C. diff: How Did a Community Hospital Cut Infections by 77%?

Lorraine L. Janeczko, MPH

May 26, 2022

Teamwork by a wide range of professional staff, coupled with support from leadership, enabled one academic community hospital to cut its rate of hospital-onset Clostridioides difficile infections (HO-CDIs) by almost two thirds in 1 year and by over three quarters in 3 years, a study published in the American Journal of Infection Control reports.

C. difficile is a major health threat. According to the US Centers for Disease Control and Prevention, CDIs, mainly linked with hospitals, caused an estimated 223,900 cases in hospitalized patients and 12,800 deaths in the United States in 2017.

Cherith Walter

"The interventions and outcomes of the project improved patient care by ensuring early testing, diagnosis, treatment if warranted, and proper isolation, which helped reduce C. difficile transmission to staff and other patients," lead study author Cherith Walter, MSN, RN, a clinical nurse specialist at Emory Saint Joseph's Hospital in Atlanta, Georgia, told Medscape Medical News. "Had we not worked together as a team, we would not have had the ability to carry out such a robust project," she added in an email.

Each HO-CDI case costs a healthcare system an estimated $12,313, and high rates of HO-CDIs incur fines from the Hospital-Acquired Condition Reduction Program of the Centers for Medicare & Medicaid Services (CMS), the authors write.

A Diverse Staff Team Collaborated

Emory Saint Joseph's, a 410-bed hospital in Atlanta, had a history of being above the national CMS benchmark for HO-CDIs. To reduce these infections, comply with CMS requirements, and avoid fines, Walter and colleagues launched a quality improvement project between 2015 and 2020.

With the approval of the chief nursing officer, chief quality officer, and hospital board, researchers mobilized a diverse team of professionals: a clinical nurse specialist, a physician champion, unit nurse champions, a hospital epidemiologist, an infection preventionist, a clinical microbiologist, an antimicrobial stewardship pharmacist, and an environmental services representative.

The team investigated what caused their hospital's HO-CDIs from 2014 through 2016 and developed appropriate, evidence-based infection prevention interventions. The integrated approach involved:

  • Diagnostic stewardship, including a diarrhea decision-tree algorithm that enabled nurses to order tests of any loose or unformed stool for C. difficile during the first 3 days of admission.

  • Enhanced environmental cleaning, which involved switching from sporicidal disinfectant only in isolation rooms to using a more effective Environmental Protection Agency-approved sporicidal disinfectant containing hydrogen peroxide and peracetic acid in all patient rooms for daily cleaning and after discharge. Every day, high-touch surfaces in C. difficile isolation rooms were cleaned and shared equipment was disinfected with bleach wipes. After patient discharge, staff cleaned mattresses on all sides, wiped walls with disinfectant, and used ultraviolet light.

  • Antimicrobial stewardship. Formulary fluoroquinolones were removed as standalone orders and made available only through order sets with built-in clinical decision support.

  • Education of staff on best practices, through emails, flyers, meetings, and training sessions. Two nurses needed to approve the appropriateness of testing specific specimens for CDI. All HO-CDIs were reviewed and findings presented at CDI team meetings.

  • Accountability. Staff on the team and units received emailed notices about compliance issues and held meetings to discuss how to improve compliance.

After 1 year, HO-CDI incidence dropped 63% from baseline, from above 12 cases per 10,000 patient-days to 4.72 per 10,000 patient-days. And after 3 years, infections dropped 77% to 2.80 per 10,000 patient-days.

The hospital's HO-CDI standardized infection ratio — the total number of infections divided by the National Healthcare Safety Network's risk-adjusted predicted number of infections — dropped below the national benchmark, from 1.11 in 2015 to 0.43 in 2020.

The hospital also increased testing of appropriate patients for CDI within the first 3 days of admission, from 54% in 2014 to 81% in late 2019.

"By testing patients within 3 days of admission, we discovered that many had acquired C. difficile before admission," Walter said. "I don't think we realized how prevalent C. difficile was in the community."

Benjamin D. Galvan

Benjamin D. Galvan, MLS(ASCP), CIC, an infection preventionist at Tampa General Hospital in Florida, and a member of the Association for Professionals in Infection Control and Epidemiology, welcomed the study's results.  

"Effective collaboration within the healthcare setting is a highly effective way to implement and sustain evidence-based practices related to infection reduction. When buy-in is obtained from the top, and pertinent stakeholders are engaged for their expertise, we can see sustainable change and improved patient outcomes," Galvan, who was not involved in the study, said in an email.

"The researchers did a fantastic job," he added. "I am grateful to see this important work addressed in the literature, as it will only improve buy-in for improvement efforts aimed at reducing infections moving forward across the healthcare continuum."

Douglas S. Paauw, MD, a professor of medicine and chair for patient-centered clinical education at the University of Washington School of Medicine in Seattle, told Medscape Medical News that the team's most important interventions were changing the environmental cleaning protocol and using agents that kill C. difficile spores.

"We know that as many as 10% to 20% of hospitalized patients carry C. difficile. Cleaning only the rooms where you know you have C. difficile (isolation rooms) will miss most of it," said Paauw, who was also not involved in the study. "Cleaning every room with cleaners that actually work is very important but costs money."

Handwashing With Soap and Water Works, Alcohol Hand Gels Do Not

Dr Douglas S. Paauw

"We know that handwashing with soap and water is the most important way to prevent hospital C. difficile transmission," Paauw noted. "Handwashing protocols implemented prior to the study were probably a big part of the team's success."

Handwashing with soap and water works, but alcohol hand gels do not, he cautioned.

"C. difficile rates in hospitals went up years ago when we started putting alcohol gels outside patients' rooms," Paauw explained. "Now, instead of washing their hands, staff quickly pump gel before they see patients. Applying gel is easy, but gel does not eliminate C. difficile spores. Handwashing is such a simple way to fix the C. difficile problem, but doctors don't take the time.

"We need to take the C. difficile problem seriously. We have enough information and we know the right things to do. We need to wash our hands. We need to clean the rooms. We need to stop cutting corners if we want to give good care," he said.

The authors plan to conduct further related research.

The study was not funded. All study authors, as well as Galvan and Paauw, have reported no relevant financial interests.

Am J Infect Control. Published online May 11, 2022. Abstract

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