ADS 30 - Reducing Inappropriate Clostridioides difficile Testing by Implementing a “second Sign Review” Process

Background: Clostridioides difficile (C. diff) is a bacterium that colonizes the gut and is the most common cause of infectious diarrhea among healthcare settings. C. diff infection (CDI) is a clinical diagnosis with laboratory support; there is no laboratory test that will distinguish active infection from colonization. It is important for patients to clinically meet criteria for testing to ensure only individuals who are truly symptomatic and need treatment receive it. Diagnostic stewardship is needed to successfully identify active CDI within the healthcare setting.

Methods: A multispecialty, 440 bed Midwestern hospital implemented a Second Sign Review process to review C. diff orders for clinical criteria using an evidence-based algorithm. Providers and nursing staff were educated on the process and algorithm during Quarter 1 (Q1) of 2022. Beginning in March 2022, a designated review team completed a secondary review on all C. diff orders placed after hospital day 3. Tests not meeting the clinical criteria algorithm were rejected. Active surveillance data was monitored to measure test volumes, rejection rates, and rates of infection.

Results: The standardized infection ratio (SIR) for Quarters 3 and 4 of 2021 was 1.125. The SIR for Quarters 2 and 3 of 2022 was 0.212. Q1 of 2022 is excluded from the results. The average number of tests ordered monthly reduced from 34 to 6.5. The percentage of tests found to be inappropriate when utilizing the algorithm was 37.7%.

Conclusions: The Second Sign Review process reduced the SIR and total number of C. diff orders placed. By decreasing the number of inappropriate orders, there has been a decrease in the number of patients diagnosed and treated inappropriately for a CDI. While deemed a successful intervention, ongoing education, consistent communication, and collaboration with team members is needed for sustainment. Investigation into viable clinical decision support and practice feedback is needed.