Intervention Improves Practices Among Nurses Managing Hospitalized Patients with C difficile

SEPTEMBER 20, 2018
Brandon May
A behavioral approach consisting of in-person discussions with nurses and prescribers regarding Clostridium difficile management recommendations was associated with self-sustained practice changes and significant improvements in specific suboptimal C difficile practices, according to a study in the Open Forum Infectious Diseases.

Optimizing testing and infection management remain substantial challenges in caring for patients with C difficile infections. Inappropriate testing, as well as inaccurate documentation of bowel movements (BMs), can result in overdiagnosis of C difficile and imperfect infection identification.

“CD Action Team’s (CDAT) face-to-face interaction with providers led to significant improvement in BM documentation, antibiotic use for concomitant non-C difficile infections, and proton pump inhibitor (PPI) use,” investigators, led by Valeria Fabre, MD, of the Johns Hopkins University School of Medicine, wrote. “For some C difficile practices (non-C difficile antibiotic therapy and BM documentation), we observed a cumulative effect after a second intervention, suggesting a potential long-term benefit of repetitive interventions.”

Fabre and colleagues prospectively reviewed medical charts of adult patients who were hospitalized with positive C difficile tests (n = 96). Using these data, they developed management recommendations for these patients. Two interventions were implemented during the 11-month study, both of which used an in-person, real-time, case-based education and discussion with the patient by a CDAT.

The CDAT comprised 3 infectious disease physicians, 2 infection preventionists, and 3 pharmacists. Case evaluations occurred within a 24-hour period of a patient receiving a positive C difficile test, whereas management was assessed within a 48-hour period following CDAT delivery of recommendations during the intervention periods.

Primary outcomes of the analysis included CDAT-prompted changes as well as CDAT-independent changes. In the CDAT-prompted change outcome, investigators compared the percentage of patients receiving optimized C difficile management within a 48-hour period following CDAT with the percentage of patients who received optimized management of C difficile during baseline.

The CDAT-independent changes were evaluated by comparing the percentage of patients who received optimized management of C difficile during both the observation period as well as before intervention, with the percentage of patients who received optimized C difficile management during baseline.

At least 1 opportunity to improve the management of C difficile was identified by the CDAT in 84 patients. During the intervention periods, the CDAT provided recommendations for a total of 76 cases. There were significant improvements in the response to CDAT-led direct interventions for patients with BM documentation, showing that suboptimal BM documentation decreased by 68% and 92% during the first intervention and second intervention, respectively; P = .02 and P<.01 respectively).

Additionally, suboptimal antibiotic use was reduced by 57% during the first intervention and 76% during the second intervention (P<.01 for both). Finally, the investigators observed a 63% decrease in inappropriate PPI use during both interventions (P<.05 for both).

Clinical acceptance of the practice change recommendations was fairly similar among categories, including recommendations to stop unnecessary PPI use (52% of cases), stop laxatives (53%), improve BM documentation (57%), change or stop C difficile therapy (58%), and change or stop antibiotics for non-C difficile infections (48%).

The relatively small sample size, the lack of a comparator or control intervention (ie, sham intervention), and the specificity of these findings to only C difficile management represent the primary limitations of the analysis.

“Our results add to the emerging literature supporting a role for nurses in antibiotic and diagnostic stewardship efforts.” the investigators added. “Nurses perform many antibiotic functions in their daily practice (eg, they review and administer antibiotics and other medications that can impact the course of an infection, they obtain specimens for microbiology testing); however, [many times] these activities are not formally aligned with antibiotic stewardship efforts.”

The study, “Impact of Case-Specific Education and Face-to-Face Feedback to Prescribers and Nurses in the Management of Hospitalized Patients with a Positive Clostridium difficile Test,” was published in Open Forum Infectious Diseases.

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