Q&A: Diagnostic stewardship can reduce unneeded C. difficile testing
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Key takeaways:
- A hospital system reduced testing for C. difficile by 20 percentage points after implementing an electronic smart order set for the test.
- An increase in 30-day readmissions was linked to interventions that carry greater risk.
Diagnostic stewardship helped reduce the number of inappropriate tests ordered for Clostridioides difficile by 20 percentage points in a Florida health care system, according to a study.
In the United States, C. difficile is estimated to cause 500,000 infections per year, and roughly one in 11 people aged 65 years or older who is diagnosed with health care-associated C. difficile dies within 1 month, according to the CDC.
Diagnostic stewardship has emerged as one method for reducing cases, leading researchers in Florida to test it.
In February 2022, they created and implemented an electronic smart order set for C difficile infection (CDI). The researchers analyzed and compared data on 118 patients who were tested for CDI between February 2022 and December 2022 with 106 patients who had been tested for CDI between March 2021 and February 2022, before the smart order was implemented.
The researchers found that a higher proportion of patients met the testing criteria by the presence of diarrhea (80.5% vs. 61.3%) and the rate of inappropriate testing decreased from 31.1% to 11% after the smart order was implemented.
They also found that there was an increase in 30-day readmissions for CDI after the smart order was implemented but determined a statistically significant portion of these patients had recently had gastrointestinal surgery, which carries additional risk for readmission.
We asked Rachel Guran, MPH, BSN, RN, CIC, FAPIC, director of epidemiology and infection prevention at Memorial Healthcare System in Hollywood, Florida, about the study. Her answers have been lightly edited for clarity and length.
Healio: What made the ID staff at Memorial decide to test this method for diagnostic stewardship?
Rachel Guran: This is something that we’ve seen published in the literature that’s worked for many other health care systems. We’re blessed to have a lot of support from the administration to the physicians to my medical director, who is the chief of infectious diseases for the entire system and medical director for infection prevention and control and antimicrobial stewardship. This was a multidisciplinary effort to identify an opportunity and take steps to make it better for our patients, as well as to make it easier for our staff by optimizing the electronic medical records that we all have to use.
Healio: Had the hospital noticed a problem, or was this instead just an internal effort?
Guran: This is required reporting for quality metrics because C. difficile is potentially an HAI. So, this is a quality metric that all hospitals are using to keep track of and prevent patient harm and HAIs. This was an opportunity for a new utilization of the electronic medical record in this way to help guide clinicians on appropriate ordering of this laboratory test.
Healio: According to the study, you were concerned about pushback from clinicians?
Guran: Yes. This is something that helps guide clinicians to an appropriate order. We really found that the greater good was being able to guide newer physicians, to help the dyads of nurse practitioners and other types of providers working with physicians — even our nursing staff — to help educate them on appropriate ordering of the laboratory tests for C. difficile. This helped do that.
Healio: In looking at ways to weigh whether or not testing was necessary, you also saw an in increase in 30-day readmissions. Although the number of tests decreased, did the increase in readmissions concern you?
Guran: Although we didn’t look back at every single chart to see what happened with that patient, we did think that this led to more appropriate testing, which could mean that they’re sicker. When you look at the literature on C. difficile, it is a concerning diagnosis, so it does make sense that the patients who we were actually accurately testing were sicker.
Healio: What is the main clinical takeaway from this study?
Guran: The clinical takeaway is that a multidisciplinary effort to optimize the electronic medical record can help prevent patient safety events and improve care.
References:
- CDC. C. diff (Clostridioides difficile): About C. diff. https://www.cdc.gov/c-diff/about/index.html. Updated March 6, 2024. Accessed Aug. 9, 2024.
- Diagnostic stewardship approach to C. diff reduces unnecessary testing. https://apic.org/news/diagnostic-stewardship-approach-to-c-diff-reduces-unnecessary-testing/. Published June 27, 2024. Accessed Aug. 9, 2024.
- Eckhardt P, et al. Am J Infect Control. 2024;doi:10.1016/j.ajic.2024.04.181.
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