Discussion

The Let’s Make a C-DIFFerence CDI prevention collaborative used data for action to identify hospitals for recruitment based on their CAD, or excess number of infections. Although infections at all hospitals remain important, this methodology allows public health partners to target resources to places where interventions may have the greatest impact. ^{Reference Soe, Gould, Pollock and Edwards6} Through a series of monthly webinars and collaborative activities, participants were assisted in implementing the TAP Strategy to identify infection prevention gaps.

CDI testing practices were identified as a consistent theme throughout, and most hospitals identified potential gaps related to appropriate testing practices from the TAP facility assessments (eg, documentation of indication for tests, ordering C. difficile tests for patients with a known cause of diarrhea, testing for cure of CDI). Interventions used during and after the collaborative were often related to CDI testing practices, including implementing two-step testing, improving specimen stewardship (eg, laboratory rejection protocols, diagnostic decision trees), and creating electronic alerts. This finding highlights the complexities of CDI testing as well as the opportunity to provide additional support and directed guidance regarding testing, such as optimal test types and methodologies. Furthermore, the results of this collaborative influenced the decision to update the CDC CDI prevention strategies to include the consideration of 2-step testing to improve diagnostic accuracy when appropriateness of testing is an issue. ³

Nurse and physician champions for CDI prevention were also among the most common gaps identified and prioritized among hospitals. This finding is consistent with data from TAP facility assessments for CAUTI and CLABSI, which highlighted that lack of awareness of champions may signal that champions do not exist within their hospitals or may not be facilitating prevention efforts effectively enough for staff to be aware of their roles. ^{Reference Snyder, White and Glowicz8} Having unit-level champions focusing on specific HAI prevention initiatives can help improve practices, ^{Reference Reed, Brock and Anderson9–Reference Damschroder, Banaszak-Holl, Kowalski, Forman, Saint and Krein12} and identification of champions for promotion of patient safety culture is an element of the World Health Organization (WHO) core components for effective infection prevention and control programs. ^{Reference Storr, Twyman and Zingg13} To address this gap, the collaborative provided strategies for establishing infection prevention champions, outlined in four primary steps (ie, identify, train, empower, and support) on the CDC Infection Prevention Champions webpage. ¹⁴ Although the implementation of infection prevention champions is not directly outlined in the CDI prevention strategies, champions should actively participate in multidisciplinary workgroups focusing on HAIs, ^{Reference Fakih, Krein, Edson, Watson, Battles and Saint15} which is an element of strategy 4 (develop infrastructure to support CDI prevention).

Although items related to antibiotic stewardship were least commonly prioritized and addressed by hospitals during the collaborative, assessment questions regarding antibiotic stewardship were among the largest gaps for most hospitals. However, this gap may be attributed to the lack of prescribers among respondents. Many hospitals described comprehensive antibiotic stewardship programs (ASPs), but this gap highlights the potential lack of awareness and involvement in stewardship efforts among nursing personnel. Nurse-based actions outlined in CDC Core Elements of Hospital ASPs include optimizing microbiology cultures, intravenous to oral medication transitions, and prompting discussions of antibiotic treatment, indication, and duration. ^{16–Reference Monsees, Tamma, Cosgrove, Miller and Fabre18} Nurses also play an important role in patient education about appropriate antibiotic use ^16,17 ; however, >31% of nurses indicated “unknown” when asked whether the hospital educated patients and family members about the risk of CDI with antibiotics, and 20% responded “never”, “rarely”, or “sometimes”. Despite the critical role nurses play in patient care, perceived engagement of nurses in ASPs is low. ^{Reference Manning and Pogorzelska-Maziarz19,Reference Monsees, Goldman and Popejoy20} As of 2019, 89% of hospitals reporting to the NHSN implemented all 7 core stewardship elements. ²¹ Although this is encouraging, future efforts should focus on increasing engagement among nurses because they are optimally positioned throughout healthcare to guide appropriate antibiotic administration and improve patient care.

Upon review, SIRs were similar for the participant and nonparticipant hospitals in the pre-recruitment period, from which the CDI data were accessed to identify hospitals for recruitment. Recruitment took place mid-2019, which coincided with greater SIR improvements among non-participating hospitals, indicating that they may have chosen not to participate due to recent reduction progress being made. Although SIRs decreased from the pre-collaborative to post-collaborative periods among participants, this decrease was less than that among nonparticipants, and consistent with potential reductions nationwide. Although these preliminary data do not indicate that reductions were a direct result of the collaborative, they do highlight that the recruitment process was successful in enrolling those in greatest need (ie, with SIRs consistently above those of nonparticipants). Furthermore, the data indicate that even among hospitals with the highest SIRs and CADs nationally, they continued to make reductions during a global pandemic that has disrupted healthcare throughout the collaborative and post-collaborative periods. Future analysis would help measure the impact over a longer period; many participants reported that the COVID-19 pandemic affected their participation. Follow-up calls with select hospitals also revealed that many had implemented interventions within the post-collaborative period and planned to implement more in the future. Although 61% of participating hospitals collected >5,600 CDI TAP facility assessments to identify infection prevention gaps, most (78%) of these hospitals collected assessments prior to the start of the pandemic, and only 20% of participating hospitals reported reviewing their results and outlining potential interventions to address the gaps during the collaborative. Thus, while the hope is that hospitals will utilize collaborative resources and assessment data moving forward, the primary activities during the collaborative were focused on identifying gaps, not necessarily on implementing interventions across facilities.

This collaborative and summary are subject to several limitations. Participating hospitals did so voluntarily and represent a convenience sample among those identified for recruitment. Collaborative engagement varied, and many hospitals reported not being able to accomplish as much as they had hoped due to the COVID-19 pandemic. In addition, approximately half of the period used for analysis occurred during the COVID-19 pandemic, which affected routine practices, patient populations, staffing, and more, and potentially influenced the CDI data comparison between the pre-collaborative and post-collaborative periods. TAP facility assessments represent self-reported perceptions among hospital staff and items identified may not indicate true gaps in policies or practices. Furthermore, summary results including barriers, prioritized gaps, and interventions implemented were self-reported and voluntarily provided, and they were not obtained from all participants. NHSN data were incomplete for some hospitals due to optional reporting during the COVID-19 pandemic.

This summary demonstrates implementation of the comprehensive CDI Prevention Collaborative in hospitals targeted based on their CDI data. The consistently reported gaps including CDI testing practices, nurse and physician champions, and nurse engagement in ASPs highlight important areas in effective CDI prevention programs. Although preliminary analysis of post-collaborative data does not indicate greater reductions among participating hospitals, it does highlight that reductions across all groups continued to be made during a global pandemic when increases in many other HAIs have been reported. ^{Reference Weiner-Lastinger, Pattabiraman and Konnor2} This summary also outlines potential future areas of focus for CDI prevention efforts based on >6,000 frontline assessments and reported challenges and barriers to prevention of one of the most common HAIs affecting hospitals and patients across the country.