TITLE: Reduction of Clostridium difficile (C diff) cases using a targeted assessment for prevention (TAP) strategy in the Department of Veterans Affairs (VA) healthcare system.

Background: C diff infection related to healthcare is an ongoing problem in the United States with associated substantial morbidity and some mortality. Therapy is generally suboptimal and recurrences are relatively common. One of the goals of the VA Multidrug-Resistant Organism (MDRO) Prevention Initiative is reduction of C diff disease in VA medical facilities. Using a TAP strategy after development of a standardized infection ratio (SIR) model, we evaluated facilities for hospital onset, healthcare facility associated (HO-HCFA) C diff in order to identify facilities for targeted intervention.

Methods: Monthly HO–HCFA C diff data were assessed for all 127 VA healthcare systems; SIRs were determined using a baseline of October 2010 to June 2012. While the model was similar to the CDC/NHSN model, it was altered to fit VA data based on VA specific variables (e.g., diagnostic test type, facility admission prevalence rate, bed size, patient days, and hospital complexity). Based on these data and a cumulative attributable differences (CAD) calculation, we held individual, structured conference call interventions with the 10 facilities with the highest CAD to assess issues and provide guidance. Calls were made at intervals of 2-6 months and preliminary results of the 8 facilities having three-month follow-up are reported. Statistical analysis was by linear regression.

Results: Based on the targeted intervention for facilities with high CAD, certain common areas for improvement were found. These included lack of quantitative assurance that environmental cleaning was undertaken properly, staffing issues in infection prevention and control, and delay in initiation of contact precautions prior to fecal testing results. For the 8 facilities with three months of follow-up data, there was an overall decrease of 37.8% (p=0.05) in HO-HCFA C. diff.

Conclusion: Using a modified SIR calculation and a CAD/TAP strategy, specific targeted intervention was undertaken for facilities with higher than expected HO–HCFA C diff. These preliminary data suggest that a conference call intervention to reinforce practices may be successful in reducing HO-HCFA C diff.