Difficile but not impossible: Improving documentation to improve outcomes for Clostridium difficile infections in NHS Ayrshire and Arran

Abstract

Background Clostridium Difficile Infection (CDI) varies in severity and presents challenges in management. Whilst incidence is decreasing, the mortality rate in NHS Ayrshire & Arran is 10%. We evaluated if a new infection severity assessment sheet improved management. Method A retrospective case note review was performed on all cases of CDI, confirmed by clinical symptoms and laboratory sampling. Our audit assessed both predisposing factors and management. The first cycle ran from January-March 2018. The second cycle ran May-November 2018 after the introduction of the new severity assessment sheet. Results There were 20 episodes of CDI in the first cycle, and 38 episodes in the second cycle (n=58). Following introduction of the new severity assessment sheet CDI diagnosis, management and documentation improved. High-risk antibiotic use prior to CDI fell from 65% in the first cycle to 34% in the second cycle. Discussion of CDI diagnosis with relatives increased from 70% to 86.8%. Documentation of day 1 and 5 infection severity scores improved (50% to 57.9% and 10% to 31.6%, respectively). Improvements were noted in prompt stool sampling after symptoms (90% to 97.4%), fluid balance chart use (80% to 89.5%), stopping unnecessary antibiotics (58.3% to 81.3%) and documentation of daily assessment (5% to 23.7%). Conclusion The results highlight positive improvement in outcomes following a well-publicised introduction of an improved CDI proforma. Despite this, further intervention and monitoring is required to improve documentation of daily assessment in CDI. Additionally, there is still progress to be made to prevent unnecessary use of high risk antibiotics.