Hard Stops for EMRs Reduces Rates of Hospital-Acquired Clostridioides difficile Infection


These are used to help reduce inappropriate testing, where an expert consults with medical directors of infection prevention and control for a test-order override.

The implementation of an electronic medical record (EMR) hard stop, used to reduce inappropriate testing, effectively reduced the rates of health care facility onset of Clostridioides difficile infection (CDI) in 5 hospital health systems, according to the results of a study published in Antimicrobial Stewardship & Healthcare Epidemiology.

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An EMR hard stop includes expert consults with medical directors of infection prevention and control so test-order override and alerts for tests decrease inappropriate testing.

Investigators compared C. difficile test order rates per 1000 patient stays, CDI rates per 1000 patient days, and standardized infection ratio (SIR) between January 2018 and December 2019, the preintervention period, and April 2020 and March 2022, the intervention period, in 5 hospital health care systems in Michigan.

The hard stop went live in February 2020, which was automated to appear after more than 3 days after admission upon signing the order, with settings including patients younger than aged 1 year, receipt of promotility agents within 48 hours, and repeated testing within 7 days for negative results or during the same admission for positive results.

The reason for the hard stop and the instructions on whom to contact were provided with the program. The medical director of infection prevention and control or designee could override the hard stop after reviewing that case after a physician’s request.

After the promotility agents were discontinued for 48 hours or more, physicians could place an order for a test if diarrhea persisted.

Investigators found that the CDI rates were 2.54 during the preintervention period and 1.48 in the postintervention period, which was a 58% reduction. In the preintervention period, the test order rate was 126.5 in and just 90.6 in the postintervention period, for a 28% reduction. The SIR decreased from 0.521 to 0.347, respectively, for a 33% reduction.

Of the 289 overrides, 14% were cancelled because of a lack of specimen, with 248 tests being performed. Of those, 11% were positive. The most common reason for overrides were diarrhea in individuals who were critically ill with sepsis and cirrhotic individuals who discontinued laxatives.

All individuals who tested positive were treated for CDI.

Furthermore, the community-onset CDI rates decreased from 1.05 in the preintervention period to 0.88 in the postintervention period, with a 16% reduction.

Investigators also reported that there were no reported adverse events associated with delayed testing, and no individuals were readmitted with CDI because of delayed testing.

They also reported that the additional benefit of the intervention could help cost savings for the health system, with investigators reporting an estimated net savings of nearly $7 million.

Limitations of the study were also included. For example, the number of hard stops that were fired were not known, which made it difficult to gauge the exact number of test orders that were reduced. Additionally, for the test orders that were approved for overrides, the reasons were not collected, so there was no analysis available.


Shallal AB, Cherabuddi M, Podsiad L, Gortat C, et al. Role of diagnostic stewardship in reducing healthcare-facility-onset Clostridioides difficile infections. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e53. doi:10.1017/ash.2022.305

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