February 18, 2020
2 min read

EMR ‘nudge’ decreases inappropriate hospital C. difficile testing

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Jessica R. Howard-Anderson, MD
Jessica R. Howard-Anderson

An electronic medical record “nudge” minimized the ordering of inappropriate tests for hospital-onset Clostridioides difficile infection, or CDI, according to a study published in Infection Control & Hospital Epidemiology.

C. difficile tests should be avoided on patients who recently received a laxative or stool softener and do not have a clinical syndrome suggestive of C. difficile infection,” Jessica R. Howard-Anderson, MD, an infectious diseases fellow at Emory University School of Medicine, told Healio. “EMR interventions that alert clinicians that their patient has recently received a laxative or stool softener can be helpful in improving diagnostic stewardship for C. difficile.”

Howard-Anderson and colleagues conducted a time series analysis of hospital-onset CDI test orders at four hospitals 2 years before and after the implementation of an EMR intervention. The automated EMR nudge encouraged health care providers to cancel “inappropriate” CDI orders if the patient had received a stool softener or laxative in the past 24 hours.

Of the 17,694 total CDI orders analyzed, 7% (8% preintervention vs. 6% postintervention; P < .001) were found to be inappropriate. Additionally, monthly CDI orders decreased by 21% postintervention (level-change rate ratio = 0.79; 95% CI, 0.73-0.86), and the postintervention inappropriate order rate decreased over time (RR = 0.95; 95% CI, 0.93-0.97). The researchers found no association between the EMR nudge and the level change in CDI orders.


Howard-Anderson emphasized the ease of implementation of the EMR nudge as one of its major benefits.

“Our results are similar to prior studies that have demonstrated that educational campaigns, EMR order sets and laboratory protocol changes are effective at decreasing inappropriate C. difficile orders,” Howard-Anderson said. “However, many of these interventions studied can be time consuming for clinicians and laboratory personnel and so we believe our simple EMR nudge may be easier to implement and less onerous for health care providers.”

She also noted that EMR nudges may have other health care applications outside of CDI testing.

“The behavioral science concept of ‘nudging’ has already been shown to be effective in many areas of health care, and I think it can be particularly effective when designing EMR order sets to improve diagnostic stewardship,” Howard-Anderson said. “Another example of a health care-associated infection where EMR nudges could be useful would be to promote appropriate testing and diagnostic stewardship in patients being worked up for catheter-associated urinary tract infections.” – by Eamon Dreisbach

Disclosures: The authors report no relevant financial disclosures.