P33 - Reducing Clostridium Difficile Over-Testing in the Acute Care Setting

Purpose: The purpose of this evidence-based practice project was to evaluate whether the implementation of a nursing communication huddle, specific to clostridium difficile (Cdiff) testing criteria, would be associated with a reduction of the number of Cdiff specimens sent to the lab that did not meet criteria for testing.

Relevance/significance: Over-testing for Cdiff can lead to detection of asymptomatic colonization, not active disease. This can prompt overtreatment and detrimental sequalae. Prior to the implementation of this intervention, White Plains Hospital did not have a standard process of nursing validation for Cdiff testing on inpatients. Although
hospital criteria existed for test ordering, it was not consistently followed. This resulted in provider orders and nurses sending specimens without thorough evaluation of whether patients met criteria for testing. The aim of this project was to decrease the number of inappropriate samples sent to the lab, which can lead to avoidance of unnecessary antibiotic use and a reduction in the number of reportable Cdiff infections in the hospital.

Strategy and implementation: The hospital had developed an algorithm and criteria for Cdiff testing, based on the Centers for Disease Control and Prevention guidance. For this project, the primary RN reviewed the algorithm and criteria each time an order was received to test for Cdiff. This review was done collaboratively with their nursing technician and nurse leader to decide whether the patient’s clinical status met criteria to send for testing. If the criteria were met, then the stool was collected and sent to the lab. If any of the criteria were not met, then the RN would discuss the test with the ordering provider. If the provider endorsed testing despite not meeting criteria, then the case was escalated to the associate medical director for approval. The nursing team was educated on the nursing communication huddle in May 2019, and the huddle was implemented on an inpatient pilot unit from June-September 2019. Data was collected via huddle sheets throughout implementation.

Evaluation/outcomes: 26 Cdiff nursing communication huddles were included in this analysis. Although the difference is not statistically significant, the proportion of events where the test was not performed due to divergence from testing criteria was higher post-implementation (43%) than during the preliminary period (28%), Χ2 = 1.71, p = .19. This finding suggests that after implementation of the Cdiff nursing communication huddle, more cases of inappropriate specimens were not processed for testing.

Implications for practice: The Cdiff nursing communication huddle has provided the opportunity for a culture change in the nursing team to collaboratively evaluate the criteria for testing and confirm accordance. The Cdiff nursing communication huddle has become standard practice on all nursing units. The implementation of this
communication tool or a similar tool could benefit nursing units and nursing practice at other hospitals or organizations as well, by providing education and an opportunity for nurses to be a part of evaluating the criteria for testing.