McManus, Dayna

Abstract Objective: To better understand clinicians’ rationale for ordering testing for C. difficile infection (CDI) for patients receiving laxatives and the impact of the implementation of a clinical decision support (CDS) intervention. Design: A mixed-methods, case series was performed from March 2, 2017 to December 31, 2018. Setting: Yale New Haven Hospital, a 1,541 bed tertiary academic medical center. Participants: Hospitalized patients ≥ 18 years old, and clinicians who were alerted by the CDS. Intervention: CDS was triggered in real-time when a clinician sought to order testing for CDI for a patient who received one or more doses of laxatives within the preceding 24 hours. Results: A total of 3,376 CDS alerts were triggered during the 21-month study period from 2,567 unique clinician interactions. Clinicians bypassed the CDS alert 74.5% of the time, more frequent among residents (48.3% bypass vs. 39.9% accept) and advanced practice providers (APPs) (34.9% bypass vs. 30.6% accept) than attendings (11.3% bypass vs. 22.5% accept). Ordering clinicians noted increased stool frequency/output (48%), current antibiotic exposure (34%), and instructions by an attending physician to test (28%) were among the most common reasons for overriding the alert and proceeding with testing for CDI. Conclusions: Testing for CDI despite patient laxative use was associated with an increased clinician concern for CDI, patient risk for CDI, and attending physician instruction for testing. Attendings frequently accepted CDS guidance while residents and APPs often reinstated CDI test orders, suggesting a need for greater empowerment and discretion when ordering tests.

Abstract Purpose Transgender patients face considerable healthcare disparities. Improved means of recognizing transgender patients and understanding their medical needs is important to provide optimal care. The electronic medical record (EMR) of our health system allows for differentiation of gender identity, legal sex, and sex at birth. With EMR recognition of transgender patients, a recommendation for estimating creatinine clearance (CLcr) and ideal body weight (IBW) was needed to standardize medication dosing. Summary The literature was reviewed for evidence on the effect of gender-affirming hormone therapy on serum creatinine concentration and lean body mass. Findings informed a recommendation for drug dosing based on CLcr and IBW in transgender patients. Four studies that reported the effect of hormone therapy on biometric laboratory values were found. Three studies reported that values of transgender patients more closely resembled the standard values of their gender identity vs sex at birth after hormone therapy; 1 study reported a range of values that more closely resembled those associated with sex at birth while still overlapping with values associated with gender identity. Consequently, it was recommended that pharmacists dose medications based on CLcr and IBW calculations consistent with gender identity after a patient has been on hormone therapy for 6 months or longer. Conclusion Providing optimal care to transgender patients includes considering the effect of gender-affirming hormone therapy on overall physiology. Consistently using the appropriate CLcr and IBW calculations for each patient ensures safe and effective care. Additional studies are needed to confirm the effect of hormone therapy on renal clearance and lean body mass.