Lessons learned from C. diff collaboratives

NYC group saves as much as $6.8 million

Amid the generally depressing news about the national epidemic of Clostridium difficile there were hopeful reports of hospital collaboratives driving infection rates down.

The Centers for Disease Control and Prevention reported that C. diff infections (CDIs) declined 20% among 71 hospitals in three states participating in targeted prevention collaboratives.1 The CDC is encouraging such projects to attack the multifaceted problem of C. diff infection (CDI), but hospitals flying solo can still apply the lessons learned.

Susanne Salem-Schatz, ScD"The structure, sharing and the learning of collaboratives can really help to build momentum and energy for change," says Susanne Salem-Schatz, ScD, program director and improvement advisor at the Massachusetts Coalition for the Prevention of Medical Errors. "But I also think with many of these same principles — as long as you have both your frontline workers passionate about it and your leadership supporting it — there is no reason that you can't do some of this on your own."

The collaborative in Massachusetts was formed to address a problem common to many other states, as CDIs increased more than 40% between 2003 and 2009. Through American Recovery and Reinvestment Act funding, the state Department of Public Health and the coalition for the Prevention of Medical Errors launched a statewide CDI prevention learning collaborative in May 2010.

Twenty-seven acute and post-acute care hospitals participated in the 20-month collaborative. Participating hospitals formed multidisciplinary teams, including representatives from infection prevention, nursing, quality improvement, clinical leadership, microbiology, pharmacy and environmental services. The collaborative supported a common set of practice recommendations in the areas of surveillance, testing, isolation policies, hand hygiene, contact precautions, and environmental cleaning and disinfection, with additional support for antibiotic stewardship. Training was offered in traditional quality improvement approaches, as well as implementation strategies, with a strong emphasis on engaging frontline staff in identifying barriers and tested solutions.

"Frontline staff at all levels are really in the best position to identify barriers to following preventive practice," Salem-Schatz says. "They can best find solutions to make the right thing to do really the easy thing to do."

Adapt changes locally within collaboratives, she advised, noting that approaches may vary within facilities. For example, some hospitals chose to tap into the serious message of a deadly infection, asking family members who lost loved ones to C. diff to share their stories with staff and collaborative teams. Others offset the tragic with the comic, using humorous videos and "flash mobs" in the hospital halls to generate support for the project.

Comparing four baseline months (Jan–April 2010) and the most recent four months (Sept–Dec 2011), the Massachusetts collaborative achieved an overall 25% decrease in hospital-acquired CDI (8.88 to 6.70 per 10,000 patient days).

Changes in cleaning and disinfection (71%), lab test ordering (71%), and contact precautions (57%) were reported most frequently by the 17 hospital infection preventionists who completed a post-program survey (68% response rate). Education was the most frequently used approach for practice improvement (81%), followed by engaging frontline staff in conversations about infection prevention (75%), and sharing data (69%). Additionally, more than half of respondents reported improving communication, engaging leadership, empowering frontline staff, using small tests of change, and developing new policies.

Lessons learned from the collaborative include the following:

  • Engaging multidisciplinary teams that represent all levels of staff is needed to drive improvement.
  • Using improvement and engagement frameworks, which support adapting changes to local needs, helps promote improvements and culture shifts; education alone does not work.
  • Balancing delivery of expert content with valuable lessons that participants share (all teach, all learn) is vital.
  • Having a clear aim and using shared data to track changes and motivate improvement is powerful.
  • Obtaining leadership support is essential, and includes actively engaging with the team, promoting a culture that allows innovation and failure as part of ongoing improvement work, and allocating resources to implement documented improvements when needed. Building on previous initiatives and statewide collaborations is important.
  • Planning for a two-year program is valuable, since change takes time and participants come at various stages of readiness.

NY state of mind

Comparable success was reported by a collaborative of 35 hospitals in New York City. The hospitals achieved a statistically significant reduction in hospital-associated CDI rates from 10.7 to 8.6 per 10,000 patient days. On average, there was a 20% reduction in hospital-associated CDI among facilities submitting sufficient data for analysis. Based on a regression estimation, hospitals had 1,084 fewer cases of hospital-onset CDI than expected. Applying published estimates of costs attributable to C. diff, total cost savings were estimated at $2.7 million to $6.8 million

"I am a big believer in collaboratives in terms of the strength through numbers," says Brian Koll, MD, FACP, FIDSA , chairman of the NYC collaborative. "It really forces [the issue] in many hospitals where there are barriers. Especially in such a hospital-dense area as New York. You look down First Avenue and there are four or five hospitals — one only two blocks down. If their C. diff rate is higher and they are facing some barriers, they are going to say, 'Well, the hospital down the block or on the Eastside has been able to do it.' I think that really helps. The other reason is that it helps all of us forge a really good spirit of cooperation so that we don't waste our time going down the road of non-success. We are able to share our successes and also share our failures in the sense of something that did not work."

The NYC collaborative project aimed to reduce CDIs by implementing an evidence-based prevention bundle and standardized daily and terminal environmental cleaning protocols. The prevention bundle included the following:

  • Placing patients on contact precautions at symptom onset
  • Monitoring the availability and use of personal protective equipment
  • Monitoring hand hygiene
  • Dedicating thermometers for C. difficile patients
  • Implementing a patient placement strategy to optimize the use of private rooms or cohort patients when necessary (no sharing of bathrooms)
  • Using a checklist to assess compliance with environmental protocols

Some of the lessons learned in New York included:

  • Initiation of a sustainable infection control program requires administrative and clinical leadership support, multidisciplinary teamwork, and ongoing communication. To help redefine the hospital's approach to infection prevention, the initiative based its interventions on the collaborative model and a "team approach." The model expanded infection control and patient safety responsibilities beyond infection preventionists to all clinicians, administrative staff, and non-traditional departments (e.g., environmental and transport services departments).
  • Data collection was time consuming for the hospitals in the collaborative. Several teams experienced difficulties with collecting environmental data, emphasizing the importance of environmental services supervisors' involvement from the beginning of this initiative.
  • The patient placement strategy was difficult for some hospitals, because of the physical layout and the limited number of private rooms in some hospitals.


  1. CDC. Vital Signs: Preventing Clostridium difficile Infections. MMWR 2012;61(09):157-162