2023 Quality Report

Hospital Quality Improvement Projects - Marshfield Medical Center – Beaver Dam

Clostridioides difficile Infection (CDI) Reduction

Healthcare-associated infections (HAIs) are among the fastest growing issues affecting health care facilities in the United States. The National Healthcare Safety Network (NHSN) and the Centers for Disease Control and Prevention (CDC) monitor them very closely.
Hospitals nationwide perform surveillance to prevent HAIs and improve patient safety. At the beginning of 2022, it was identified that the Standardized Infection Ratio (SIR) for healthcare-associated Clostridioides difficile (HAI CDI) was trending upward at Marshfield Medical Center-Beaver Dam (MMC-BD). The Infection Preventionist along with the Quality/Patient Safety/Risk Management/Performance Improvement Manager investigated the current state of HAI CDI at MMC-BD with the goal of reducing the SIR for the inpatient Medical/Surgical/Intensive Care Units by 20% by the end of 2022.   

In the investigation, it was identified that the CDI lab test was part of the GI stool panel. It was also discovered that in the current electronic medical record, the CDI order remained active until the stool sample was collected and sent, regardless how long it took to obtain the sample. Both of these could lead to inappropriate CDI testing. To help ensure appropriate CDI testing, the following counter measures were identified and implemented:
  • Conducted real-time report-outs to evaluate the five “whys” to identify the root cause.
  • Reported fallouts monthly to the MMC-BD executive team which became part of the quality and process improvement’s leadership performance evaluation goals to assist with transparency and accountability.
  • Performed a major education initiative on the Bristol Stool Chart for all inpatient staff including education on the MCHS Inpatient Adult CDI Testing Algorithm. This was accomplished by the infection preventionist attending nursing huddles, developing an educational poster for the Nursing Skills Fair, and handing out “pocket cards” to nursing staff that had the Bristol Stool Chart with types of stool on one side and the approved Inpatient Adult CDI Testing Algorithm on the other. 
  • Provided education to physicians and nurse practitioners on the criteria for ordering CDI analysis and the established Inpatient Adult CDI Testing Algorithm. 
  • Sent reminder emails to laboratory staff to reject any stool sample with formed stool that were sent for CDI testing.
  • Transitioned to a different EMR, which removed the CDI lab from the GI stool panel. The CDI lab order also “fell off” after 24 hours if the sample was not obtained and sent, prompting the provider to reorder and again meet criteria for ordering the lab. 

When all countermeasures were implemented, MMC-Beaver Dam saw significant results. The HAI CDI SIR was 0.00 for quarters 2 through 4 of 2022. CDI results will continue to be monitored to support appropriate patient testing.