Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health–academic collaborative: an evaluation of a quality improvement intervention

Abstract

To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health–academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals’ experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health–academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.

Leveraging diagnostic stewardship within antimicrobial stewardship programmes

“…For example, showing recent laxative use in an order panel or dates/results of prior CDI testing has been shown to facilitate appropriate ordering of CDI tests. 73 There is increasing recognition of the challenges inherent in making one group responsible for antimicrobial use within an institution or health system and a call to broaden this responsibility to individual prescribers. By harnessing CCDS, educational tools, local syndrome-based guidelines, established frameworks for decision-making and other stewardship strategies, programmes can engage prescribers in taking ownership of diagnostic and antimicrobial stewardship to drive appropriate use of diagnostic tests and antimicrobial agents.…”

“…Most publications reporting the impact of CDI test ordering interventions on antimicrobial use describe the implementation of clinical decision support tools or questions posed to clinicians at the time of test ordering. [71][72][73][74] One centre used a 'soft stop', whereby the clinician can continue to place an order after viewing alerts reminding them of appropriate criteria, followed by a 'hard stop' that prevents the order from being placed unless certain criteria are met. They were able to demonstrate a decrease in test ordering of 24% as well as a decrease in oral vancomycin use.…”