C. difficile Infection in Inflammatory Bowel Disease: A Nursing-Based Quality Improvement Strategy

Abstract

Introduction: Patients with IBD not only have a higher prevalence of C. difficile infection (CDI), but also significantly worse outcomes. Numerous IBD treatment guidelines include ruling out CDI for all patients who present with a flare. Recent research has highlighted the inconsistent, and occasionally inappropriate, care that is provided to IBD patients. At our institution, the baseline C. difficile testing rate for patients admitted to our gastrointestinal unit with exacerbation of IBD was 41%. The present quality improvement intervention sought to increase the rate of testing for C. difficile for IBD inpatients with a flare. Methods: Fifty-three patients admitted to our gastrointestinal unit under medical (n=27) or surgical (n=26) specialties from December 1, 2014 to June 1, 2014 with a primary diagnosis of IBD and with symptoms and laboratory findings suggestive of flare were eligible for the study. If a patient did not have a C. difficile test ordered, the admitting floor nurse collected stool and alerted the primary provider to order the test. Monthly educational meetings were held with nursing to maintain study objectives. The primary outcome was percent of eligible patients receiving a C. difficile test. Secondary outcomes included rate of CDI, length of hospital stay, colectomy rate, readmission rate within 6 months, and mortality. Chi-square analysis was used to determine statistical significance. Results: There was a significant increase in percent of eligible patients receiving a C. difficile test such that by the end of the study period, greater than 65% of all patients received a test (p<0.001). This increased to nearly 100% for patients admitted to medical subspecialty services. There was a significant difference in testing rates between subspecialties with patients admitted to surgical services less likely to receive a test (p<0.001), and this remained unchanged throughout the study period. In addition, patients who received a C. difficile test were more likely to have CDI (p<0.001), shorter hospital stays (p=0.02), and fewer readmissions within 6 months (p=0.01). Conclusion: IBD is a heterogeneous disease with patients often cared for by a multidisciplinary team. Despite known guidelines for CDI in IBD, the rate of testing remains suboptimal. The present study utilized the nursing admission workflow to increase rate of testing. This strategy was widely successful for patients admitted to a medical service, but failed to improve testing rates for patients admitted to a surgical service. More work is needed to understand barriers to C. difficile testing in surgical patients. Future studies should further characterize inconsistencies in IBD care and implement universal quality improvements aimed at reducing this harmful disparity.