How to Reduce Hospital-Onset Clostridioides Difficile

After the first year of interventions at Emory Saint Joseph's Hospital, there was a 63% decrease in hospital-onset C. diff cases as compared to the two years prior.

Through a series of interventions since 2016, Emory Saint Joseph's Hospital in Atlanta has been able to significantly reduce hospital-onset Clostridioides difficile.

Clostridioides difficile (C. diff) is a bacterium that causes severe diarrhea and colitis, with nearly half a million infections in the United States annually, according to the Centers for Disease Control and Prevention. One in 11 patients over age 65 with a healthcare-associated C. diff infection die within one month, the CDC says.

Timing is crucial in determining whether a C. diff infection in the inpatient setting is categorized as a hospital-onset C. diff case. If a patient tests positive for C. diff in the first three days of a hospital admission, the case is categorized as community acquired. If a patient tests positive for C. diff after four days or more of a hospital admission, the case is categorized as hospital-onset C. diff. High rates of hospital-onset C. diff draw financial penalties from the Centers for Medicare & Medicaid Services.

Increasing the testing of patients for C. diff in the first three days of hospital admission was a key intervention at Emory Saint Joseph's Hospital, says Cherith Walter, RN, MSN, APRN, a clinical nurse specialist at the facility who led an interdisciplinary team formed in 2016 to tackle hospital-onset C. diff. "A lot of our hospital-onset C. diff cases were being erroneously categorized as hospital-onset infections because we were not testing in the first three days. So, we wanted to make sure we were accurately capturing and reporting community-acquired C. diff.”

The interdisciplinary C. diff reduction team had several stakeholders on the panel's roster.

• As a clinical nurse specialist, Walter was chosen to lead the team because a major part of her role at the hospital is to improve outcomes for patients and the organization
   
• Inpatient unit nurse champions helped with education efforts and the rollout of interventions
   
• An infection preventionist brought C. diff expertise in areas such as diagnosis and testing
   
• A physician champion and the hospital epidemiologist helped to make sure clinicians were engaged in C. diff interventions
   
• A clinical microbiologist helped in areas such as setting testing criteria
   
• An environmental services representative helped make changes in how patient rooms were cleaned
   
• An antimicrobial stewardship pharmacist helped to make sure antibiotics were used appropriately and to reduce usage of fluoroquinolone antibiotics, which are a risk factor for the development of C. diff

The primary C. diff reduction interventions included a new testing protocol, enhanced environmental cleaning, antimicrobial stewardship, and education efforts. The ongoing initiative is detailed in a research article published recently by American Journal of Infection Control.

New testing protocol

The interdisciplinary team developed a "diarrhea decision tree algorithm" to increase the testing of patients for C. diff in the first three days of a hospital admission, Walter says. "In the first three days of a patient's admission, nurses have the autonomy to test any unformed stool for C. diff. They do not have to get a provider order. As soon as they recognize that a patient has an unformed stool, nurses can go ahead and put an order into the electronic medical record themselves and get the stool tested. At that time, the patient is placed on contact enteric isolation until we receive a negative result."

Contact enteric isolation includes requiring staff members to wear gloves and gowns in a patient's room. In addition, staff members must conduct hand hygiene with soap and water rather than hand sanitizer.

Increasing C. diff testing in the first three days of a patient's admission benefits the hospital and the patient, she says. "When we looked back at our hospital-onset C. diff cases and found that many of the cases that we were testing were in Day 4 and after, we identified that was one of our greatest opportunities—increasing testing during the community-acquired window in the first three days of an admission. We not only wanted to appropriately categorize cases as community onset but also wanted to get early diagnosis to improve patient outcomes and infection prevention. If a patient has C. diff, we want to get it diagnosed early, we want to get it treated early, and we want to get the patient in isolation to avoid the spread of infection to other patients and staff members."

Enhanced environmental cleaning

Environmental services workers made changes to how they cleaned patient rooms, Walter says. "For the enhanced environmental cleaning, we changed the type of sporicidal products that we were using. Previously, they were using a sporicidal disinfectant in the isolation rooms. In 2018, they moved to a more effective sporicidal disinfectant and started using that in all patient rooms regardless of isolation status. We became more proactive with our cleaning."

In patient rooms that were placed under contact enteric isolation for a C. diff infection, cleaning was intensified, she says. "For patients who were on C. diff isolation, at discharge we did a terminal cleaning with disinfectant and UV light disinfection. Any equipment was cleaned with bleach wipes."

Antimicrobial stewardship

Antimicrobial stewardship focused on reducing the use of fluoroquinolones, Walter says.

"They put protocols in place to make sure providers could not order fluoroquinolones as standalone orders—they had to order them as part of an order set and they had to use clinical decision support that was built in to the electronic medical record. We also added some Food and Drug Administration warnings that popped up in the electronic medical record. So, we made it more difficult for providers to order fluoroquinolones because they are associated with the development of C. diff. Fluoroquinolones are a risk factor for C. diff because they disrupt the gut flora."

C. diff education

The interdisciplinary team has introduced several educational initiatives for the hospital staff, she says.

"When the protocols first rolled out, our nurses were heavily involved in getting the protocols out to the inpatient units. We did educational emails, flyers, and huddles. We added new protocols to the orientation that we do for new hires. We designated a 'C. diff Day,' where we set up prizes and games in our cafeteria, and we had roving carts that went into all of the inpatient units to conduct quizzes and provide teaching opportunities for the nurses about C. diff and the new protocols."

Impact and lessons learned

The interventions have generated impressive results. After the first year, there was a 63% decrease in hospital-onset C. diff cases as compared to the two years prior. C. diff testing for appropriate patients within the first three days of hospital admission increased from 54% in 2014 to 81% in late 2019.

Walter has several suggestions for other hospitals seeking to decrease hospital-onset C. diff infections.

"First, I would recommend gathering an interdisciplinary team. We could not have done this work without the support and collaboration of each discipline working together because each discipline brought their own expertise and the ability to make sure that interventions were rolled out in their department. Our interdisciplinary team allowed us to do a robust project with multiple interventions. It is also important to focus on diagnostic stewardship and appropriate ordering as well as evidence-based interventions. Another thing that our team has done that is important is to continuously look for opportunities for improvement. Even after the submission of the American Journal of Infection Control manuscript, we continued to find opportunities for improvement."