provided the following alerts (Figure 1): 1  If the patient had not had ≥3 loose stools documented in the past 24 hours2  If the patient had received a laxative in the past 48 hours 3  If the patient had negative C. difficile in the past 7 days  4   If the patient had a positive C. difficile test in the past  14 daysWe retrospectively reviewed all hospitalized patients who had C. difficile testing for a one-year period prior to (Jan. 1, 2016–Dec. 31, 2016) and after education (Jan. 1, 2017–December 31, 2017), as well as prior to (January 1, 2017-Dec. 31, 2017) and after changes to order entry (Jan. 1, 2018–Dec. 31, 2018). We reviewed how many tests were performed during this period, laxative use, and if patients met the clinical definition of diarrhea (≥3 loose bowel movements/24 hours). RESULTSAfter education was provided regarding appropriate C. difficile testing, we found a 22% decline in C. difficile testing. After the implementation of changes to order entry, we found an additional 12% decline in C. difficile testing (Figure 2). We were not able to detect a significant change in appropriate testing with regards to the percentage of patients tested who had diarrhea in the 24 hours prior to testing (Figure 3) or to the percentage of patients who received a laxative in the 48 hours prior to testing (Figure 4). Figure 3: % Patients with ≥3 Stools/24 hours from Jan. 2017–Dec. 2018JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC.JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC.■Diarrhea  ■LCL  ■CL  ■UCL2017 2018Change to Order Jan. 20180510152025303540Figure 4: % Patients Who Received a Laxative ≤48 hours Prior to Testing from Jan. 2017–Dec 2018JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC.JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC.■%Laxative  ■LCL  ■CL  ■UCL2017 2018Change to Order Jan. 20180510152025303540references 1  McDonald LC, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2017 update by the Society for Health care Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Clin Inf Dis; 2018: 66:e2-48.2  Polage CR, Gyorke CE, Kennedy MA et al. Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era. JAMA Intern Med. 2015 Nov;175(11):1792-8013  Katz DA, Lynch ME, Littenberg B. Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea. Am J Med. 1996;100(5):4874  Alerting Physicians during Electronic Order Entry Effectively Reduces Unnecessary Repeat PCR Testing for Clostridium difficile J. Clin. Microbiol. November 2013 51:11 3872-3874Figure 1: C. difficile Order Entry Real-time Educational ScreenFigure 2: # C. difficile Tests per 1000 Patient Days from Jan. 2016–Dec. 2018JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC.JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC. JAN.FEB.MAR.APR.MAYJUNEJULYAUG. SEPT.OCT.NOV.DEC.     ■# C. difficile Tests per 1,000 Patient Days  ■LCL  ■CL  ■UCL2016 2017 2018Education Feb. 2017 Change to Order Jan. 2018012345678910CONCLUSIONSEducation provided in lecture-format and as just-in-time education upon order entry can successfully reduce inappropriate C. difficile testing. CLINICAL IMPLICATIONSReduction in inappropriate C. difficile testing can prevent overdiagnosis, inappropriate treatment, and has potential implications for cost-savings. 

Reduction in Inappropriate C. difficile Testing through Just-in-Time Education upon Order Entry

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=2751&context=medicine

Reduction in Inappropriate C. difficile Testing through Just-in-Time Education upon Order Entry

Abstract

Similar works

Full text

Available Versions

Lehigh Valley Health Network: LVHN Scholarly Works