QAPI 141 - Infection Preventionist Involvement Enhances Electronic Health Record Prompts for Appropriate C. Diff Testing

Background: Clostridioides difficile infection (CDI) is one of the most common organisms to cause healthcare acquired infections (HAI) in the United States. Diagnostic stewardship is needed to accurately identify CDI within the healthcare setting. Different processes to ensure emphasis on clinically appropriateness for CDI testing were compared.

Methods: A healthcare system including 45 hospitals in midwestern United States developed and implemented a process for early recognition of community-onset CDI utilizing electronic health record Best Practice Advisories (BPA). Initial and annual review of BPAs improved their ability to educate providers and empower nurses to place an order for testing per protocol within the first three days of admission. Infection Preventionists (IPs) supplement the work of the BPAs in a variety of manners. The effect of engagement of IPs, nurses and lab in various processes were compared using Chi square analysis (EpiInfo, CDC, Atlanta GA) of hospital-onset CDI from October 2021-September 2023, as measured by Standardized Infection Ratio (SIR).

Results: Hospitals where the lab sought approval from IP for CDI tests ordered within the first 3 days of admission reported 45% lower SIR (0.22 versus 0.45, p=0.03); those that sought approval for CDI tests ordered 4 or more days after admission reported 55% lower SIR (0.23 versus 0.51, p< 0.01). Hospitals where the IPs rated moderate or high engagement from nursing to follow the BPAs had 23% lower SIR (0.36 versus 0.47, p=0.01). Those where IPs discontinued inappropriate protocol orders from nursing 4 or more days after admission had 21% lower SIR (0.35 versus 0.44, p=0.02).

Conclusions: BPAs, while able to impact CDI ordering practices, are not universally followed. Hospitals where IP actively engages with lab and ordering providers, or nursing has higher engagement with the BPAs, had lower SIRs, likely related to limiting inappropriate testing.