Impact of Case-Specific Education and Face-to-Face Feedback to Prescribers and Nurses in the Management of Hospitalized Patients With a Positive Clostridium difficile Test

Abstract

BackgroundApproaches to changing providers’ behavior around Clostridium difficile (CD) management are needed. We hypothesized that case-specific teaching points and face-to-face discussions with prescribers and nurses would improve management of patients with a positive CD test.MethodsCharts of patients age ≥18 years with positive CD tests hospitalized July 2016 to May 2017 were prospectively reviewed to assess CD practices and generate management recommendations. The study had 4 periods: baseline (pre-intervention), intervention #1, observation, and intervention #2. Both interventions consisted of an in-person, real-time, case-based discussion and education by a CD Action Team (CDAT). Assessment occurred within 24 hours of a positive CD test for all periods; during the intervention periods, management was also assessed within 48 hours after CDAT-delivered recommendations. Outcomes included proportion of patients receiving optimized treatment and incidence rate ratios of practice changes (both CDAT-prompted and CDAT-independent).ResultsOverall, the CDAT made recommendations to 84 of 96 CD cases during intervention periods, and providers accepted 43% of CDAT recommendations. The implementation of the CDAT led to significant improvement in bowel movement (BM) documentation, use of proton pump inhibitors, and antibiotic selection for non-CD infections. Selection of CD-specific therapy improved only in the first intervention period. Laxative use and treatment of CD colonization cases remained unchanged. Only BM documentation, a nurse-driven task, was sustained independent of CDAT prompting.ConclusionsA behavioral approach to changing the management of positive CD tests led to self-sustained practice changes among nurses but not physicians. Better understanding of prescribers’ decision-making is needed to devise enduring interventions.

Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health–academic collaborative: an evaluation of a quality improvement intervention

“…Thus, identification of high-burden facilities and tailoring interventions to facility-specific gaps are defining attributes of this targeted SPARC strategy. Because CDC TAP assessment tools and implementation guides for C. difficile prevention were still in development when SPARC launched, the SPARC team created its own tools de novo 13–22. SPARC developed assessment tools and resources to support QI efforts focused on four domains: infection prevention, environmental cleaning, antimicrobial stewardship and diagnostic stewardship.…”

“…Because CDC TAP assessment tools and implementation guides for C. difficile prevention were still in development when SPARC launched, the SPARC team created its own tools de novo. [13][14][15][16][17][18][19][20][21][22] SPARC developed assessment tools and resources to support QI efforts focused on four domains: infection prevention, environmental cleaning, antimicrobial stewardship and diagnostic stewardship. on December 21, 2021 by guest.…”

Utilizing a real-time discussion approach to improve the appropriateness of Clostridioides difficile testing and the potential unintended consequences of this strategy

“…Electronic medical record (EMR)-based solutions, such as hard and soft stops, have been associated with reductions in the number of tests sent, but they may not be sustainable due to 'alert fatigue.' 1 Although these measures are effective, fewer studies address the potential for undertesting, missed diagnoses, and the implications for patient safety or clusters of transmission. 2,3 This aspect is important because computer-based solutions rely on criteria that take into account the number of stools and laxative use, which are derived from weak evidence, [4][5][6] and they do not take the whole clinical picture into account.…”