Where: Cleveland Veterans Affairs (VA) Medical Center, a 215-bed acute care hospital and adjacent long-term care facility in Ohio.
The issue: Improving treatment for patients with Clostridium difficile.
In 2011, the VA was preparing to launch a national initiative to reduce Clostridium difficile transmission in its hospitals. The Cleveland VA Medical Center was chosen as one of the pilot sites, and clinicians there started improvement efforts by assessing current care for C. difficile.
“We took a quick look at a lot of these process measures and found a lot of areas where we could improve,” said Curtis J. Donskey, MD, associate professor of medicine at Case Western Reserve University and an infectious disease specialist at the Cleveland VA. “We found that there were several cases where patients had been discharged, and looking at their lab results after discharge, they'd missed cases of C. diff infection. In one case, a patient was readmitted to the hospital with diarrhea.”
In addition to the diagnostic process, the VA team also wanted to improve the timing and appropriateness of prescribed treatment for C. difficile. “That inspired us to put together a formal stewardship initiative,” said Dr. Donskey.
How it works
The initiative involved several components, starting with the forming of a stewardship team (mainly a nurse practitioner and an infectious disease physician, but sometimes including a pharmacist, too). Whenever the lab had a positive C. diff test, the team would get a phone call about it and they would then review the patient's chart and contact the treating physician if needed.
“We would get some direct input to ensure that physicians provided the correct treatment and dosing and to ensure that treatment was started efficiently,” said Dr. Donskey. “That was modeled on our program for [positive] blood cultures.”
To further increase the likelihood of timely, appropriate treatment, physicians in the hospital were educated by the team about the latest recommendations for C. difficile testing and treatment. The team also made some changes to the electronic medical record to help clinicians provide optimal care.
“When you placed an order for C. diff testing, a flag would pop up to prompt the provider with questions that might help guide them on whether testing was appropriate,” said Dr. Donskey. “When you had a positive test for C. diff, we put in an order set that provided the recommendations for correct dosing and duration of treatment.”
Results and challenges
The initiative made several significant differences on targeted outcomes. “The thing that's easiest is to ensure that patients are receiving the appropriate medications. Prior to the initiative, 60% of our patients with severe C. diff were being prescribed metronidazole, which is not the recommended therapy,” said Dr. Donskey. “That went from 60% to 0%.”
In about a year, the time from test order to positive result also dropped, from a median of 23 hours to 12, as did the time from result to treatment, from 4 hours to 1, according to results published in the November 2013 Infection Control and Hospital Epidemiology.
“There were no positive test results that were not acted on, so we no longer had patients being discharged from the hospital and then being diagnosed,” added Dr. Donskey. Anecdotal assessment of staff response to the program was also favorable. “It's an extra layer of quality control, and physicians view it very positively,” he said.
The initiative has not yet completely perfected C. diff care at the hospital. “Testing ordered inappropriately for a patient who never received an antibiotic and didn't really meet the criteria—we still see that. That's been an ongoing challenge,” said Dr. Donskey.
The team also found that assessment of individual cases continued to be necessary, even after initial education about recommended treatment. “Direct assessment with feedback and education at the time the case comes in is more efficient than continually educating people, because we have rotating residents…Have a dedicated person who ensures appropriate care is being provided,” said Dr. Donskey.
Dr. Donskey offered some advice for those interested in following his hospital's example. If getting staff time dedicated to such an initiative is difficult (the study estimated it as about an hour a day for the nurse practitioner and 2 hours a week for the physician), consider which other hospital departments might want to offer support.
“Infection control programs should be very interested in trying to reduce delays in diagnostic testing for C. diff, because those patients who are newly diagnosed with C. diff are at high risk for transmission,” Dr. Donskey said.
The improvements could also be easily incorporated into a hospital's existing stewardship program by just expanding protocols for infectious disease specialist involvement to include C. diff cases, he noted.