Several members have requested clarification regarding the discussion of DNRs that appeared in the September 15 E-Bulletin.

In the absence of a substitute decision-maker in a mentally incompetent patient, treatment may proceed for an emergency medical condition as long as the physician documents that such an emergency medical condition is present.

Policy 01829: Section III. TEXT, H.: In the case of a medical emergency, treatment may proceed without the patient's consent so long as no evidence exists to indicate that the patient or the patient's representative would refuse treatment (such as religious beliefs or a relative's statement regarding the patient's wishes).

1. the medical determination that an emergency exists shall be documented by the physician.

a. The physician shall not sign the consent form on behalf of the patient, but shall document in the medical record that an emergency exist.
b. The treatment provided shall be limited to that which is needed for the emergency condition.
c. The emergency exception is not applicable when a patient has validly refused treatment and the emergency arises because of this refusal.

The decision to suspend a pre-existing DNR order in such a case would need to be documented by the physician.

If the DNR order is suspended peri-operatively, an order needs to be written.

It would be prudent for the surgeon to discuss whether or not to suspend the DNR order peri-operatively with the anesthesiologist and/or other physicians involved in the care of the patient.

New C difficile antigen and toxin test will improve sensitivity and specificity over the current toxin specific EIA assay that has a sensitivity of 75-85%.

When a test for C. difficile is ordered, all fecal samples will be tested simultaneously (by membrane EIA) for C. difficile glutamate dehydrogenase (GDH, the common antigen) and for C. difficile toxins A and B. The combined test shows a negative predictive value of >99%.

The new test method will increase sensitivity and due to the high negative predictive value will allow definitive diagnosis in more than 90% of samples with >99% certainty.

If a sample is found to be positive for GDH but negative for the toxin it could be due to presence of a non toxigenic strain or the level of toxin in the sample is below the level of detection. All such samples are automatically reflexed to molecular testing (PCR) for detection of tcdB gene. Molecular results will resulted in the final test report.

Test Ordering
Cerner Millennium: Clostridium difficile Antigen and Toxin; (replaces Clostridium difficile Toxin A&B EIA)

CareCast: Clostridium difficile Antigen and Toxin - (replaces Clostridium difficile Toxin A&B EIA) syn: MIC Clostridium diff Antigen and Toxin - syn: C diff AG & Toxin

Specimen Collection
This test is approved for diagnosis of C difficile disease in symptomatic patients only (patients with more than 3 episodes of diarrhea per 24 hours). Therefore, only liquid or soft stool specimens (specimens that take the shape of the container) are accepted for testing, all formed stools will be rejected.

Result Reporting Tests are run daily and results reported throughout the day. Turnaround time for specimens needing molecular testing is approximately 24 hours.

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