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Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities.
We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record–based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used.
Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63–0.88; P = .001) and C. difficile–positive tests (IRR, 0.83; 95% CI, 0.76–0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals.
An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.
To evaluate the usability and effectiveness of a computerized clinical decision support (CDS) intervention aimed at reducing the duration of urinary tract catheterizations.
Retrospective cohort study.
Academic healthcare system.
All adult patients admitted from March 2009 through May 2012.
A CDS intervention was integrated into a commercial electronic health record. Providers were prompted at order entry to specify the indication for urinary catheter insertion. On the basis of the indication chosen, providers were alerted to reassess the need for the urinary catheter if it was not removed within the recommended time. Three time periods were examined: baseline, after implementation of the first intervention (stock reminder), and after a second iteration (homegrown reminder). The primary endpoint was the usability of the intervention as measured by the proportion of reminders through which providers submitted a remove urinary catheter order. Secondary endpoints were the urinary catheter utilization ratio and the rate of hospital-acquired catheter-associated urinary tract infections (CAUTIs).
The first intervention displayed limited usability, with 2% of reminders resulting in a remove order. Usability improved to 15% with the revised reminder. The catheter utilization ratio declined over the 3 time periods (0.22, 0.20, and 0.19, respectively; P < .001), as did CAUTIs per 1,000 patient-days (0.84, 0.70, and 0.51, respectively; P < .001).
A urinary catheter removal reminder system was successfully integrated within a healthcare system’s electronic health record. The usability of the reminder was highly dependent on its user interface, with a homegrown version of the reminder resulting in higher impact than a stock reminder.
Infect Control Hosp Epidemiol 2014;35(9):1147-1155
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