Collaboration and experimentation reduce C. difficile infections

Rates drop by 73% on pilot wards at English hospital Salford Royal.

Where: Salford Royal, an 850-bed teaching hospital in England.

The issue: Reducing the hospital's rate of Clostridium difficile infection.


In 2006, Maxine Power, now the national improvement advisor for the Department of Health in London, had just returned to Salford Royal after a fellowship at the Institute for Healthcare Improvement in Boston.

She had studied the Breakthrough Series collaborative model, a method of quality improvement in which teams of clinicians learn about quality improvement methods together, develop strategies and then pilot-test changes in practice before implementing them more broadly.

“I went back to the organization from Boston and said, ‘I think we've got an approach that we can test, but what we need is a particularly intractable problem.’ The director of nursing wrung her hands and said, ‘I've got just the thing for you,’” explained Ms. Power. At the time, Salford Royal had the fourth-highest rate of C. difficile infection in northwest England. Efforts had been made to improve infection control and cleaning practices, yet the hospital's C. difficile rate was on the rise. “The figures were going up rather than down and we were really trying hard to contain the problem,” said Ms. Power.

How it works

In 2007, Ms. Power and colleagues recruited five of the hospital's geriatrics wards to participate in a collaborative improvement program targeting C. difficile. Over the next nine months, the participants (including everyone from physicians to housekeepers) attended three two-day instructional sessions about quality improvement and developed and piloted a number of changes to hospital procedures.

Some of the piloted changes proved effective; some did not. “For example, one of the ward managers was adamant that if she got badges made that said, ‘Please ask me to wash my hands,’ that would empower the patients sufficiently to get [clinicians] to wash their hands,” said Ms. Power. The idea was tested and it turned out that only three out of 10 patients asked the badge-wearers to wash their hands.

That intervention was abandoned, but it helped to prove the value of the program's approach, according to Ms. Power. “Before we used this approach, we would have formed a committee; we would have brought in all the important people; we would have spent hours deciding how big the badges should be, whether they should be infection-proof. We would have decided what to write on them; we would have put together a business case; we'd have sent it to the right committee; we would have got it back and ordered the badges; we would have put them on and thought, ‘Job done.’”

Instead, when the pilot proved ineffective, the team moved on to other strategies. Those that were successful were taught by the pilot participants to staff on other wards and then implemented and assessed hospital-wide.

Some of the changes included:

  • daily rounds by an antimicrobial management team, including a pharmacist and a microbiologist,
  • restricted access to cephalosporins and oral quinolones by changes to ward stocks and dispensing guidelines,
  • institution of isolation precautions as soon as symptoms were spotted, before testing or medical consults,
  • peer audits and strict enforcement of clinicians' hand hygiene,
  • encouragement of patient hand hygiene, including handwashing rounds before meals and bathroom posters, and
  • new policies on cleaning of equipment and patient rooms.


“It seems to have worked really, really well for the organization,” said Ms. Power. The results of the project were published by BMJ in July.

At the start of the program, the collaborating pilot wards had 2.60 cases of C. difficile per 1,000 bed-days. By April 2007, that number had dropped by 73% and the decrease has been maintained since. A control group of wards, which didn't participate in the collaborative but did make changes in antibiotic stewardship, saw a smaller drop in C. difficile cases during the time period, only 56%. Overall, the hospital's C. difficile rate dropped by 66% between 2006 (when the project started) and 2008 (when the changes had been implemented throughout the hospital).


“Interestingly, I think some of the people who were most resistant were people who had enormous content expertise in the area,” said Ms. Power. She described one such response: “Do you think I, with all of my microbiology and all of the skills I've built up over the years, don't know how to fix this? What are you going to bring?”

Once the interventions showed success, however, the doubtful experts became strong supporters of the program. The program leaders also used patient anecdotes and examples from other hospitals to convince hospital staff of the value of the project.

Next steps

The collaborative model is now being applied to other improvement projects at Salford Royal. “The next one that came up pretty quickly off the back of the C. diff was a project looking at acutely unwell patients in our system and our failure to rescue or failure to notice that they were deteriorating despite evidence in the patients' records,” said Ms. Power.

The project resulted in an impressive 50% decline in inpatient cardiac arrest rates. “We now go a month without a cardiac arrest,” said Ms. Power.

Words of wisdom

“There's a temptation in clinical settings to feel that working with a small community is somehow disenfranchising the rest,” said Ms. Power. “What we demonstrated is that you can get pretty beneficial effects for the whole organization by focused innovation in a small number of clinical teams and getting the spread strategy right.”