SEE the DIFFerence: Reducing Unnecessary C. difficile Orders Through Clinical Decision Support in a Large, Urban Safety-Net System

Published:November 09, 2022DOI:


      • 3-26% of inpatients are colonized with C. difficile, which contributes to false positive tests
      • It is not recommended to test for C. difficile if administered laxatives in the last 48 hours, or a recent positive or negative test within 7 days.
      • Utilizing best practice advisories for recent administration of laxatives, or recent positive or negative test successfully reduced C. difficile orders by 27.3%.



      Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C. difficile leads to false positive results due to a high rate of asymptomatic colonization, resulting in unnecessary and harmful treatment for patients.


      This was a quality improvement initiative to decrease the rate of inappropriate C. difficile testing across 11 hospitals in an urban, safety-net setting. Three best practice advisories were created, alerting providers of recent laxative administration within 48 hours, a recent positive test within 14 days, and a recent negative test within 7 days. The outcome measures were the number of C. difficile tests per 1000 patient days, as well as the rate of hospital onset C. difficile infection was compared pre- and post-intervention. The process measures included the rate of removal of the C. difficile test from the best practice advisory, as well as the subsequent 24-hour re-order rate.


      The number of C. difficile tests decreased by 27.3% from 1.1 per 1000 patient days pre-intervention (May 25, 2020-May 24, 2021) to 0.8 per 1000 patient days post-intervention, (May 25, 2021 to March 25, 2022), p<0.001. When stratified by hospital, changes in testing ranged from an increase of 12.5% to a decrease of 60.0%. Analysis among provider type showed higher behavior change among attendings than compared to trainees or advanced practice providers. There was a 12.1%, non-significant decrease in C. difficile rates from pre-intervention, 0.33 per 1000 patient days compared to post-intervention, 0.29 per 1000 patient days, p=0.32.


      Using only an electronic health record intervention, we successfully decreased C. difficile orders after 72 hours of admission in a large, safety-net system. Variation existed among hospitals and by provider type.


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