Nurse-Driven Protocol for Testing and Isolation for Clostridioides (formerly Clostridium) difficile

From the 2021 HVPAA National Conference

Michele Obeid (Hurley Medical Center/Michigan State University), Ryan D. Murphy (University of Utah), Philip McDonald


Clostridioides difficile (C. diff) is a gram positive spore-forming anaerobe. The manifestations of C. diff infection (CDI) range from mild or moderate diarrhea to severe, potentially fatal disease including toxic megacolon and septic shock. Regular monitoring of CDI rates allows healthcare systems to determine the CDI burden in their facilities. If patients are not diagnosed promptly on admission, they are subject to being inappropriately coded as having hospital-acquired C. diff infection (HA-CDI) rather than community-acquired infection, which can lead to financial penalties.


The goal of this study is to reduce the rate of HA-CDI at Hurley Medical Center in Flint, Michigan by 50% within 12 months of implementing a nurse-driven protocol for testing and isolation for CDI.


A nurse-driven protocol for testing and isolation for C. diff was designed based on review interventions previously described in the literature and was tailored to the specific needs of our institution. Team members and Infection Control personnel met with nurse managers to provide education on the new protocol. Meetings were held with nurse managers approximately monthly to assess adherence to the protocol, obtain, during those meetings, verbal feedback on barriers to adherence , and provide re-education if needed. Infection Control will continue to monitor HA-CDI rates and CDI standardized infection ratio (SIR) throughout the project. Lastly, the protocol is anticipated to remain in place indefinitely, and based on nursing feedback and other issues that may arise, the protocol may be modified accordingly.


The protocol was implemented in our EMR (Epic) on December 1st of 2020. Monthly reports were generated to track both key process and outcome measures. Preliminary data from the first three months of this project show that C. diff best practice alerts (BPA) identified potential C. diff cases, with 5.5% of patients meeting criteria for C. diff testing, as determined by the nurse-driven protocol. Four cases of C.diff were identified early enough (less than 72 hours into the admission) to be labeled as community-acquired C.diff.


The nurse-driven protocol empowers nurses to look for and recognize the signs and symptoms of C. diff, and order testing that otherwise might be missed by the physician or delayed until late in hospitalization. Preliminary results suggest that the protocol is an effective intervention to improve prompt testing and isolation for C. diff. Given the low incidence of HA-CDI, we anticipate this will have a significant impact on the rates of HA-CDI and improve lengthy hospital stays.

Clinical Implications

Implementing and using this protocol allows early diagnosis of CDI and ultimately early patient treatment, thus improving patient care, avoiding C. diff complications and lengthy hospital stays.

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