Problems, solutions at core of UTI, C. diff modules

Dr. Beal says putting the UTI module to work offers a range of benefits. “The med techs you work with will appreciate that you are advocating for a better use of their time,” she says. “Pathologists, in general, love to learn. This is a quick way to learn something new and, with a little effort, see a big improvement. At a minimum, glancing through the document might help lab directors feel more at ease. Oftentimes they have issues they don’t realize other laboratories also have.

“The truth is we share many of the same frustrations, and now we can share the solutions as well.”

A positive C. diff test, particularly by nucleic acid amplification, does not always equate to disease. “Therefore, it is imperative that only the most appropriate patients are tested,” Dr. Beal says. “Labeling patients as C. diff positive when they don’t have an infection caused by C. diff has many downstream consequences. And because C. diff is considered a hospital-acquired infection, an increased rate of infection has financial consequences for the health care system.”

C. diff was considered appropriate for a module for those reasons and another: There are numerous testing options, each with advantages and disadvantages. “Among the tests, there are various combinations that can be used to make various algorithms,” Dr. Beal says. “We describe the different methods, from the gold standard of cytotoxic culture to PCR panels that include C. diff as one of several analytes. Understanding how each test works and which one might be best for your own situation is a great reason to read this module.”

Of the various assays used to detect C. difficile, Dr. Procop says: “We did not want to get into that quagmire of trying to pick which one is best when there are benefits and drawbacks to all. But there are some things about C. difficile testing that people do not debate, such as avoiding tests of cure or performing tests on formed stool or on a child less than a year old who can be colonized without disease. We know positive tests do not need to be repeated within seven days. The authors of the module highlighted these and other areas of agreement that are universal to all types of C. diff testing methods.”

Dr. Beal says her own lab grappled with some of the problems associated with C. diff testing. “We noticed that there was C. diff screening in asymptomatic patients, improper collection of C. diff samples, C. diff test orders on formed stool, repeat C. diff testing, C. diff tests on patients receiving tube feeds or laxatives and who clearly had a different reason for developing diarrhea, and C. diff testing as a test of cure to see if it was resolved, which was not very accurate,” Dr. Beal says.

To combat repeat or inappropriate testing, Dr. Beal says, “We created a pop-up alert if a patient had a recent C. diff test. And in the order-entry screen, we have ordering providers answer questions to make sure this is the most appropriate test. It’s only three questions. If they answer them in a way that would deem the test inappropriate, an alert flags the order as ‘likely inappropriate.’”

Dr. Procop says repetitive C. difficile test ordering is a common problem that’s easy to explain. “Back in the day, we didn’t have sensitive tests. So if a doctor thought a patient had C. diff and got a negative result from a test, they’d just order another one. We basically trained people to order multiple tests. Then along came PCR, which is highly sensitive. Now we don’t want doctors to order a second test; we want them to believe the first result because it’s so highly sensitive. But people have been stuck in that old-fashioned mindset of ‘three C. diffs.’”

Repetitive testing leads to unnecessary treatment and expense, he notes.

“Let’s say you have 100 people with diarrhea and you’re worried they have C. diff disease. When you perform a highly sensitive test on their specimen, then you find out who is positive and who is negative with a great degree of certainty. Now, what happens if you retest the group that you already proved was negative? Regardless of the test, when you start testing a low-prevalence population, most of the positives you get will be false-positives.”

“Thoughtless ordering,” Dr. Procop says, is when there are no appropriate clinical signs and symptoms or when a C. diff test is in an admission order. “‘Patient has diarrhea? Just do a C. diff’—that’s a thoughtless reaction. The patient may come in after two days of regular stooling, get a little constipated, receive a laxative, and then have diarrhea. That diarrhea is from the laxative, not from C. diff. But if that admission order is sitting out there, the test may be run. That’s a huge issue.”

At Cleveland Clinic, infectious diseases and infection prevention providers agreed that a repeat positive is never needed. “So if you get a positive result, you’re done. And if you try to order another one, you’ll be blocked,” Dr. Procop says. “If you get a negative, you can’t order another C. diff test for seven days unless there’s a change in the signs and symptoms. We put in electronic interventions to stop unnecessary test ordering, and these have had a substantial impact.”

Electronic interventions that limit orders based on timing are among the several possible interventions the C. diff module suggests. Other suggested electronic interventions limit tests of cure, and another consists of questions built into the order-entry screen for physicians or included in a nursing protocol.

Still other interventions are to review clinical ordering patterns or to provide selective feedback relative to peers, or to review standing orders, panels, reflex testing workflows, and diagnostic aids that contain C. diff tests to ensure they’re appropriately designed and used.

Another new module, Testing for Carcinoid Syndrome, was released in March. Others are on thyroid disorders, tickborne disease testing, urine myoglobin, vitamin D, and more. There are 16 modules in all. A 17th module, on testing for pheochromocytoma and paraganglioma, is due out soon.

“The committee aims to release about four to five per year,” Dr. Beal says. “And we have a system in place to monitor the ones we’ve already done to make sure they’re updated. These are not static; they’re living documents.”

Says Dr. Procop: “When we take the oath as physicians, we commit to improving patient care. We can do that through our skill set at the microscope or by improving test use. It’s our duty.”

Valerie Neff Newitt is a writer in Audubon, Pa.