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Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing

Published online by Cambridge University Press:  03 June 2020

Nikki N. Tran Open the ORCID record for Nikki N. Tran [Opens in a new window] ,
John P. Mills ,
Christopher Zimmerman ,
Tejal N. Gandhi ,
Alison C. Tribble ,
Lindsay A. Petty ,
Jerod Nagel ,
Adamo Brancaccio ,
Gianni Scappaticci  and
Twisha Patel
...Show all authors
Nikki N. Tran
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
John P. Mills
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
Christopher Zimmerman
Affiliation:
Departments of Health Information and Technology Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, Michigan
Tejal N. Gandhi
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
Alison C. Tribble
Affiliation:
Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
Lindsay A. Petty
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
Jerod Nagel
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Adamo Brancaccio
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Gianni Scappaticci
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Twisha Patel
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Nicholas O. Dillman
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Randolph Regal
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Kristin C. Klein
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Laraine Washer
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
Vincent D. Marshall
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
Jennifer Sweeney
Affiliation:
Department of Infection Control & Epidemiology, University of Michigan, Ann Arbor, Michigan
Krishna Rao
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
Gregory A. Eschenauer*
Affiliation:
Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
*
Author for correspondence: Gregory Eschenauer, E-mail: gregorye@med.umich.edu
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Abstract

Objective:

To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea.

Design:

Single center, quasi-experimental before-and-after study.

Setting:

Tertiary-care, academic medical center in Ann Arbor, Michigan.

Patients:

Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours.

Intervention:

A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained.

Results:

An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56–0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37–0.77; P = .001), respectively.

Conclusions:

We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 10 , October 2020 , pp. 1136 - 1141
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Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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References

McDonald, LC, Gerding, DN, Johnson, S, et al.Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66:e1–e48.10.1093/cid/cix1085CrossRefGoogle Scholar
Crobach, MJT, Vernon, JJ, Loo, VG, et al.Understanding Clostridium difficile colonization. Clin Microbiol Rev 2018;31.Google ScholarPubMed
Cannon, K, Byrne, B, Happe, J, et al.Enteric microbiome profiles during a randomized Phase 2 clinical trial of surotomycin versus vancomycin for the treatment of Clostridium difficile infection. J Antimicrob Chemother 2017;72:3453–3461.10.1093/jac/dkx318CrossRefGoogle ScholarPubMed
Al-Nassir, WN, Sethi, AK, Li, Y, Pultz, MJ, Riggs, MM, Donskey, CJ.Both oral metronidazole and oral vancomycin promote persistent overgrowth of vancomycin-resistant enterococci during treatment of Clostridium difficile–associated disease. Antimicrob Agents Chemother 2008; 52:2403–2406.10.1128/AAC.00090-08CrossRefGoogle ScholarPubMed
Fiscal year (FY) 2016 results for the CMS hospital value-based purchasing program. Centers for Medicare and Medicaid Services website. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2016-results-cms-hospital-value-based-purchasing-program. Published 2015. Accessed February 5, 2020.Google Scholar
Mills, JP, Chang, R, Rao, K, et al. Use of electronic best practice alert (BPA) to reduce inappropriate testing for Clostridium difficile infection (CDI) at a tertiary care center. In: Poster Abstract Session of the 2018 IDWeek; October 3–7, 2018; San Francisco, CA. Abstract 177.10.1093/ofid/ofy210.190CrossRefGoogle Scholar
Solomon, DA, Milner, DA Jr. ID learning unit: understanding and interpreting testing for Clostridium difficile. Open Forum Infect Dis 2014; 1:ofu007.10.1093/ofid/ofu007CrossRefGoogle ScholarPubMed
Zeileis, A.Object-oriented computation of sandwich estimators. J Statist Softw 2006;16:1–16.10.18637/jss.v016.i09CrossRefGoogle Scholar
Zeileis, A.Econometric Computing with HC and HAC Covariance Matrix Estimators. J Statist Softw 2004; 11:1–17.10.18637/jss.v011.i10CrossRefGoogle Scholar
The R project for statistical computing. R-project website. https://www.r-project.org/. Published 2019. Accessed February 5, 2020.Google Scholar
Quan, KA, Yim, J, Merrill, D, et al.Reductions in Clostridium difficile infection rates using real-time automated clinical criteria verification to enforce appropriate testing. Infect Control Hosp Epidemiol 2018;39:625–627.10.1017/ice.2018.32CrossRefGoogle ScholarPubMed
Mizusawa, M, Small, BA, Hsu, YJ, et al.Prescriber behavior in Clostridioides difficile testing: a 3-hospital diagnostic stewardship intervention. Clin Infect Dis 2019;69:2019–2021.10.1093/cid/ciz295CrossRefGoogle ScholarPubMed
Christensen, AB, Varr, VO, Martin, DW, et al.Diagnostic stewardship of C. difficile testing: a quasi-experimental antimicrobial stewardship study. Infect Control Hosp Epidemiol 2019;40:269–275.10.1017/ice.2018.336CrossRefGoogle ScholarPubMed
Jakharia, KK, Ilaiwy, G, Moose, SS, et al.Use of whole-genome sequencing to guide a Clostridioides difficile diagnostic stewardship program. Infect Control Hosp Epidemiol 2019;40:804–806.10.1017/ice.2019.124CrossRefGoogle ScholarPubMed
Marcelin, JR, Brewer, C, Beachy, M, et al.Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing. Infect Control Hosp Epidemiol 2019;40:668–673.10.1017/ice.2019.78CrossRefGoogle ScholarPubMed