Clostridium difficile Over Testing (C-DOT) Improvement initiative; a Multi-Prevention Epicenter Collaborative Project

项目总结 不必要的艰难梭菌检测在美国的许多医院都很普遍。高达50%的 诊断和治疗艰难梭菌感染(CDI)的住院患者可能没有真正的CDI。这 这是由于四个相互关联的因素：1)艰难梭菌在结肠的定植在住院患者中很常见，2) 广泛使用的艰难梭菌核酸扩增试验(NAAT)诊断试验检测艰难梭菌的存在 毒素基因，但阳性检测不一定表明毒素产生或活动性感染，3)住院 病人经常因为各种原因腹泻，4)不必要的检查在病例中经常发生 CDI预测概率较低。被错误归类为感染的殖民地患者接受了不必要的抗生素 破坏结肠微生物群，这可能会增加随后艰难梭菌感染的风险，获得 具有多重抗药性的生物。不必要的检测人为地夸大了公开报道的实验室比率- 确定艰难梭菌事件，疾病控制和预防中心国家医疗安全 网络患者安全指标。这项研究的总体目标是以最佳方式减少不必要的艰难梭菌检测 在10家急性护理医院，使用由人为因素加强的诊断管理干预方案 工程学(HFE)和文化人类学方法。我们将实施和传播一项电子 参与医院的病历临床决策支持工具，并将纳入新数据 反馈策略，以加强对干预措施的理解。这项工作将由系统工程部门提供信息 患者安全倡议(SEIPS)模型，该模型框架了工作系统要素(例如，人、 物理环境、任务、组织、工具/技术)以及它们的交互作用如何影响 艰难梭菌试验排序。我们将与前线进行汇报、半结构化访谈和焦点小组 医护人员确定导致不必要的测试和不符合要求的主要问题 电子病历临床决策支持工具。成功完成拟议的研究将 对减少急性护理环境中不适当的艰难梭菌检测有重大、直接的影响，减少 不必要的抗生素使用，并提供一个新的工具包，可用于未来的诊断管理 干预。

PROJECT SUMMARY Unnecessary Clostridium difficile testing is pervasive across many hospitals in the United States. Up to 50% of hospitalized patients diagnosed and treated for Clostridium difficile infection (CDI) may not have true CDI. This is due to four interrelated factors: 1) C. difficile colonization of the colon is common in hospitalized patients, 2) widely used C. difficile nucleic acid amplification testing (NAAT) diagnostic tests detect presence of C. difficile toxin gene, but a positive test does not necessarily indicate toxin production or active infection, 3) hospitalized patients frequently have diarrhea for a variety of reasons, and 4) unnecessary testing occurs frequently in cases of low CDI pre-test probability. Colonized patients, misclassified as infected, receive unnecessary antibiotics that disrupt the colon microbiome, which may increase risk for subsequent C. difficile infection, acquisition of multidrug resistant organisms. Unnecessary testing artificially inflates publicly reported rates of Laboratory- identified Clostridium difficile events, a Centers for Disease Control and Prevention National Healthcare Safety Network patient safety metric. The overall goal of this study is to optimally reduce unnecessary C. difficile testing at ten acute care hospitals, using a diagnostic stewardship intervention package enhanced by human factors engineering (HFE) and cultural anthropological approaches. We will implement and disseminate an electronic medical record clinical decision support tool across participating hospitals and will incorporate novel data feedback strategies to enhance uptake of the intervention. This work will be informed by the Systems Engineering Initiative for Patient Safety (SEIPS) Model, which frames the design of the work system elements (e.g., people, physical environment, task, organization, tools/ technologies) and how their interactions influence the process of C. difficile test ordering. We will conduct debriefs, semi-structured interviews and focus groups with front line healthcare workers to identify the major issues that lead to unnecessary testing and non-compliance with electronic medical record clinical decision support tools. Successful completion of the proposed research will have a major, direct impact on reducing inappropriate C. difficile testing in acute care settings, decrease unnecessary antibiotic use, and inform a novel toolkit that could be adapted for future diagnostic stewardship intervention.