Real-Time Clinical Data Tracking Enables Enforcement of Diarrhea and Absence of Laxatives in Hospitalized Patients Undergoing Clostridium difficile Testing

Background: Health care providers often test and treat patients for Clostridium difficile infection in the absence of diarrhea. Our objective was to develop and apply a real-time data tracking tool to restrict Clostridium difficile testing to patients with diarrhea and an absence of laxative therapy.

Methods: A real-time electronic medical chart (EMR) report, displaying bowel movement occurrence and consistency and laxative administration was developed and implemented in the EMR.  From 6/22/15 to 3/27/16, upon receipt of stool samples from inpatients, laboratory accessioners used the report to enforce testing criteria, which was defined as presence of 3 or more unformed stool in 24 hours and no laxatives administered in the prior 48 hours.  The efficacy of the intervention was assessed as a measure of laboratory non-compliance with criteria per 4-week period. CDI-associated complications were evaluated in patients that did not meet testing criteria but whose stool samples were tested under a research protocol.

Results: Between 6/22/15 and 3/27/16, 561 (31.7%) of 1769 C. difficile test orders were rejected due to any reason of which 132 (23.5%) and 183 (32.6%) were due to <3 unformed stool in 24 hours and laxatives in prior 48 hours, respectively. Accessioner’s non-compliance with testing criteria rapidly declined from 35.4% in the 1^st 4-week period to 3.4% in the 10^th period (Figure 1).  Provider behavior did not improve during the study (Figure 1). CDI-associated complications were not significantly different in rejected patients with positive and negative C. difficile results.

Conclusion: Real-time clinical data tracking was highly effective for reducing inappropriate C. difficile testing in patients without diarrhea. 

Figure 1. Non-compliance with C. difficile testing criteria per 4-week period. Dashed line shows percentage of all C. difficile tests ordered and collected by physician and nurses, respectively, from patients with <3 unformed stool in 24 hours or laxatives in prior 48 hours. Solid line shows percentage of C. difficile orders for patients with <3 unformed stool in 24 hours or laxatives in prior 48 hours that were incorrectly accepted for testing by the laboratory.