Hospital lowers rate of nosocomial C. difficile with revised approach
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Key takeaways:
- Testing for C. difficile in the first 3 days of admission and proper care helped differentiate between community-acquired and hospital-onset cases.
- The process resulted in a 61% decline in hospital-onset cases.
ORLANDO — A hospital reduced the rate of hospital-onset cases of Clostridioides difficile infection with a standardized system for early recognition and testing, researchers found.
According to results presented by Stephanie DiGiovanni, MA, BSN, RN, CIC, director of infection prevention at NYU Langone-Long Island, at the Association for Professionals in Infection Control and Epidemiology annual conference, standardizing a process of early recognition and testing for C. difficile infection (CDI) can effectively reduce rates of hospital-onset CDI.
Community-acquired CDI was slightly more common in 2020 than hospital-onset CDI in the United States, averaging 51.2 cases per 100,000 persons compared with 50.1 cases per 100,000 persons, according to the CDC.
“The objectives of this project, when we started out, were to recognize the inconsistencies of current CDI testing processes that impacted our quality of care,” DiGiovanni said in a presentation. “Our organizational metrics demonstrate the benefit of using a standardized testing process for hospital-onset C. difficile and implementing comprehensive stewardship to improve patient safety.”
DiGiovanni and colleagues revised the hospital’s approach to recognizing community-onset CDI, which included minimizing barriers to testing, because patients would come to the hospital with diarrhea but were not receiving the proper tests — and were later being diagnosed with hospital-onset CDI.
Starting with the hospital’s ED, she said the team educated staff on how to recognize potential CDI, creating a tip sheet with guidance to differentiate and be sure of community-acquired CDI vs. hospital-onset CDI.
ED clinicians were often counting hours, rather than days, to make decisions on whether to order a C. difficile test, and these delays were thought to be increasing the rate of hospital-acquired cases.
They also created an escalation process for medical unit director approval of C. difficile testing after day 3 of hospitalization to be sure the test was appropriate.
Although some doctors and nurses were concerned about clinical judgement being taken away in favor of a dictated process, DiGiovanni said “clinical judgement always trumps our process — and that’s something we continue to educate [them about].”
According to the study, the median monthly rate of hospital-onset CDI between January 2021 and October 2021 was 4.29 per 10,000 patient days. After the medical unit director approval process was implemented in November 2021, the median monthly hospital-onset CDI rate dropped to 1.68 per 10,000 patient days by July 2022 — a 61% difference in case rate per month, or three fewer hospital-onset cases per month.
“Early testing has not only improved our metrics but, more importantly, it improved patient safety,” DiGiovanni said. “Enhanced C. difficile testing stewardship has been proven as an effective strategy when implemented, and this is supported by our hospital data. Utilizing a multidisciplinary approach fostered an engagement and commitment to success.”
References:
- CDC. 2020 annual report for the emerging infections program for Clostridiodes difficile infection. https://www.cdc.gov/hai/eip/Annual-CDI-Report-2020.html. Accessed July 5, 2023.
- Johnson D, et al. Reducing hospital-onset Clostridioides difficile. Presented at: APIC 2023; June 26-28, 2023; Orlando.
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Johnson D, et al. Reducing hospital-onset Clostridioides difficile. Presented at: APIC 2023; June 26-28, 2023; Orlando.
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