A Process Approach to Decreasing Hospital Onset Clostridium difficile Infections

Health care facility-onset Clostridium difficile infections (HO-CDI) contribute to prolonged hospital stays, inappropriate antimicrobial use, increased readmissions, and excess expenditures for health care institutions. National guidelines define appropriate C. difficile testing criteria as ≥ 3 unformed stools within a 24-hour period and the absence of laxative administration within 48 hours, criteria developed to reduce inappropriate reporting.

Stony Brook University Hospital (SBUH) quality improvement team implemented a process approach aimed at decreasing HO-CDI events. Through a number of improvement cycles in 2016, SBUH implemented (1) Information Technology hard stops and alert systems to enforce appropriate specimen collection and laboratory testing, (2) incorporation of an antimicrobial stewardship program, (3) heightened room turnover monitoring, and (4) an extensive educational module. Outcome measures included HO-CDI rate per 10,000 patient days and testing volume.

The analysis timelines were divided into three periods: baseline (January 2014 - November 2014), Rejection of Formed Stools/Electronic Alert (December 2014 - September 2015) and Laxative Rule (October 2015 - July 2018). The average monthly HO-CDI rate at baseline of 11.94 (SD: 2.86) per 10,000 patient days had fallen to 7.35 (SD: 2.91) for the Laxative Rule period (p < 0.0001). Baseline average lab testing volume decreased from 290.27 tests per month (SD: 22.61) to 177.21 (SD: 33.24) in the Laxative Rule period (p < 0.0001). Hospital surveillance systems confirmed no undiagnosed missed cases within the postimplementation period.

By reducing inappropriate testing and hardwiring best-practice guidelines into a system with real-time monitoring, a sustainable decrease in hospitalwide HO-CDI rates was observed.