C. difficile and Hospital Process Measures: What Works?

One of the more difficult things to cover is a study that you've already written about in an accompanying editorial. It's quite hard to come up with anything "new" to write that you haven't already written. Such is the case with a very nice study examining hospital process measures and C. difficile infections just published in BMJ Quality and Safety by Nick Daneman and colleagues from Sunnybrook Health Sciences Centre in Toronto.

Using results of a mandatory CDI prevention practices survey they compared facility-level processes measures and patient level (via ICD-10 codes) CDI rates in 159 Ontario hospitals. Specifically, they looked at implementation of six hospital-level measures: (1) isolation at diarrhea onset, (2) audit of antibiotic use, (3) audit of environmental cleaning, (4) vancomycin as first line therapy and (5) on-site diagnostic testing and (6) reporting of rates to senior leadership. Somewhat surprisingly, none of the process measures were associated with lower risk of CDI.

In the editorial, Nasia Safdar and I wrote:

"First, the authors identified low self-reported implementation of most CDI prevention practices, with only 27% of facilities reporting isolation of all patients at onset of diarrhoea, and 16% reporting auditing of antibiotic stewardship practices. Low adherence rates for these two practices in particular are concerning because prompt institution of contact precautions is necessary to reduce nosocomial transmission of C. difficile. And antimicrobial stewardship is at least as important as infection prevention practices, if not more so, for reducing CDI."

"This study also highlights the importance of implementation science research to tackle the vexing yet pervasive problem of low and variable adherence to evidence-based interventions for reducing HAI, including CDI. The scope of this study did not extend to exploring barriers to implementation or an in-depth assessment of the self-reported practices that may help inform implementation strategies to increase uptake of proven practices."

and of course my favorite part:

"Last, increasing the evidence base for preventing CDI by undertaking pragmatic randomised controlled trials of novel interventions incorporating efficacy and effectiveness is essential to successfully bridge the quality chasm that currently exists in CDI prevention."

Reference: Daneman N. et al. BMJ Qual Saf. 2015 Apr 24 (open access)