Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm

Abstract

Health care facility-onset infections (HO-CDI) are an important national problem, causing increased morbidity and mortality. HO-CDI is an important metric for the Center for Medicare and Medicaid Service's (CMS) performance measures. Hospitals that fall into the worst-performing quartile in preventing hospital-acquired infections, including HO-CDI, may lose millions of dollars in reimbursement. Under pressure to reduce CDI and without a clear optimal method for detection, health care facilities are questioning how best to use highly sensitive nucleic acid amplification tests (NAATs) to aid in the diagnosis of CDI. Our institution has used a two-step glutamate dehydrogenase (GDH)/toxin immunochromatographic assay/NAAT algorithm since 2009. In 2016, our institution set an organizational goal to reduce our CDI rates by 10% by July 2017. We achieved a statistically significant reduction of 42.7% in our HO-CDI rate by forming a multidisciplinary group to implement and monitor eight key categories of infection prevention interventions over a period of 13 months. Notably, we achieved this reduction without modifying our laboratory algorithm. Significant reductions in CDI rates can be achieved without altering sensitive laboratory testing methods.

Effect of testing methods on incidence of Clostridioides difficile infection rates in Veterans’ Affairs medical centers

“…6 Although the VA does not receive reimbursement from CMS for service, the VA has a legislative mandate to participate in CMS Hospital Compare, the program within which the Value-Based Purchasing module resides, which includes reporting of healthcare-acquired CDI. 7 This factor may have had an impact on testing across VA facilities. In 2017, 83.5% of VA facilities used NAAT only.…”

Appropriate Use and Future Directions of Molecular Diagnostic Testing

“…Perhaps the most concerning impact of implementing a syndromic GI panel without diagnostic stewardship is the potential over-diagnosis of C. difficile infection (CDI) in colonized individuals and related financial consequences [27]. The IDSA currently recommends limiting testing to individuals greater than 2 years of age with diarrhea following antimicrobial use and/or healthcare-acquired diarrhea, though individuals with persistent diarrhea lacking an etiology may be considered for testing [26].…”

Influence of Probiotics on the Development of Clostridioides difficile Infection in Patients Receiving Fluoroquinolones

“…In 2016, healthcare facility-onset CDI was added to the CMS hospital-acquired condition reduction program. Hospitals that do not meet the 75-percentile cut off are subjected to CMS reimbursement penalties, furthering the financial burden on these institutions [15].…”