Reducing Hospital Acquired Clostridium difficile (C diff) Rates for Veterans in Acute by Greater than 50% and CLC by 100%
Last updated
Share PrintImproving the diagnostic accuracy of identifying toxigenic C diff through two-step C diff testing and reducing the incidence of hospital onset C diff facilitates the Medical Center's journey toward Zero Harm. Effective two-step testing differentiates between C diff infection vs. C diff colonization allowing providers to avoid unnecessary antibiotic use for Veterans. With improved C diff testing, Veterans benefit with reduced incidence of health-care acquired C diff and appropriate antimicrobial use and the VA Medical Center benefits financially and with improved scores in IPEC/SAIL.
Origin:
February 2021, Wm. Jennings Bryan Dorn Department of Veterans Affairs Medical Center (Columbia, South Carolina)
Adoptions:
1 successful
Partners:
Clinical Services, Hospital Medicine, Nursing, Patient Care Services
Recent Updates
Overview
The problem
From FY19 – FY20, the C diff rate at CVAHCS increased from 5.16 to 7.24 per 10,000 patient days in our acute areas and from 1.6 to 2.8 per 10,000 patient days in our CLC. These rates exceed our internal best practice rate for Acute which was 4.89 for FY18 and 0.00 for CLC in FY16. This rise leads to:
• increased patient length of stay and additional health ... From FY19 – FY20, the C diff rate at CVAHCS increased from 5.16 to 7.24 per 10,000 patient days in our acute areas and from 1.6 to 2.8 per 10,000 patient days in our CLC. These rates exceed our internal best practice rate for Acute which was 4.89 for FY18 and 0.00 for CLC in FY16. This rise leads to:
• increased patient length of stay and additional healthcare expense
• additional antibiotic exposure
• increased patient safety risk for complications such as toxin megacolon
• decreased patient satisfaction
Note: All rates for C diff are per 10,000 patient days See more
• increased patient length of stay and additional health ... From FY19 – FY20, the C diff rate at CVAHCS increased from 5.16 to 7.24 per 10,000 patient days in our acute areas and from 1.6 to 2.8 per 10,000 patient days in our CLC. These rates exceed our internal best practice rate for Acute which was 4.89 for FY18 and 0.00 for CLC in FY16. This rise leads to:
• increased patient length of stay and additional healthcare expense
• additional antibiotic exposure
• increased patient safety risk for complications such as toxin megacolon
• decreased patient satisfaction
Note: All rates for C diff are per 10,000 patient days See more
Images
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Acute Hospital Onset C diff Incidence Rate vs. Patient Days increased to 7.24 per 10,000 patient days
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CLC Hospital Onset C diff Incidence Rate vs. Patient Days
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Cost of Hospital Onset C diff
The solution
The CVAHCS solution was to develop a multi-disciplinary team to review the literature and examine all C diff Management practices beginning with the clinical assessment of patients through lab processes for accepting, processing, and resulting C diff tests. Best practices were identified and implemented to include the following:
*Adoption of the Bristol St ... The CVAHCS solution was to develop a multi-disciplinary team to review the literature and examine all C diff Management practices beginning with the clinical assessment of patients through lab processes for accepting, processing, and resulting C diff tests. Best practices were identified and implemented to include the following:
*Adoption of the Bristol Stool Scale for consistent stool assessment
*Incorporation of a nurse driven C diff testing protocol applicable for first 3 days of admission
*C diff education for Nursing staff
* Specimen requirement criteria for Nursing and Lab
*Authority for Lab to reject inappropriate specimens
*Addition of GDH antigen and EIA toxin testing as reflex tests for PCR positive C diff samples
*Standardized lab reporting mechanisms
*Enhanced antimicrobial stewardship education for inpatient and outpatient providers
*Provider education on two-step C diff testing, computer order template changes
*Enhanced reporting capabilities for Infection Prevention. See more
*Adoption of the Bristol St ... The CVAHCS solution was to develop a multi-disciplinary team to review the literature and examine all C diff Management practices beginning with the clinical assessment of patients through lab processes for accepting, processing, and resulting C diff tests. Best practices were identified and implemented to include the following:
*Adoption of the Bristol Stool Scale for consistent stool assessment
*Incorporation of a nurse driven C diff testing protocol applicable for first 3 days of admission
*C diff education for Nursing staff
* Specimen requirement criteria for Nursing and Lab
*Authority for Lab to reject inappropriate specimens
*Addition of GDH antigen and EIA toxin testing as reflex tests for PCR positive C diff samples
*Standardized lab reporting mechanisms
*Enhanced antimicrobial stewardship education for inpatient and outpatient providers
*Provider education on two-step C diff testing, computer order template changes
*Enhanced reporting capabilities for Infection Prevention. See more
Images
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C diff Team Members and our shark mascot
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Test Kit for GDH antigen and EIA toxin testing
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C diff 1st Step test - Microbiology Manager Performing PCR Testing for C diff on Polymerase Chain Reaction (PCR) machine
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C diff 2nd Step test - Microbiology Manager Completing 2-step Testing under safety hood
Files
- Bristol Stool chart used to standardize stool assessments and educate nursing and lab staff on the appropriate type of stool for C.diff testing. Bristol stool charts were also printed and placed in patient bathrooms to assist with patient education of stool assessment. Columbia VA Bristol Stool Chart
- Reinforcement education flyer for bedside staff to identify and send only appropriate stool samples to the lab for c. diff testing. C diff Collection Specimen Reinforcement
Links
- Two step c.diff testing training that covers the rationale for change, ordering criteria and process, test results and interpretation, and EMHR C.diff notifications. C diff Two Step Testing Training
- TMS lesson # VA4567310 completed by staff that were unable to attend in-person inservices. TMS C diff 2-step Testing Training
The results
Healthcare acquired C diff rates decreased dramatically for both Acute and CLC.
* Acute C diff fell from 7.24 for FY20 to 3.56 for FY21 (51% decrease).
* CLC C diff fell from 2.80 for FY20 to 0.00 for FY21 (100% decrease).
(C diff rates are per 10,000 patient days)
* Acute C diff fell from 7.24 for FY20 to 3.56 for FY21 (51% decrease).
* CLC C diff fell from 2.80 for FY20 to 0.00 for FY21 (100% decrease).
(C diff rates are per 10,000 patient days)
Images
Above:
Acute healthcare onset C Diff Rate reduced from FY20 of 7.24 to FY21 of 3.56 per 10,000 patient days
Above:
CLC Hospital Onset C diff Incidence Rate reduced from FY20 of 2.80 to FY21 of 0.00 per 10,000 patient days
Metrics
- Acute Healthcare onset of C diff reduced by 51% from the previous fiscal year.
- CLC Healthcare onset of C diff reduced by 100% from the previous fiscal year.
- Acute Healthcare costs reduced by $204,942.00 from FY20 to FY21.
- CLC Healthcare costs reduced by $170,785.00 from FY20 to FY21.
- 2nd step of C diff test - GDH antigen/EIA toxin testing - Average 15 minutes of Microbiology time per month (3 minutes per 2nd step test; Average 5 tests/month)
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
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Acute C diff Rates FY20 to FY21
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CLC C diff Rates FY20 to FY21
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Overall Savings at CVAHCS per Time Spent on Process
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Acute Cost Reduction for C diff FY20 to FY21
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CLC Cost Reduction for C diff FY20 to FY21
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Nationwide VA VISN Map
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VISN 1, 2, 4, 5 Projected Cost Savings
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VISN 6, 7, 8, and 9 Projected Cost Savings
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VISN 10, 12, 15, and 16 Projected Cost Savings
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VISN 17, 19, and 20 Projected Cost Savings
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VISN 21, 22, and 23 Projected Cost Savings
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All VISN Cost Savings Projections Before/After Implementation of 2-step C diff Collection
Implementation
Timeline
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November 2020
Identify team membersInitial team meetingDevelop Project CharterInitiate A3 – identify Process Start and Stop Points, Project Scope, and Criteria/Limitations -
December 2020
Continue development of A3*Define Current State and metrics being used*Gemba walks to review current processes and determine process improvement opportunities*Define Target State and desired target metrics*Perform Gap Analysis identifying barriers, direct causes and root cause -
January 2021 through mid-February 2021
Simultaneous activities*Continue development of A3 identifying possible solutions*Secure new two-step testing materials (GDH antigen/EIA toxin testing) for microbiology*Development of training and competency validation for microbiology staff to perform two-step testing*Microbiology reinforcement education related to rejecting inappropriate specimens that do not meet testing criteria*Laboratory Information System (LIS) coordinator built new lab test in the LIS system*Infection Prevention developed interim training video with “live” demonstration of stool types using Bristol Stool Scale for nursing to use until TMS lesson fully developed. Interim education rolled out to Nursing. Emphasis placed on collecting only Bristol Stool types 6 and 7 for C diff testing.*Clinical Application Coordinator (CAC) redesigned C diff order set in CPRS based on Team recommendations*Antimicrobial Stewardship Pharmacist - developed and educational handouts and provided education for Primary Care related to C. diff testing. Also developed educational handouts for Acute and CLC Clinical staff explaining how two-step C. diff testing works to include new CPRS ordering screen shots, ordering criteria, specimen collection*Antimicrobial Stewardship Pharmacist reinforced appropriate antibiotic use for multiple clinical conditions as part of antibiotic management for inpatient and outpatient providers*Conducting rapid experiments (clinical staff education and performing two-step testing in microbiology) using PDCA determine if interventions should be adapted or adopted*Development of the projected Completion Plan for A3 -
February 12, 2021
First two-step C diff testing performed in microbiology!! -
March 2021
Continued development of TMS lesson for Nursing -
April 2021
Infection Prevention completed TMS lesson development and assignment for all Clinical Nursing staff with 30-day completion date. -
May 2021 and ongoing
*Infection Control surveillance for healthcare onset C diff rates occurs monthly for Acute and CLC*C diff two step testing education is provided for new hires and reinforcement education is provided for existing staff as needed.*Lab continues to actively reject inappropriate specimens that do not meet testing criteria*Antimicrobial stewardship continues to work with providers on appropriate antibiotic use.Lessons Learned:* Education is critical for providers and nursing staff to understand Stool Specimen types that will be tested and/or rejected as inappropriate.* Buy in can be difficult if staff do not see the issue impacts their clinical area.Recommendations/ Next Steps:* Ensure education is provided for new providers and new nursing staff.
Departments
- Pharmacy
- Microbiology
- Geriatrics
- Infection control
- Education and training
- Nursing services
- Quality control
- Infectious disease
- Internal medicine
- Laboratory and pathology
Core Resources
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Links
- CLICK HERE to get a sample stakeholder list, implementation, and education documents in our 2-step C diff Starter Kit! In addition, the document gives you the contact information for individuals who have been through the implementation process. We look forward to hearing from you soon! 2 step C diff STARTER KIT!
Optional Resources
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Support Resources
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Files
- American journal of Infection Control Article that relates how an Antimicrobial Stewardship program achieved marked decreases in C. diff infections in a Veterans hospital. AJIC: Antimicrobial stewardship program achieved marked decrease in C diff infections in a Veterans Hospital; 2020
- Article from the Journal of Clinical Microbiology that reviews NAAT Quantitation as a predictor of toxin presence in C diff infection. Journal of Clinical Microbiology: Nucleic Acid Amplification Test Quantitation as Predictor of Toxin Presence in C diff Infection; 2020
- Article that describes the adoption of nucleic acid amplification tests (NAAT) for Clostridium difficile diagnosis and their impact on stool rejection policies and C. difficile positivity rates. Journal of Clinical Microbiology: Impact of Changes in Clostridium difficile Testing Practices on Stool Rejection Policies and C. difficile Positivity Rates across Multiple Laboratories in the United States
- A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. IDSA Guideline: 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)
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Inappropriate testing of specimens that do not meet defined criteria. | Lab has authority to reject inappropriate specimens. |
| Order process drift resulting from unintended provider order shortcuts/deviation. | CPRS order set written to contain desired order process visuals at the point of entry. |
| Nursing submission of inappropriate stool specimens. | Process drift was mitigated by adding copies of the Bristol stool chart at the point of care where specimens are collected. |
Contact
Comment
Comments and replies are disabled for retired innovations and non-VA users.
Email lucy.austin@va.gov with questions about this innovation.
About
Origin story
The C. diff project started when C. diff rates for this facility were noted to far exceed standard benchmarks. New literature had been identified showing that two-step C. diff testing using PCR and antigen/toxin testing improved diagnostic accuracy in identifying toxigenic C. diff.
Original team
Rebecca Berdel, MD
Infectious Disease
Lucy Austin, RN, CIC
Infection Preventionist
Paula Guild, RN, CIC
Infection Preventionist
Evanne Leblanc-Wyckoff, RN
Infection Preventionist
Lisa Bell, LPN
MDRO Coordinator
Jailan Osman, MD
Chief Laboratory and Pathology
Alphonso Barker
Microbiology Manager
Mary Gustafson, RN
Nurse Practitioner
Alyssa Grill, RpH
Anitimicrobial Stewardship Pharmacist
Indra Sriram, MD
CLC Physician
Nichole Brown, RN
Quality Management HRO Coordinator
Katrina Goff, HSS
System Redesign
Great project. This demonstrates wonderful foresight and the collaboration.
Great project for quality improvement and infectious disease control!
Outstanding Team-based project!
Awesome work! Kudos to your team for thinking outside of the box to enhance quality of care for our C. Diff Veterans all with significant cost savings! So proud of the team.
You all did a wonderful job! Kudos to the entire team.
Wonderful project.
Truly a Fantastic Project! Thanks for all the great work from an Awesome Implementation team!
What a simple and yet profound way to improve care and save cost to the VA! Great job team!!
Awesome project! Thank you for making a difference in enhancing the quality of health care to our Veterans who suffer from C. Diff.
Great work!
Great work to enhance the quality of health care we provide to our Veterans.
Great project! The team did an amazing job.
I am happy to be part of the team and saving money for all the medical centers.
This is such a needed innovation! Thank you for being so innovative and thinking outside of the box to improve the quality of life of our Veterans with C. Diff!
Interesting and informative. Great work CVAHCS team.
Congratulations on a great project! Wonderful work!
Excellent work!! I'm proud to be a part of this amazing organization!
The team at the Columbia VA is committed to partnering with any sister facilities to help you attain the same positive results we have achieved. We have an exceptional Quality Management Service and and data analytics team that is poised to maximize your operations.
We have an excellent team, and I am very proud of their work and results. We would be happy to share this innovation!
We are happy to help with this innovation for other facilities who choose to implement it.