Iatrogenic clostridium difficile (CD) is a preventable infection that can lead to morbidity and mortality in the surgical patient. Therefore, CD infection rates can be used as a marker of surgical quality, and its prevention requires a multidisciplinary approach.1,2
Duke University Hospital, Durham, NC, was identified as a high outlier for CD in the 2017 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Interim Semi-Annual Report for all cases with data from October 2015–September 2016, and for general, vascular, and urologic cases, with data from January 2016–December 2016.
Putting the QI activity in place
Duke University Hospital is a tertiary academic medical center with more than 900 beds. The surgical volume is 70,000 cases per year. Following identification as a high outlier for CD, the department of surgery formed a CD task force composed of clinical champions and experts in CD prevention from surgery, infectious disease, pharmacy, and performance services. Prior implementation of enhanced recovery protocols and surgical site infection prevention bundles had been successful in improving postoperative outcomes.3
The task force analyzed the available data, including the following:
- ACS NSQIP CD occurrences from July 2015–December 2016
- The Centers for Disease Control and Prevention’s National Healthcare Safety Network’s (NHSN) CD rates
- Institutional audits, including CD rates by ward, antibiotic stewardship, environmental cleaning, hand hygiene, personal protective equipment (PPE), and testing/diagnostics
The task force used this information to identify opportunities for improvement and implement strategies for reducing CD infection.4 The group members and clinical champions collated data from the literature. Proposals were presented to the group and decisions were made by consensus.
Protected time and financial incentives were not offered for this quality improvement (QI) project. The work of this task force is not concurrent with any larger initiative, although a parallel program in infection control is in place to decrease perceived penicillin allergies through confirmatory skin testing.5
Description of the QI activity
Following three meetings of the task force, the efforts were made to improve the following: antibiotic stewardship, environmental cleanliness, hand hygiene, PPE, and diagnostic stewardship.
Pharmacy, infectious disease, technology services, and surgery are all responsible for antibiotic stewardship. Two complex procedures, pancreatectomy and cystectomy, were identified as associated with non-guideline adherent antibiotic practices and were high outliers for CD infection at Duke. Electronic evidence-based perioperative antibiotic order sets were created after receiving consensus from surgery, infectious disease, and pharmacy. Electronic prescription defaults were implemented to cue prescribing physicians in real time to guideline adherent antibiotic coverage and duration, which led to a reduction in unnecessary fluoroquinolone exposure in the inpatient setting (see Figure 1).6
Surgery, administration, infection control, performance services, and environmental services analyzed environmental cleanliness.7 Additional environmental service staff was requested through traditional hiring processes. Audits of the quality of terminal room cleans were implemented in 15 percent of rooms. We also increased use of TRU-D, an ultraviolet light disinfection system, for all rooms with a known CD-positive occupant. Targeted unit use of TRU-D will include rooms on high-risk units once per month, regardless of occupant CD status.
Because soap-and-water hand washing is the best method of preventing human-to-human transmission, infection control and performance services recommended improved signage for enteric precautions, with instructions for soap-and-water hand hygiene. These signs were posted on surgical wards. Auditing of hand hygiene is completed with in-person monitoring, and increased monitoring was established in high-risk CD areas, such as intensive care units (ICU) and surgical wards.
Infection control and performance services made recommendations regarding PPE. Disposable gowns and gloves are now made available outside CD patient rooms. Auditing of compliance by providers is done on high-risk units.
Infectious disease, laboratory services, surgery, and technology services looked at means to improve diagnostic stewardship. Before the intervention, all stool samples sent for diagnosis were tested with polymerase chain reaction (PCR). Alternative approaches include antigen and antibody testing; however, our institution elected to continue a PCR-based diagnostic practice. An electronic best practice advisory pop-up was established to reduce unindicated CD testing (see Figure 2). The pop-up is triggered when a CD diagnostic test is ordered when the patient has been receiving laxatives.
Performance services and surgery were charged with providing routine data feedback using ACS NSQIP and NHSN CD infection reports. This information is disseminated to surgical division heads. Audit systems are in place for hand hygiene, PPE use, and quality of terminal room cleans. These scores are disseminated to surgical and quality leadership. Performance services organize data representation and visualization for improved interpretation and dissemination (see Figure 3).
Pharmacy, surgery, infectious diseases, and performance services have worked to educate their teams on CD testing and antibiotic stewardship at surgery and urology grand rounds (see Figure 4).
More than 100 members of the surgical staff attend surgical grand rounds, and more than 30 members of the urology staff attend urology grand rounds.
Resources used and skills needed
Task force members attend quarterly meetings and provide feedback to their respective divisions. Costs incurred have been absorbed within the operations budget of each department. No additional funding has been used in this quality initiative.
See Table 1 for a list of involved staff.
Table 1. Involved staff
Christopher R. Mantyh, MD, FACS, surgical champion
Megan Turner, MD, data collection and analysis
Wendy Webster, MBA, data analysis
Infectious disease and infection control
Becky Smith, MD, infectious disease expert
Rebekah Wrenn, PharmD, antibiotic expert
Kirk Huslage, MSPH, BSN, RN, data collection, infection control specialist
Regina Woody, RN, surgical clinical registry data source and analysis
The primary metric of success following the implementation of the quality initiative was the ACS NSQIP observed CD rate. Duke had an initial high-outlier status of 1.19 percent in October 2016, which we reduced to 0.7 percent in September 2017 (see Figure 5).
Furthermore, we decreased fluoroquinolones prescriptions and number of days of therapy by 9 percent and decreased CD testing for patients on laxatives from 23 percent prior to the QI initiation to 7 percent. We also experienced a 58 percent increase in terminally cleaned rooms with the TRU-D technology.
Cost savings have not been a measured outcome for this quality initiative. The literature indicates that new diagnoses of CD are estimated to generate $24,205 in costs in six months of follow-up,8 and the Centers for Medicare & Medicaid Services estimates that a CD diagnosis generates $5,682–$8,096 in nonchargeable costs.1
Specific costs for antibiotics, as well as cost savings, are variable pending reimbursement metrics. The ultraviolet device costs are variable based on use within a study and total number of staff trained to use the device. The environmental services budgets are not publicly available.
Given the multidisciplinary nature of the QI initiative, several barriers occurred in implementation. Environmental services had established contractual agreements, which limited flexibility in increasing staff numbers and hours, as well as overall work distribution, and created difficulty purchasing additional TRU-D technology.
In addition, our microbiologic laboratories have a policy that prohibits speciation of mixed flora urine samples, rendering us unable to narrow antibiotic coverage. This situation proved to be a specific barrier to antibiotic stewardship on urologic service. Ongoing conversations are taking place between stakeholders to improve policies and support workflow.
Additionally, NHSN data is by default reported by admitting service. Thus, transitioning to reporting formats by surgical ward, ICU versus stepdown versus ward, has been essential to create a heat-map of locations for targeted resource allocation.
As a next step, we intend to monitor outpatient antibiotic use and improve electronic defaults. We also plan to create a CD prevention dashboard to display quality measures in one electronic location with easy-to-interpret graphics.
As with all QI implementation projects, consistent feedback to stakeholders by champions is essential to maintain gains achieved over the last year. Developing a pathway to sustainability includes automating data feedback, managing defaults to reflect current literature and practice patterns, and fostering innovation for adherence to established protocols.
Tips for others
Other institutions seeking to reduce CD infections should bear in mind the following:
- Identification of areas of improvement is important in creating and implementing targeted interventions for management of CD.
- Use of NSQIP and NHSN metrics are essential, although institutional-level data can provide increased granularity to direct interventions.
- Identification of multidisciplinary champions by department and division with support from departmental leadership is paramount.
- Targeted feedback by division is essential for supporting changes in work flow, modifying defaults, and developing a culture of evidence-based medicine and guideline adherence.
- Data visualization services are instrumental in addressing busy provider deficiencies and successful QI implementation.
Using these mechanisms, institutions can implement a CD reduction QI initiative to improve the care of the patients they serve.
- Centers for Medicare & Medicaid Services. Hospital-acquired condition reduction program. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions.html. Accessed July 27, 2018.
- McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987-994.
- Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR. The preventive surgical site infection bundle in colorectal surgery: An effective approach to surgical site infection reduction and health care cost savings. JAMA Surg. 2014;149(10):1045-1052.
- Barker AK, Ngam C, Musuuza JS, Vaughn VM, Safdar N. Reducing clostridium difficile in the inpatient setting: A systematic review of the adherence to and effectiveness of C. difficile prevention bundles. Infect Control Hosp Epidemiol. 2017;38(6):639-650.
- Unger NR, Gauthier TP, Cheung LW. Penicillin skin testing: Potential implications for antimicrobial stewardship. Pharmacotherapy. 2013;33(8):856-867.
- Dingle KE, Didelot X, Quan TP, et al. Effects of control interventions on clostridium difficile infection in England: An observational study. Lancet Infect Dis. 2017;17(4):411-421.
- Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An environmental disinfection odyssey: Evaluation of sequential interventions to improve disinfection of clostridium difficile isolation rooms. Infect Control Hosp Epidemiol. 2013;34(5):459-465.
- Zhang D, Prabhu VS, Marcella SW. Attributable healthcare resource utilization and costs for patients with primary and recurrent clostridium difficile infection in the United States. Clin Infect Dis. 2018;66(9):1326-1332.