Reduction in Inappropriate C. difficile Testing through Just-in-Time Education upon Order Entry

From the 2019 HVPAA National Conference

Dr. Amy Slenker (Lehigh Valley Health Network), Dr. Matthew Miller (Lehigh Valley Health Network), Mr. Joshua Rosentel (Lehigh Valley Health Network)


C. difficile infection is one of the most common healthcare-associated infections and a significant cause of morbidity and mortality among older adult hospitalized patients.1 Lehigh Valley Health Network (LVHN) uses a C. difficile polymerase chain reaction (PCR) test to diagnose suspected C. difficile colitis. This test detects genes specific to toxigenic strains of C. difficile and is highly sensitive, but does not test for active toxin production and cannot distinguish between infection and asymptomatic colonization. Exclusive reliance on molecular testing without regard to clinical symptoms may result in overdiagnosis and overtreatment.2 There are multiple evidence-based interventions that can safely and effectively decrease inappropriate testing.3-5


We aimed to provide education and implement changes in computerized-order entry to provide just-in-time feedback regarding the appropriateness of C. difficile testing.


We presented education to providers regarding C. difficile testing and introduced clinical criteria for appropriate testing beginning February 2017. We implemented changes to our C. difficile testing computerized order entry on January 1st, 2018 that provided the following alerts:

(1) If the patient had not had ≥3 loose stools documented in the past 24 hours

(2) If the patient had received a laxative in the past 48 hours

(3) If the patient had a negative C. difficile test in the past 7 days

(4) If the patient had a positive C. difficile test in the past 14 days

We retrospectively reviewed all hospitalized patients who had C. difficile testing for a one-year period prior to (January 1, 2016-December 31, 2016) and after education (January 1, 2017-December 31, 2017), as well as prior to (January 1, 2017-December 31, 2017) and after changes to order entry (January 1, 2018-December 31, 2018). We reviewed how many tests were performed during this period, laxative use, if patients met the clinical definition of diarrhea (≥3 loose bowel movements/24 hours), and if patients had prior C. difficile testing.


After education was provided regarding appropriate C. difficile testing, we found a 22% decline in C. difficile testing from a baseline rate of 5.7 tests/1000 patient days to 4.4 tests/1000 patient days. After the implementation of changes to C. difficile order entry, we found an additional 12% decline in C. difficile testing to 3.9 tests/1000 patient days. Interestingly, we were not able to detect a significant change in appropriate testing with regards to the percentage of patients tested who had diarrhea in the 24 hours prior to testing or to the percentage of patients who did not receive a laxative in the 48 hours prior to testing.


Education provided in lecture-format and as just-in-time education upon order entry can successfully reduce inappropriate C. difficile testing.

Clinical Implications

Reduction in inappropriate C. difficile testing can prevent overdiagnosis, inappropriate treatment, and has potential implications for cost-savings.


1. McDonald LC et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2017 update by the society for healthcare epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Clin Inf Dis; 2018: 66:e2-48.
2. Polage CR et al. Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era. JAMA Intern Med. 2015 Nov;175(11):1792-801
3. Luo RF et al. Alerting Physicians during Electronic Order Entry Effectively Reduces Unnecessary Repeat PCR Testing for Clostridium difficile J. Clin. Microbiol. November 2013 51:11 3872-3874