ADS 28 - Streamlining Diagnosis, Enhancing Stewardship: The REFLECT Mnemonic Helps Facilitate Decision-making in Clostridioides difficile Testing, Reducing Incidence and Preventing Harm

Background: The standardized infection ratio (SIR) exposed a notable issue of excessive Clostridioides difficile (CDI) testing, marked by frequent orders lacking clinical justification. This overutilization underscored a broader challenge associated with the prevalent one-step testing method, revealing limitations and diagnostic pitfalls in CDI testing protocols.

Methods: Infection Prevention reviewed tools available for direct care teams to determine appropriate CDI polymerase chain reaction testing. To improve understanding, the acronym REFLECT was created to include elements that should be considered before utilizing one-step testing methods: (R) – risk factors, (E) – exclusions, (F) – frequency, (L) – leukocytosis, (E) – elevated temperature, (C) – consistency, and (T) – tenderness. Providers received education about limitations of one-step CDI testing and were introduced to the REFLECT tool. The acronym was then socialized to frontline nurses through a newsletter and laminated pocket card dissemination.

Results: Testing appropriateness and hospital-onset CDI counts were reviewed one year before implementation (01/2022 – 12/2022) and followed for nine months after implementation (01/2023 – 09/2023). Results from the follow-up period were compared by quarter to the first nine months of the baseline period. The first and second quarters showed a 62.5% reduction in hospital-onset CDI incidence. The third quarter showed a 57.1% reduction, with an overall three-quarters reduction of 60.8% (p <.001).

Conclusions: This study reveals a pivotal shift in CDI testing practices, effectively addressing the identified overutilization by implementing the REFLECT tool. The results, demonstrating a 60.8% reduction in hospital-onset CDI incidence, underscore the efficacy of the mnemonic algorithm in promoting judicious testing. This study found that by incorporating risk factors, exclusions, frequency, leukocytosis, elevated temperature, consistency, and tenderness into the decision-making process, the REFLECT tool facilitates precise and clinically justified CDI testing. The implications of these findings extend to enhancing evidence-based practices, fostering a culture of diagnostic stewardship, and subsequently improving patient outcomes.