Study shows hospital policy allowing nurses to initiate C. difficile testing could reduce infection spread and associated morbidity

Arlington, Va., May 11, 2023 – A new study published today in the American Journal of Infection Control (AJIC) suggests that allowing bedside nurses to independently order testing for C. difficile significantly decreased the amount of time to receive test results as compared to requiring physician approval. The findings suggest that the testing policy change could potentially decrease the risk of additional patient infections and the corresponding hospital economic burden.

Individuals with C. difficile infection (CDI) can be asymptomatic or have symptoms ranging from mild diarrhea to severe and life-threatening inflammation of the colon. CDI is responsible for 223,000 healthcare-associated infections (HAIs) resulting in more than 12,000 deaths and $6.3 billion in costs in the United States annually. [1]^,[2] Despite numerous implementation strategies to address prevention of the infection, it remains one of the most common HAIs.[3]^,[4] Early detection, isolation and contact precautions, environmental cleaning, and appropriate antibiotic treatment greatly decrease the rate of morbidity and mortality and can prevent further spread to other patients, decreasing the overall clinical and economic impact.

“Given the implications of CDI on both a hospital and patient level, incentives exist for improving approaches to the prevention and spread of this infection in the clinical environment,” said Ashley Bartlett, MD, Fargo VA Healthcare System, Fargo, ND, and the lead author on the published study. “Our findings suggest that allowing bedside nurses with appropriate training to order C. diff testing based on patient symptomology could be a valid strategy to help healthcare systems achieve this goal.”

At a single site within the Veterans Affairs (VA) Healthcare System in Fargo, ND, infectious disease and nursing staff developed a policy change allowing nurses to independently order stool samples for new patients displaying CDI symptoms, rather than requiring a physician’s electronic signature. Researchers then evaluated the effectiveness of the new policy by comparing the frequency of tests being ordered, the time to obtain test results, the number of positive and negative tests, and the time to initiate treatment for positive C. difficile tests for the 44 months prior to and 59 months after the change.

  Results show:

• After the policy change, there were a relatively even proportion of physicians and nurses ordering the stool PCR labs (51.1% vs 48.9%, respectively).
• The percent of positive and negative tests results before and after the policy change was relatively unaffected (13.9% vs. 11.5% respectively), suggesting that allowing nursing staff to order stool samples does not lead to increased unnecessary laboratory resource use or financial burden to the hospital.
• Following the policy change, the average difference in time to obtain the test result after the PCR lab order was statistically significant before, versus after, the policy change (mean [sd]; 2.1 (1.3) vs. 1.3 (0.7) hours; p<0.1).
• The average difference in time to obtain the test result after the PCR lab order between nurses and physicians was also statistically significant after the change (mean [sd]; 1.2 (0.7) vs. 1.3 (0.7) hours; p=.02).
• There was no significant difference in time to initiate treatment before and after the policy change (1.7 hours vs. 1.7 hours). The authors suggest this was because the process of notifying physicians to initiate antibiotic treatment did not change – nurses did not receive test results directly, nor could they order antibiotics.

“We need practical strategies to reduce the significant burden of C. diff infections,” said Patricia Jackson, RN, BSN, MA, CIC, FAPIC, 2023 APIC president. “This study highlights one such strategy that healthcare facilities should consider to expedite appropriate C. diff testing and speed up implementation of appropriate treatment and infection control measures.”

About APIC

Founded in 1972, the Association for Professionals in Infection Control and Epidemiology (APIC) is the leading association for infection preventionists and epidemiologists. With more than 15,000 members, APIC advances the science and practice of infection prevention and control. APIC carries out its mission through research, advocacy, and patient safety; education, credentialing, and certification; and fostering development of the infection prevention and control workforce of the future. Together with our members and partners, we are working toward a safer world through the prevention of infection. Join us and learn more at apic.org.

About AJIC

As the official peer-reviewed journal of APIC, The American Journal of Infection Control (AJIC) is the foremost resource on infection control, epidemiology, infectious diseases, quality management, occupational health, and disease prevention. Published by Elsevier, AJIC also publishes infection control guidelines from APIC and the CDC. AJIC is included in Index Medicus and CINAHL. Visit AJIC at ajicjournal.org.

NOTE FOR EDITORS

“Does clinician-initiated Clostridioides difficile testing improve outcomes of patients with Clostridioides Difficile infection?” by Ashley Bartlett, Anna Montgomery, Kimberly Hammer, Siddharth Singhal, and Tze Shien Lo, was published online in AJIC on May 11, 2023. The article may be found at: https://doi.org/10.1016/j.ajic.2023.02.017

AUTHORS

Ashley Bartlett, MD, Fargo VA Healthcare System, Fargo, North Dakota, USA

Anna Montgomery, MPH (corresponding author: denee.montgomery@hotmail.com), Palo Alto VA Healthcare System , Palo Alto, California, USA

Kimberly Hammer, PhD, Fargo VA Healthcare System, Fargo, North Dakota, USA

Siddharth Singhal, MD, Fargo VA Healthcare System, Fargo, North Dakota, USA

Tze Shien Lo, MD, Fargo VA Healthcare System, Fargo, North Dakota, USA

# # #

[1] Centers for Disease Control and Prevention. Clostridioides difficile Infection. https://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html. Published 2019.

[2] The Joint Commission Center for Transforming Healthcare. (2016). Reducing Clostridium Difficile Infections Project. Oakbrook Terrace: The Joint Commission.

[3] Sandhu BK, McBride SM. Clostridioides difficile. Trends Microbiol. 2018;26:1049–1050.

[4] Kang M, Abeles SR, El-Kareh R, et al. The effect of Clostridioides difficile diagnostic stewardship interventions on the diagnosis of hospital-onset Clostridioides difficile infections. Joint Commission J Quality Patient Safety. 2020;46:457–463.