From the 2018 HVPAA National Conference
Omair Sheikh (Greenwich Hospital), Mrinalini Modak (Greenwich Hospital), Ellika Mardh (Greenwich Hospital), Charles Seelig (Greenwich Hospital), Shirui Chen (Greenwich Hospital), Charles Fry (Greenwich Hospital), John Rogener (Greenwich Hospital)
Of the many tests ordered on the inpatient service, the C.Difficile assay has become one of the most ubiquitous. There is a lack of consensus on the appropriate ordering algorithm leading to over-testing, which increases both the financial and medical burdens on hospitals and patients.
Our project aimed to educate both medical residents and hospital staff at Greenwich Hospital, a 204 bed community teaching hospital in Connecticut with 24 Internal Medicine Residents, on a core ordering algorithm based on the Infectious Disease Society of America (IDSA) guidelines in an effort to reduce testing for C.Difficile when not indicated.
With the support of the Greenwich Hospital High Value Work Group, which includes the heads of the ICU, ED, Hospitalist Program, and Laboratory, an algorithm for C.Difficile testing was created using the 2010 IDSA guidelines. We collaborated with Infection Control representatives from other hospitals in the YNHH System to review their implemented measures to reduce C.Difficile testing.
We conducted a 3 month retrospective chart review to gather a C.Difficile testing baseline for Greenwich Hospital. Then, a multimodal educational initiative was implemented to reach all staff – including medical residents, attending physicians, nursing and nursing aides, hospital leadership, infection control, and laboratory staff. Each outreach was individualized to the department being educated and their specific role in the testing process.
We worked with planned EPIC EMR changes, and a hard stop on ordering multiple C.Difficile tests within 72 hours was implemented. A Best-Practice-Advisory was created to alert caregivers when a test was ordered on a patient who received laxatives in the prior 24 hours.
A 3 month post-intervention chart review will be performed to assess the impact of our intervention on appropriate C diff testing.
Of the 179 pre-intervention tests, 79 tests (42%) were noted to be inappropriate per the IDSA guidelines. The first month post-intervention, 20 of the 56 tests (36%) were noted to be inappropriate, with a reduction of 6% in inappropriate testing. These results show a reduction in the number of inappropriate tests and we can assume reduced costs to both the hospital and the patient. Further results from 2 months, post-intervention, are pending, and our current data is preliminary. As more data is collected, we are confident that this trend will continue.
The reduction in the number of inappropriate C.Difficile tests consistent with the IDSA guidelines is the result of a multimodal educational intervention provided to residents and staff of Greenwich Hospital.
Implications for the Patient
A reduction in inappropriate testing of inpatients for C.Difficile benefits both patients and hospitals by reducing cost, appropriately utilizing resources for isolation, decreasing inappropriate antibiotic treatments, and reducing length of hospital stay.