Decreased Healthcare Associated Clostridium difficile Infections in a Large Community Hospital System thru Standardized Practices

Background: In 2009, HCA implemented an evidenced based initiative in 160 hospitals, across 20 states, to reduce healthcare associated (HA) Clostridium difficile infections (CDI) via toolkits and coaching webinars using an ABC’s approach:   Antimicrobial stewardship (implemented in 2010), Barrier precautions, Compulsive hand hygiene practices, Disinfection and cleaning of the environment and Executive leadership.

Objective: To reduce HA CDI and standardize proven evidence based practices.

Methods: Infection preventionists were surveyed on pre and post initiative CDI surveillance data, detection and prevention practices.  Facility exclusions were: CDI not surveyed and no acute care inpatient services.    CDI self reported cases used 2008 SHEA Compendium surveillance criteria definitions for HA CDI = Healthcare Onset-HealthCare Facility Associated (HO-HCFA).     ICD-9-CM coding 008.45 [intestinal infection due to C. difficile] and present on admission (POA) indicators have been used as a surrogate marker for HA CDI and were compared with self reported criteria based cases.

Results: Annual patient days totaled over 7 million in both 2008 and 2009.  In both surveys, similar practices were reported for CDI by toxin detection > 85%, patients with CDI not cohorted 75% and hand hygiene used or preferred soap and water >85%; and practices varied for discontinuing precautions and number of stools tested per patient diarrheal episode.

Metric or Practice	2008 Pre Implementation Average (Range)	2009 Post Implementation Average (Range)
No. Hospitals Reporting Surveys	118 (75%)	139 (90%)
Total CDI Surveillance Cases*	N/A**	14.4 (0-39.8)
Total ICD-9-CM 008.45 coding data* POA indicator = all	18.4 (0.5-50.2)	17.6 (0.4-47.1)
HO-HCFA CDI Cases*	5 to 6    (0-26)	4.5 (0-11.3)
ICD-9-CM 008.45 coding data* excluding POA indicator =Yes	5.5  (0-13.9)	5.0 (0-15.5)
Bleach disinfection of environment	52%	70%
Lab rejects formed stools	38%	82%
Stool tested for “CDI proof of cure” not a practice	67%	84%
Monitored CDI severity	8%	45%
Nursing triggers for new onset diarrhea	11%	48%

*=per 10,000 patient days                                 ** N/A=Data not available 

In both surveys, <20% and <30% of hospitals reported HO-HCFA CDI rates of <1 and <2 per 10,000 patient days, respectively.    HA CDI rates varied across geographic regions as suggested by both 2008 coding (2-8.6) and self reported (0.9-9.8) data and 2009 coding (2-7.2) and self reported (1.3-6.3) data.  

Conclusions: Standardized practices reduced HA CDI rates in the presence of sustained total cases which were primarily community acquired CDI.   ICD-9-CM 008.45 coding data correlated with self reported rates.  Geographic differences were observed for total and HA CDI cases.   Next steps are to assess antimicrobial stewardship effects and implement strategies to improve key practices to >90%.