Unnecessary testing for Clostridium difficile (C diff) infection (CDI) can be both wasteful and contra productive retesting the same positive patient after transfer to a new nursing unit will only to confirm the patient has CDI (already known) and likely be classified as a new case of hospital-onset (HO) CDI. Yet, it is also important to recognize community-onset (CO) CDI in hospital, not only because it prevents late recognition of CO CDI as being classified as a HO event, will also to afford appropriate contact precautions and therapeutic measures are instituted in a timely fashion. Laboratory stewardship (LS) can be helpful in improving appropriateness of C diff testing.
We developed 2 CDI testing algorithms. One focused on hospital days 1-3, the other for all C diff testing after hospital day 3 (AHD3). The LS quality improvement (QI) project was rolled out in 2 stages. During the first 6 months we focused on improving early detection of CO-CDI, while during the next 6 months a mandatory review of all C diff testing orders AHD3 was conducted by a 10 person team. Testing that concurred with the algorithm was approved. Non-approval was communicated to the care teams. Appeals could be made on a case by case basis to the medical director of infection control. Validation audits of non-approved cases were performed to determine if testing algorithms were sound.
CO-CDI detection steadily increased over the yearlong LS QI period (average of 6 cases/week at start vs 12 cases/week at year's end). During the 6 months of the AHD3 mandatory order review 678 C diff orders were placed, 428 (63.1%) were approved, 250 (36.9%) were rejected. Reduced use of lab resources is estimated to have saved $14,950. LS and frequent communication with care teams contributed better recognition of CO-CDI, decreased inappropriate repeat testing, avoidance of diagnosing colonized patients as HO-CDI and was associated with a significantly drop our CDI SIR (Figure 1).
A algorithm-based guideline for a 2 step LS QI program focused on reviews of all C diff orders AFHD3 as well as improving early detection of CO-CDI and was associated with better lab resource utilization and markedly decreased C diff SIR. Efforts are currently underway to automate much of the review process.
J. P. Parada,
S. Suarez-Ponce, None
E. Trulis, None
P. Linchangco, None
A. Abuihmoud, None
H. Pua, None
M. Green, None
H. Hedlund, None
K. R. Smith, None
A. Harrington, Biofire: Grant Investigator and Scientific Advisor , Consulting fee , Research grant and Speaker honorarium . Cepheid: Grant Investigator and Speaker's Bureau , Research grant .