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Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing

Published online by Cambridge University Press:  23 April 2019

Jasmine R. Marcelin Open the ORCID record for Jasmine R. Marcelin [Opens in a new window] ,
Charlotte Brewer ,
Micah Beachy ,
Elizabeth Lyden ,
Tammy Winterboer ,
Caitlin N. Murphy ,
Paul D. Fey ,
Lauren Hood  and
Trevor C. Van Schooneveld
Jasmine R. Marcelin*
Affiliation:
Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
Charlotte Brewer
Affiliation:
Nebraska Medicine, Omaha, Nebraska
Micah Beachy
Affiliation:
Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
Elizabeth Lyden
Affiliation:
College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
Tammy Winterboer
Affiliation:
Nebraska Medicine, Omaha, Nebraska
Caitlin N. Murphy
Affiliation:
Department of Pathology & Microbiology, University of Nebraska Medical Center, Omaha, Nebraska
Paul D. Fey
Affiliation:
Department of Pathology & Microbiology, University of Nebraska Medical Center, Omaha, Nebraska
Lauren Hood
Affiliation:
Nebraska Medicine, Omaha, Nebraska
Trevor C. Van Schooneveld
Affiliation:
Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
*
Author for correspondence: Jasmine R. Marcelin, Email: jasmine.marcelin@unmc.edu
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Abstract

Objective:

To evaluate the impact of a hard stop in the electronic health record (EHR) on inappropriate gastrointestinal pathogen panel testing (GIPP).

Design:

We used a quasi-experimental study to evaluate testing before and after the implementation of an EHR alert to stop inappropriate GIPP ordering.

Setting:

Midwest academic medical center.

Participants:

Hospitalized patients with diarrhea for which GIPP testing was ordered, between January 2016 through March 2017 (period 1) and April 2017 through June 2018 (period 2).

Intervention:

A hard stop in the EHR prevented clinicians from ordering a GIPP more than once per admission or in patients hospitalized for >72 hours.

Results:

During period 1, 1,587 GIPP tests were ordered over 212,212 patient days, at a rate of 7.48 per 1,000 patient days. In period 2, 1,165 GIPP tests were ordered over 222,343 patient days, at a rate of 5.24 per 1,000 patient days. The Poisson model estimated a 30% reduction in total GIPP ordering rates between the 2 periods (relative risk, 0.70; 95% confidence interval [CI], 0.63–0.78; P < .001). The rate of inappropriate tests ordered decreased from 21.5% to 4.9% between the 2 periods (P < .001). The total savings calculated factoring only GIPP orders that triggered the hard stop was ∼$67,000, with potential savings of $168,000 when factoring silent best-practice alert data.

Conclusions:

A simple hard stop alert in the EHR resulted in significant reduction of inappropriate GIPP testing, which was associated with significant cost savings. Clinicians can practice diagnostic stewardship by avoiding ordering this test more than once per admission or in patients hospitalized >72 hours.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 6 , June 2019 , pp. 668 - 673
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

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Footnotes

PREVIOUS PRESENTATION: Portions of data from this manuscript were presented at IDWeek 2018 on October 5, 2018, in San Francisco, California.

References

Elaine, S, Patricia, MG, Frederick, JA, Robert, VT, Robert, MH. Foodborne illness acquired in the United States—unspecified agents. Emerg Infect Dis 2011;17:16.Google Scholar
Shane, AL, Mody, RK, Crump, JA, et al. 2017 infectious diseases society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis 2017; 65:e45–e80.CrossRefGoogle Scholar
Smieja, M, Goldfarb, DM. Molecular detection of diarrheal pathogens. Clin Microbiol News 2016; 38:137–145.CrossRefGoogle Scholar
Cybulski, RJ Jr, Bateman, AC, Bourassa, L, et al. Clinical impact of a multiplex gastrointestinal PCR panel in patients with acute gastroenteritis. Clin Infect Dis 2018; 67:1688–1696.Google Scholar
Ramanan, P, Bryson, AL, Binnicker, MJ, Pritt, BS, Patel, R. Syndromic panel-based testing in clinical microbiology. Clin Microbiol Rev 2017; 31:pii: e00024–17.CrossRefGoogle ScholarPubMed
Beal, SG, Tremblay, EE, Toffel, S, Velez, L, Rand, KH. A gastrointestinal PCR panel improves clinical management and lowers health care costs. J Clin Microbiol 2018; 56:pii: e01457–17.Google ScholarPubMed
Goldenberg, SD, Bacelar, M, Brazier, P, Bisnauthsing, K, Edgeworth, JD. A cost benefit analysis of the Luminex xTAG gastrointestinal pathogen panel for detection of infectious gastroenteritis in hospitalised patients. J Infect 2015; 70:504–511.CrossRefGoogle ScholarPubMed
Buss, SN, Leber, A, Chapin, K, et al. Multicenter evaluation of the BioFire FilmArray gastrointestinal panel for etiologic diagnosis of infectious gastroenteritis. J Clin Microbiol 2015; 53:915–925.CrossRefGoogle ScholarPubMed
Nikolic, D, Richter, SS, Asamoto, K, Wyllie, R, Tuttle, R, Procop, GW. Implementation of a clinical decision support tool for stool cultures and parasitological studies in hospitalized patients. J Clin Microbiol 2017; 55:3350–3354.CrossRefGoogle ScholarPubMed
Tewell, CE, Talbot, TR, Nelson, GE, et al. Reducing inappropriate testing for the evaluation of diarrhea among hospitalized patients. Am J Med 2018; 131:193–199.CrossRefGoogle ScholarPubMed
Murphy, CN, Fowler, RC, Iwen, PC, Fey, PD. Evaluation of the BioFire FilmArray(R) gastrointestinal panel in a Midwestern academic hospital. Eur J Clin Microbiol Infect Dis 2017; 36:747–754.CrossRefGoogle Scholar
Van Schooneveld, TC RK, Fey, P, Rupp, ME. Nebraska Medicine gastrointestinal pathogen panel guidance. Nebraska Medicine website. https://www.nebraskamed.com/for-providers/asp/clinical-microbiology. Accessed February 26, 2019.Google Scholar
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.CrossRefGoogle Scholar
Bernal, JL, Cummins, S, Gasparrini, A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol 2017; 46:348–355.Google ScholarPubMed
Hitchcock, MM, Gomez, CA, Banaei, N. Low yield of filmarray GI panel in hospitalized patients with diarrhea: an opportunity for diagnostic stewardship intervention. J Clin Microbiol 2018;56: pii: e01558–17.Google ScholarPubMed
Park, S, Hitchcock, MM, Gomez, CA, Banaei, N. Is follow-up testing with the FilmArray gastrointestinal multiplex PCR panel necessary? J Clin Microbiol 2017; 55:1154–1161.CrossRefGoogle ScholarPubMed
Eaton, KP, Levy, K, Soong, C, et al. Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Intern Med 2017; 177:1833–1839.CrossRefGoogle ScholarPubMed
Krasowski, MD, Chudzik, D, Dolezal, A, et al. Promoting improved utilization of laboratory testing through changes in an electronic medical record: experience at an academic medical center. BMC Med Inform Decis Mak 2015; 15:11.CrossRefGoogle Scholar
Luo, RF, Spradley, S, Banaei, N. Alerting physicians during electronic order entry effectively reduces unnecessary repeat PCR testing for Clostridium difficile. J Clin Microbiol 2013; 51:3872–3874.CrossRefGoogle ScholarPubMed
Otto, CC, Shuptar, SL, Milord, P, et al. Reducing unnecessary and duplicate ordering for ovum and parasite examinations and Clostridium difficile PCR in immunocompromised patients by using an alert at the time of request in the order management system. J Clin Microbiol 2015; 53:2745–2748.CrossRefGoogle ScholarPubMed
Ancker, JS, Edwards, A, Nosal, S, et al. Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Med Inform Decis Mak 2017; 17:36.CrossRefGoogle Scholar
Procop, GW, Keating, C, Stagno, P, et al. Reducing duplicate testing a comparison of two clinical decision support tools. Am J Clin Pathol 2015; 143:623–626.CrossRefGoogle ScholarPubMed
Bauer, TM, Lalvani, A, Fehrenbach, J, et al. Derivation and validation of guidelines for stool cultures for enteropathogenic bacteria other than Clostridium difficile in hospitalized adults. JAMA 2001; 285:313–319.CrossRefGoogle ScholarPubMed
Keske, Ş, Zabun, B, Aksoy, K, Can, F, Palaoğlu, E, Ergönül, Ö. Rapid molecular detection of gastrointestinal pathogens and its role in antimicrobial stewardship. J Clin Microbiol 2018;56: pii: e00148–18.Google ScholarPubMed