The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection

Abstract

Objective:To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).Design:An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.Setting:Four hospitals in an academic healthcare network.Patients:All patients with a C. difficile order after hospital day 3.Intervention:Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).Results:Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).Conclusion:An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.

A Baker’s Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020

“…In 2020, ASPs continued to publish results of efforts to reduce inappropriate testing for CDI. Howard-Anderson et al described an EMR intervention that prompted a warning screen for prescribers to cancel CDI tests when test orders were placed for patients admitted >3 days who had received laxatives or stool softeners in the prior 24 hours [ 24 ]. Prescribers were able to continue with the order if they selected a button to proceed.…”

“…Second, many successful ASP interventions incorporate diagnostic stewardship. This year’s baker’s dozen included diagnostic interventions using electronic decision support to decrease ordering of UCs and CDI testing, and rapid diagnostic technology for treating the sickest patient populations [ 9 , 18 , 24 ]. ASPs can examine all steps in the diagnostic process for opportunities to improve patients’ management.…”

Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention

“…These interventions likely had a much larger impact on HO-CDI rates than our stewardship intervention. [26][27][28] However, they would not explain the change in PD-CDI observed after the stewardship intervention that occurred late in the study period, so that is likely the most critical finding. Our systemwide intervention using electronic order sets with built-in decision support reduced inpatient FQ use by 21% beyond an ongoing drop in month-to-month FQ use that preceded the intervention.…”

Implementation and Evaluation of Two Nudges in a Hospital’s Electronic Prescribing System to Optimise Cost-Effective Prescribing

“…A recent systematic review of 15 studies, evaluating 20 different intervention studies found that 20% of the interventions did not work [ 25 ]. Nudges are designed to non-coercively influence behaviour without forbidding options [ 26 , 27 , 28 , 29 ], and it is the clinicians who must interpret and act. Four potential reasons why our nudges did not change prescribing are explored here.…”