Clostridium difficile infection (CDI) rates suddenly increased 30%, coincident with adoption of a new electronic medical record (EMR) and a reduction in our Environmental Services (ES) workforce. A Targeted Assessment for Prevention (TAP) report suggested we had the greatest opportunity for improvement among Massachusetts hospitals. Senior leadership identified CDI as an institutional top priority.
We prospectively measured CDI rates, using CDC criteria. A multidisciplinary team applied root cause analysis to each case; many represented repetitive testing or did not meet criteria for clinically significant disease. We reviewed, revised, and reinforced already robust efforts regarding hand hygiene, environmental cleaning and disinfection, antimicrobial stewardship, and test ordering behaviors. We revised C. difficile testing guidelines in accord with IDSA/SHEA Guidelines and leveraged EMR orders to help providers test more appropriately.
o Limit testing to patients with ≥3 unformed stools/day
o Exclude testing within 24 hrs of laxative use
o Lab rejects specimens within 7 days after negative result and within 28 days after positive result; orders expire after 48 hrs
We compared monthly ES staffing (FTEs/1,000 Pt-day) and CDI rates, using linear regression.
o C difficile testing decreased 47%, from 358 to 188 tests per month (Figure 1)
o CDI rates decreased 39% in one year (from 141 to 83), reducing the rate of infection below expected (Figure 2)
o Despite improvement, 40-60% of CDI testing still occurs during laxative use
o ES staffing rates were associated with 5.2% of CDI rate changes (p<0.05); adequate staffing reduced CDI rates 44% (Figure 3)
Implementation of a new EMR brought to light over-diagnosis of hospital-acquired CDI, resulting in unnecessary isolation and treatment of patients without significant illness. Inadequate ES staffing correlates with increased CDI rates. These factors also contribute to vulnerability to CMS Hospital-Acquired Condition (HAC) penalties. Revising laboratory testing and laxative EMR orders is laborious but significantly reduces inappropriate testing. It is essential to have senior leadership endorsement to marshal quality improvement and EMR resources.
J. Cartagena, None
M. Gawlick, None
R. Delacy, None
A. Villanueva, None
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