clinical nurse specialist,



  1. Pate, Kimberly MSN, RN, ACCNS-AG, PCCN
  2. Reece, Jennifer BSN, RN
  3. Smyre, Alex BCJ


Purpose/Objectives: The purpose of this project was to design and implement a sustainable program to reduce hospital-acquired cases of Clostridioides difficile.


Description of the Project: Experiencing higher rates in a large, academic medical center, hospital leaders were assembled. The overall facility rate was 6.9% in 2014 with a first quarter rate of 8.4% in 2015. Individual unit rates were as high as 19.8%. A team of key stakeholders was assembled to plan, execute, and reevaluate targeted solutions. Strategies implemented were an innovative, automated screening tool, an evidence-based prevention bundle; and staff education.


Outcomes: A facility-wide C difficile prevention program was implemented with a sustained decrease in rates observed from 8.4% in the first quarter of 2015 to 6.0% in the fourth quarter of 2017. The standardized infection ratio ranged from 0.541 to 0.889, consistently below the national mean.


Conclusion: Clostridioides difficile is a leading cause of hospital-associated diarrhea and a tremendous burden on healthcare systems increasing morbidity, mortality, and financial strain. A multidisciplinary, multifaceted approach was critical to ensure early detection, reduce risk of transmission, and decrease overall rates.


Article Content

Clostridioides (Clostridium) difficile (C difficile) infection is a leading cause of hospital-associated diarrhea with increasing incidence and severity. In the United States, there are an estimated 293 000 cases of C difficile per year. Clostridioides difficile is associated with significant morbidity and mortality. This places a financial strain on the healthcare system as total costs of C difficile inpatient management were estimated to be $6.3 billion (range, $1.9 billion to $7.0 billion) in 2015 and required 2.4 million days of hospital stay.1 The development of a hypervirulent epidemic strain and community-acquired disease in previously low-risk populations is enhancing the burden on patients and the healthcare system.2 Approximately 1 in 4 patients who respond to initial treatment will have another episode of C difficile, usually occurring within several weeks of treatment for the first episode.3 Management of C difficile is further complicated as approximately 29% of hospitalized patients are readmitted within 30 days of discharge, and approximately 13% are readmitted with C difficile with an estimated cost of more than $13 000 per patient. As the Centers for Medicare & Medicaid Services continues to establish financial incentives to reduce readmissions, hospitals strive to improve quality outcomes and avoid financial penalties.4


Because of experiencing higher than expected rates in a level I trauma and academic medical center, hospital leaders assembled to discuss plans for addressing this important issue. In 2014, the overall rate for the facility was 6.9% including a bone marrow transplant unit with rates up to 19.8% and a hepatopancreaticobiliary unit with rates up to 14.4%. The most common diagnoses related to this illness were sepsis and complicated surgical procedures. It was imperative to move forward with a plan to decrease occurrences of hospital-acquired C difficile.


Prevention of C difficile infections is challenging and should include preventing the initial acquisition and stopping transmission of the organism to additional hospitalized patients. Early recognition of patients with a suspected or diagnosed infection is the primary step in prevention of transmission. Prevention should also include implementation of contact isolation precautions, proper cleaning of environmental factors, and proper hand hygiene.2 Decreasing C difficile rates could lead to a reduction in length of stay, better throughput, reduced cost, fewer patient harm events, and increased patient satisfaction.



A team consisting of key stakeholders was developed. Using a Plan-Do-Study-Act framework, targeted solutions were planned, executed, and reevaluated.



In January 2015, a multidisciplinary team including administration, clinical nurses, infection prevention, nurses from the quality department, dietary services, environmental services, antimicrobial support network, and pharmacy was created. The Performance Improvement (PI) team was led by a clinical nurse specialist (CNS) and was responsible for reviewing current literature, evaluating data, and determining appropriate course of action. Nursing units with the highest rates of hospital-acquired cases from 2014 were identified, and unit-based champions were recruited from these units to join the PI team. The team discussed current practice and clinical observations to identify opportunities.


In a review of current evidence, the PI team identified that C difficile testing should be performed only on unformed stool, and testing of stool from asymptomatic patients is not clinically useful. Also, repeat testing during the same episode of diarrhea is of limited value.5-8 Risk factors for C difficile include previous or concomitant antibiotic exposure and prolonged stay in a healthcare facility.4 Clinical manifestations include abdominal tenderness, elevated temperature, and elevated white blood cell count.2 Nurses spend a great deal of time assessing patients and notifying providers of any changes in condition. Thus, standing orders or nurse-driven protocols to test patients with diarrhea for C difficile can be of value if nurses are educated on proper patient selection for testing. Nurses frequently identify patients with diarrhea before the treating physician does.6


Despite this information, literature on nurse-driven screening remains limited. In 2018, Khoury et al9 evaluated symptomatic patients with 3 or more unformed stools in 24 hours. Symptoms included elevated temperature, abdominal pain, nausea, vomiting, or leukocytosis. However, screening relies heavily on physicians. Other predictive models have been developed. While Smith et al10 developed a statistical model to predict C difficile based on prior admission, endoscopy within 30 days, cephalosporin/fluoroquinolone use, length of stay, age, body mass index, and albumin, Dubberke et al11 included admission to an intensive care unit and use of laxatives, gastric acid suppressants, or antimotility drugs. In 2012, Chandra et al12 developed a predictive tool focusing on length of stay, age, albumin level, and antibiotic use. Tanner and colleagues13 took a different approach and utilized a Waterlow score of 20 or more to be predictive of C difficile. The Waterlow score assesses age, body mass index, sex, continence, and mobility.


While determining the best method in identifying possible C difficile cases and common risk factors, it was discovered that another hospital in the healthcare system was on a similar journey to decrease hospital-acquired C difficile. Our PI team expanded on their criteria in 2015 to develop a screening tool. Patients were screened on admission and daily utilizing a paper tool (Figure 1). The bedside clinician assessed if the patient had at least 3 watery stools or a significant increase in baseline diarrhea in the previous 24 hours.5-7 If the patient was experiencing frequent loose stools, the clinician would then evaluate white blood cell count, abdominal tenderness/cramping, elevated temperatures, antibiotic usage, history of C difficile, and transfer from another facility. If the patient met any additional criteria, clinicians were instructed to enter an order in the electronic medical record (EMR), send a stool sample for testing, and place the patient on contact enteric precautions utilizing a standing order. Exclusion criteria were diagnosis/treatment of C difficile on this admission; C difficile testing within the last 14 days regardless of result, diarrhea associated with clinical condition or medications; and soft, formed, or baseline stools.

Figure 1 - Click to enlarge in new windowFIGURE 1. Paper

In March 2016, an evidence-based prevention bundle was implemented (Figure 2). Based on Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines,5 the bundle emphasized the importance of appropriate hand hygiene with soap and water,2,5,6,14,15 daily bathing to reduce bioburden,5,16 routine disinfection of high touch surfaces,17 maintenance of contact enteric precautions5,6,15 including required usage of gloves and gowns,2,5,15,18 standardized signage,6 utilization of single-use disposable equipment if possible,5,6,15 and thorough cleaning of nondedicated equipment following use in the room of a patient with C difficile.5,6,15 In addition, a number of items were physically gathered into a single carrier to make them more readily available to bedside clinicians (Figure 3). Patient care items included patient education materials, disposable stethoscopes, disposable thermometers, and C difficile-specific signage to be displayed in the patient room. Signage included reminders to use soap and water for hand hygiene and for visitors not to use the patient's bathroom.

Figure 2 - Click to enlarge in new windowFIGURE 2. Evidence-based
Figure 3 - Click to enlarge in new windowFIGURE 3. Single carrier for patient care items.


Preparing for implementation, comprehensive teammate education was provided to various disciplines throughout the facility.6 Nurses and nursing assistants were educated on appropriate testing including consistency of stool sample and discouraged to perform repeat testing/no test for cure. Additional education components included current data trends, goals, required personal protective equipment for contact enteric precautions, responsibilities for cleaning patient care items, and routine review of daily isolation reports. Education was provided via an online learning management system to 100% of nurses and nursing assistants. This required approximately 30 minutes to complete.


To incorporate a team approach to decrease C difficile rates, respiratory therapy, physical therapy, occupational therapy, case management, provider colleagues, environmental services, and transporters received focused education. Education was provided via didactic presentations during routine meetings. This required approximately 10 to 15 minutes to complete. Handouts were distributed to staff not able to attend, and area managers were responsible for ensuring understanding.


Following education, the C difficile screening tool was piloted on 10 nursing units as well as an evidence-based prevention bundle. Unit-based champions attended biweekly meetings and ensured that key messages were relayed to the individual units. While on their respective unit, the unit-based champions were responsible for assessing current practice, identifying opportunities, supporting selected interventions, and ongoing review of the C difficile data. Routine meetings and knowledge sharing encouraged buy-in from the attendees and key stakeholders. The CNS facilitating the PI team meetings ensured dissemination of pertinent materials.



As the interventions were initiated, infection prevention and the unit-based champions performed routine audits to ensure compliance with the evidence-based prevention bundle. They shared their observations with the rest of the PI team. This allowed for sharing of best practices and revisions to the original plan. Compliance audits also allowed for assessment of nursing knowledge. Education and real-time feedback were provided to their peers as opportunities were identified. Compiling required items in the single carrier improved adherence with the policy regarding care of patients with C difficile and decreased time spent collecting required items. Lack of compliance was noted when the bundle was not readily available on the unit.


Infection prevention also monitored the number of C difficile tests ordered by providers and nurses to evaluate for missed opportunities. They also ensured that C difficile tests were not being ordered more frequently than was required. It was noted that documentation on the paper form was limited and frequently omitted.



In May 2016, the process was expanded to include the entire facility. With the support of the Information Services, infection prevention and the CNS collaborated to develop an automated C difficile screening tool, which was included in the EMR. On admission, patients were screened in the admission history for 3 watery stools in the last 24 hours not related to clinical condition or medication, antibiotics in the last 60 days, and a history of C difficile (Figure 4). If the nurse confirms the presence of at least one factor, the system ordered contact enteric precautions and a C difficile antigen and toxin test.9 If testing required confirmation, a reflexive polymerase chain reaction test was automatically ordered.

Figure 4 - Click to enlarge in new windowFIGURE 4. Automated

As the C difficile screening tool was transitioned into the EMR, the system was also capable of recognizing nursing documentation and potential risk of C difficile with each charted assessment of stool throughout the hospital stay. Initially, documentation of diarrhea stimulated a prompt asking the nurse if the patient has had 3 or more liquid, watery stools in the past 24 hours not related to clinical condition or medication (Figure 5). If the nurse responds with a yes, a program runs in the background to assess for the additional criteria mentioned previously. If any additional criteria were met, the system ordered contact enteric precautions and a C difficile antigen and toxin test. Polymerase chain reaction testing was utilized for confirmation of test results if needed. An additional documentation element of liquid, watery stools was added as a prompt to allow for the identification of patients who were previously missed.

Figure 5 - Click to enlarge in new windowFIGURE 5. Ongoing automated

To further ensure compliance with the automated screening tool, the hospital epidemiologist sent written feedback to providers who were ordering C difficile testing without allowing the screening tool to drive testing. The administrative facilitator followed a similar process for nurses.


The PI team provided feedback on limited compliance with the evidence-based prevention bundle when products were not available. So, the evidence-based prevention bundle was transitioned from a product assembled by volunteers to a vendor-sponsored product. This ensured that an adequate number were stocked on each unit daily and replaced as needed.



Hospital data are submitted to the National Healthcare Safety Network, which collects, compares, and standardizes data from hospitals across the nation. A downward trend in C difficile rates within the entire facility has been observed from 8.4% in the first quarter of 2015 to 6.0% in the fourth quarter of 2017. Rates as low as 4.8% were demonstrated. Spikes in C difficile rates were experienced and correlated with turnover and onboarding of new teammates. Education was refocused to prepare new hires to incorporate the screening tool and prevention bundle into their daily workflow in the orientation process.


The National Healthcare Safety Network computes the standardized infection ratio (SIR), which compares the observed number of infections within the hospital to the predicted number of infections. The predicted number is an estimate based on comparative national data and considers certain risk factors such as hospital affiliation, size, and patient population served. If the SIR is less than 1, the number of observed infections is less than the number of predicted infections. The SIR for the entire facility ranged from 0.541 to 0.889 and is consistently below the national mean (Figure 6).

Figure 6 - Click to enlarge in new windowFIGURE 6. Facility


Imperative to successful implementation was having the unique skill set of a CNS. Practicing within the 3 spheres of influence (patient care, nursing, and system), the CNS is a clinical expert in the following core competencies: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision making. Considering each core competency, the CNS is well positioned to lead practice change as he/she demonstrates robust knowledge of evidence-based practice and the ability to work collaboratively within teams.19 The CNS was utilized for project management including review of evidence, assembly of key stakeholders, facilitation of meetings with information sharing, content expertise in development of materials, proficiency in collaboration, and knowledge of workflow at the facility and organizational level. Support and collaboration with the facility's administration, infection prevention department, and epidemiologist were also essential.


Barriers included initial establishment of buy-in from clinical nurses and knowledge deficits related to clinical conditions that mimic the symptoms of C difficile. The rapidly changing environment of healthcare is an additional barrier as the team had to continue to demonstrate the value of this initiative against competing initiatives.


While hospital-acquired C difficile was declining, compliance with completion of the screening tool in a paper format was only moderately successful in an environment accustomed to computer documentation. Building C difficile screening into the EMR and daily workflow improved compliance as evidenced by review of new hospital-acquired cases. However, nonuse of the automated screening tool can be easily correlated with accuracy of nursing documentation. When documentation is consistent, the tool fires as intended. Sustainability requires awareness and accountability for documentation of assessment findings, which are outside normal parameters.


Units with highly engaged unit-based champions demonstrated the greatest outcomes. These individuals worked collaboratively with unit leadership and their assigned infection preventionist to provide a consistent message, set expectations, and hold their peers accountable. To sustain change, an ongoing evaluation process must be maintained with consistent feedback. Spot audits continue to evaluate compliance with the evidence-based prevention bundle by the unit champions, infection prevention, and the CNS. Infection prevention also reviews each case of hospital-acquired C difficile. Each case is evaluated for opportunities related to timeliness of screening and appropriate use of the screening tool. Results are shared with unit champions for further dissemination.



A multidisciplinary, multifaceted approach with the support of leadership is required to reduce morbidity, mortality, and the financial burden of C difficile. By implementing an automated C difficile screening tool with an associated standing order, autonomy in nursing practice increased as nurses could move forward with testing instead of waiting for provider order. Patients with C difficile were identified and placed on contact enteric precautions earlier, decreasing risk of transmission. Through implementation of an evidence-based patient care bundle, items required to prevent transmission were made readily available to bedside clinicians, thus increasing compliance with the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America guidelines and enhancing the overall quality of care provided.


Based on success of the pilot, this process is being adopted throughout the healthcare system. The continued dissemination of this best practice will sustain positive results and contribute to ongoing improvements in patient care. It requires accountability, ongoing focus, and a dedicated team to ensure successful adoption and sustainability.



The authors express their sincere gratitude to the entire C difficile PI team and the Department of Infection Prevention. They gratefully appreciate Joanne Sitaras for her contributions to the development of the daily screening tool, Tonya Lenoir for the development of the patient care bundle, and Anmed Health for initial work with the C difficile screening tool. They thank Catherine Passaretti, MD, medical director of infection prevention; Shelley Kester, MSN, RN, director of infection prevention; Robyn Turton, MPH, RN, CIC, infection preventionist; Tom Calabro, MSN, RN, assistant vice president; and Eugene Christian, MD, chief medical officer for administrative support, which was pivotal to the success of this initiative.




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