Clostridium difficile Infections (CDI): Collaborative for the State of Ohio (OH)

Background: Statewide CDI public reporting occurred in 2006 in OH; identifying ~14,000 new and recurrent infections; case counting continued in most facilities, using a variety of definitions. With a four fold rise in OH deaths associated with CDI, a voluntary collaborative for surveillance and auditing of infection control practices was discussed by the OH Dept. of Health Healthcare Associated Infections Task Force.

Objective: To re-initiate statewide CDI surveillance in 2009 according to the CDC/NHSN definitions and to implement a tiered performance improvement project (PIP) to assess compliance with recommended practices to decrease CDI amongst the participating facilities.

Methods: In conjunction with the OH Hospital Association (OHA), and the Ohio State University (OSU) CDC Prevention Epicenter, the collaborative was initiated to assess CDIs in Jan. 2009; with agreement to complete a baseline survey on infection control (IC) practices, and initiation of a PIP on 1 patient care unit (PCU) of each facility in July 2009. The PIP PCU chosen would require monthly audits of hand hygiene, contact isolation and environmental cleaning compliance via a standardized monitoring tool; results would guide advancement to subsequent tiers based on PIP PCU CDI rates. The OHA is serving as the web-based data-repository for collecting individual facility CDI cases/10K patient days (PD). Healthcare onset-healthcare facility associated (HO-HCFA) and community onset-HCFA own facility (CO-HCFA) cases were collated/10KPD. All data is de-identified by OHA and analyzed by OSU.

Results: The bed sizes for the 63 participating hospitals are: 0-100 beds/N=19, 101-200/N=18, 201-400/N=17, ≥401/N=9. Baseline (January-June 2009) adult HO-HCFA mean rate is 7.7cases /10KPD, and CO-HCFA own facility is 2.3/10K PD. Baseline pediatric HO-HCFA mean rate is 5.7/10KPD and CO-HCFA own facility 1.7 cases /10KPD. The 0-100 bed size adult facilities had the lowest mean rate at 6.0 cases/10KPD; the ≥ 400 bed size had the highest mean rate at 8.2 cases per 10KPD. Baseline survey results indicated 36% were teaching facilities, 100% recommended contact isolation, 46% had an antimicrobial stewardship program and 80% required dedicated equipment for patients with CDI. When the audits on the PIP patient care units began, compliance with these IC policies was found to be quite disparate from the baseline survey results.

Conclusions: This represents the first multi-facility large scale statewide performance improvement collaborative for CDI. Standardized CDI case counting is feasible and can serve as the basis for public reporting. Audits of IC practices will help formulate the best strategies to prevent healthcare acquired CDI.