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Diarrhea don'ts: Reducing inappropriate stool cultures and ova and parasite testing for nosocomial diarrhea
Mariely Garcia1, Mona Krouss2, Joseph Talledo1
1Department of Quality and Safety, NYC Health + Hospitals, New York, NY.
Background:
Diarrhea that develops in patients after 72 hours of hospitalization is likely to have a nosocomial or iatrogenic etiology. Testing with stool cultures and stool ova and parasites (O&P) is not recommended. Our goal was to reduce this inappropriate testing within a large, urban safety-net hospital system.
Methods:
This was a quality improvement project. We created a best practice advisory (BPA) within the electronic medical record that fires when a stool culture or O&P order is placed 72 hours after admission for any immunocompetent patient. It states that stool testing is low yield and offers the option to remove the order. We measured weekly counts of stool culture and stool O&P orders pre- and postintervention. We also measured the BPA acceptance rate, the 24-hour stool testing reorder rate, and Clostridioides difficile infection rates. Data were analyzed using Welch tests as well as a quasi-experimental pre- and postintervention interrupted time series regression analysis.
Results:
Stool culture orders decreased by 24.4% (P < .001). There was a significant level difference and slope difference with linear regression. Five of the 11 hospitals had a significant reduction in stool culture orders. Stool O&P orders decreased by 18.2% (P < .01). Three of the 11 hospitals had a significant reduction in stool O&P orders.
Conclusions:
Our intervention successfully reduced inappropriate stool testing within a large safety-net hospital system.
Insights
Hospital-acquired diarrhea testing was reduced by implementing a best practice advisory (BPA) in electronic medical records. This quality improvement project successfully decreased unnecessary stool cultures and ova and parasite (O&P) testing in immunocompetent patients.
Area of Science:
- Healthcare Quality Improvement
- Infectious Disease Diagnostics
- Hospital-Acquired Infections
Background:
- Nosocomial diarrhea, developing over 72 hours post-admission, often stems from hospital-acquired or iatrogenic causes.
- Routine stool cultures and ova and parasite (O&P) testing are generally not recommended for these cases due to low diagnostic yield.
- A quality improvement initiative aimed to curb inappropriate stool testing in a large, urban safety-net hospital system.
Purpose of the Study:
- To decrease the frequency of non-indicated stool culture and ova and parasite (O&P) testing in hospitalized patients.
- To implement an electronic medical record-based intervention to guide appropriate diagnostic test ordering.
- To evaluate the impact of the intervention on testing rates and related clinical outcomes.
Main Methods:
- A quality improvement project utilizing a best practice advisory (BPA) integrated into the electronic medical record.
- The BPA alerted clinicians to low-yield stool testing orders placed after 72 hours of admission for immunocompetent patients, offering order removal.
- Key metrics included weekly stool culture and O&P order counts, BPA acceptance rates, reordering rates, and Clostridioides difficile infection rates, analyzed via interrupted time series regression.
Main Results:
- Stool culture orders significantly decreased by 24.4% (P < .001) across the hospital system.
- Stool ova and parasite (O&P) orders saw an 18.2% reduction (P < .01).
- Five out of eleven hospitals demonstrated a significant reduction in stool culture orders, while three showed a significant decrease in O&P orders.
Conclusions:
- The implemented best practice advisory effectively reduced inappropriate stool testing in a large safety-net hospital network.
- The intervention demonstrates a successful strategy for optimizing diagnostic test utilization in hospitalized patients.
- This approach highlights the potential of EMR-based decision support tools in improving healthcare quality and reducing unnecessary procedures.
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