Abstract
Background
Clinical decision support for Clostridioides difficile infection (CDI) diagnostics reduces inappropriate testing, leading to decreased need for isolation and antibiotic use. Our institution utilized manual discontinuation by laboratory staff of CDI testing for inappropriate specimens, including formed stool and age < 1 year. We aimed to assess the financial impact of instituting a CDI best practice alert at a quaternary care children’s hospital.
Methods
A multidisciplinary team mapped inappropriate testing criteria identified from literature review with discrete fields in our electronic health record (EHR, EpicCare) to design an alert. The exclusion criteria identified included: (1) age < 1 year; (2) positive C. difficile test within past 14 days; (3) less than or equal to 3 unformed stools in past 24 hours; (4) current receipt of CDI-directed therapy; or (5) laxative use or barium exposure in prior 48 hours. 6 months of data prior to implementation were reviewed to estimate impact of the alert. At implementation, any exclusion criteria detected in the EHR at the time of order entry triggered an alert to deter CDI testing. Cost estimates for averted tests (Quick Check Complete Assay/Illumigene) included cost of test ($50), cost of isolation/personal protective equipment ($159/day), and cost of treatment with oral vancomycin in false-positives ($2250/treatment course).
Results
In a 6-month pre-implementation period, 586 tests for CDI were ordered; of which, 23% were identified by our criteria as inappropriate. During the first 3 months of alert implementation, 256 tests were ordered, of which 105 (41%) caused the alert to fire. Of those, 56 tests were not ordered, for a 22% reduction in testing. Laboratory staff continued to manually stop tests not meeting criteria, such as patient age <1 year when possible. Based on avoidance of testing, use of PPE, and 10 day antibiotic treatment for false-positives (assumed 25% by literature review), this translated to cost savings of $69,916, and an annual cost savings of $279,664.
Conclusion
Implementation of an alert for select patients using a bioinformatics algorithm reduced inappropriate CDI testing. Clinical decision support for CDI can lead to substantial cost savings for both antibiotic use and isolation precautions.
Disclosures
All authors: No reported disclosures.
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