Implement Electronic Decision Support to Decrease Hospital-Onset Clostridium difficile Infections at Two Community Hospitals

Abstract

Background: Literature supports appropriate testing as a key factor affecting the hospital-onset (HO) Clostridium difficile infections (CDI) standardized infection ratio (SIR). In 2016, facility A was a significant outlier in HO CDI with an SIR of 2.57. In 2017, facility B had a peak SIR of 1.9. Both SIRs were considerably higher than the Centers for Medicare and Medicaid Services (CMS) national SIR of 0.997. Methods: Hospital-onset CDIF cases from both hospitals were reviewed. Current electronic decision support in the electronic health record (EHR) was evaluated for CDI laboratory orders. Literature was reviewed for best practice of appropriate specimen collection and testing. Interventions were implemented at facility A in November 2016 and facility B in June 2018. Results: In total, 67 HO CDIF cases were reviewed from both facilities (October 2015–September 2016 for facility A and April 2017–June 2018 for facility B), and 46% were due to inappropriate testing. A CDI testing order set with decision support and best practice alerts was implemented based on national best-practice guidelines (Fig. 1). Physician and nurse education were completed on appropriate testing for CDI, including symptoms and timely specimen collection. Real-time review of appropriate testing was validated by the infection prevention team, and outliers were communicated to the ordering provider. After implementation, decreases in HO-CDIF SIRs occurred at both facilities (facility A SIR, 0.36; facility B SIR, 0.56). Both facilities have been able to sustain an SIR below the current CMS national average of 0.784. Conclusions: By implementing a sophisticated order-entry process that includes electronic decision support based on best practices, clinician education, and real-time feedback to providers, patients are appropriately tested for CDI. This intervention has allowed for appropriate classification within the NHSN and has decreased the overall HO-CDIF SIR.

Funding: None

Disclosures: None