A Policy Change to Reduce Hospital-Acquired Clostridium Difficile Infection Rates: A Quality Improvement Project

Practice Problem: At a small community facility in Los Angeles County, there was a reporting rate of hospital-acquired Clostridium difficile cases that was higher than both state and national benchmarks. PICOT: The PICOT question that guided this project was: In acute care patients aged 18-90, does not retesting for CDI for at least seven days compared to retesting in less than seven days reduce the incidence of false positive CDI tests during the first seven days of the hospital stay? Evidence: The evidence demonstrates that if patients are tested initially for Clostridium difficile and then retested seven days after, the rate of hospital-acquired Clostridium difficile decreases. Intervention: A facility policy was implemented to restrict CDI testing until seven or more days after the initial test. Outcome: A total of 19 patients were initially tested for Clostridium difficile. Medical personnel determined that only two of those patients needed a second test, which was done after seven days. There were no hospital-acquired cases during the project period, unlike during the same time frame the previous year. Conclusion: The project results supported the literature showing that waiting seven days before performing a repeat Clostridium difficile test can reduce the number of hospital-acquired Clostridium difficile cases by reducing false positives. This was beneficial to the hospital which was able to reduce costs, and improve the quality of the care. CLOSTRIDIUM DIFFICLE RETESTING 4 A Policy Change to Reduce Hospital-Acquired Clostridium Difficile Infection Rates: A Quality Improvement Project The purpose of this project was to implement a policy change that would reduce the number of patients being misdiagnosed with hospital-acquired Clostridium difficile infection (CDI). Infections caused by the bacteria can cost hospitals as much as $3.2 billion annually (Surawicz et al., 2013). This paper describes the significance and the framework of the problem, synthesize and interpret the related literature, define practice recommendations, describe the project setting, report the project mission and objectives, discuss the project implementation and evaluation, and explain its dissemination. Significance of the Practice Problem Clostridium difficile is a gram-positive bacterium (Block et al., 2018). It is a leading cause of gastrointestinal illness. About 500,000 patients contract CDI each year, resulting in 30,000 deaths in the United States (Lee, 2018). According to Mao et al. (2018), Caucasian patients have a higher risk for CDI when compared to African-American, Hispanic, Asian and Native American patients. Infection rates have increased steadily since the year 2000, mostly affecting the elderly (Pechal, et al., 2016). Eighty percent off patients who die from CDI are 65 and over; one out of every 11 patients who are aged 65 or over will die if they contract the infection (Pechal, et al., 2016). Patients who have CDI have been known to have long lengths of stay can be increased by as much as six or seven days (Chopra et al., 2015). According to Zhang et al. (2016), the cost per hospital-acquired CDI case is $34,157, CDI case management and CDI-attributable costs per case are $42,316. However, the length of stay, and the costs associated with a complex infection, are not the only concerns, as patients who contract CDI are twice as CLOSTRIDIUM DIFFICLE RETESTING 5 likely to be readmitted to the hospital (Chopra et al., 2015). Readmission costs for CDI can be as high as $13,000. Due to the costs of this preventable infection, the Centers for Medicare Medicaid Services (CMS) mandates hospitals to report CDI rates. The CDI data is calculated by the Standardized Infection Ratio (SIR) as required by the National Healthcare Safety Network (CDC, 2018). The SIR is computed by dividing the number of observed CDI infections by the number of predicted infections. If the SIR is >1, then there were more CDI cases than predicted, based on the 2015 national aggregate data (California Health & Human Services Agency, 2017). The goal is to have less than that (CDC, 2018). According to Pimentel, et al. (2018), “CMS is seeking to shed light on this type of preventable patient harm and raising the stakes by putting financial penalties and a hospital’s public reputation at risk” (p.414). Patients or their families may further damage a hospital’s reputation by suing the hospitals because of CDI. If the patient or family can prove that medical negligence was involved, then they have a case (Boeschen, n.d.). In one lawsuit where a patient died due to CDI, the facility had to pay $218,500 (Waldsmith, n.d.). Reducing CDI rates, hospitals will improve patients’ quality of life. Lowering hospitalacquired CDI will decrease length of stay, death, and suffering from symptoms and time spent in isolation (Block et al., 2018). Patients’ family members who visit will be at a decreased risk of contracting CDI (Barker et al., 2017). And hospitals will reduce the potential for costly CDIrelated hospital stays and CMS penalties. Framework of the Problem For the purpose of this project, the Kurt Lewin Change Theory was utilized (Cumbler et al., 2013). This model has been used previously for this type of project (Shingler-Nace et al., CLOSTRIDIUM DIFFICLE RETESTING 6 2019). It has three steps: unfreezing, change, and refreezing (Cumbler, et al., 2013). The unfreezing phase consists of convincing people to change their current pattern of behavior (Cumbler et al., 2013). For the current project, this step involved implementing an evidencebased policy so that CDI testing cannot be repeated within a seven-day period, and educating the staff about the new policy. Before this policy change, patients who came into the hospital with diarrhea were tested initially for CDI. Then the test happens again within a day or two; most of these patients would have had a Clostridium difficile test orders three times within a three-day period. As described in the Themes from Literature section of this paper such repeated testing is not warranted because it increases false positives. Thus, the practica site’s Handling Patients with Clostridium Difficile Infections Policy was changed under the section that states, “Testing will be performed using EIA.” A statement was added that if a patient has been tested once, they will not be retested until seven days have passed. This policy can be reviewed in Appendix A. In the change phase, people are convinced that the new way is better (Cumbler et al., 2013). The nurses at the practica site were shown a brief PowerPoint presentation so that they understood the severity of the CDI testing problem, and why the change was necessary. Then, in the refreezing phase, the change becomes a new and accepted process (Cumbler et al., 2013). The refreezing step was deemed complete when the staff realized that they are not being reminded to stop reordering the CDI testing. Ongoing monitoring of CDI testing at the facility in question was conducted by the project manager, charge nurses and the infection preventionist.

likely to be readmitted to the hospital (Chopra et al., 2015). Readmission costs for CDI can be as high as $13,000.
Due to the costs of this preventable infection, the Centers for Medicare Medicaid Services (CMS) mandates hospitals to report CDI rates. The CDI data is calculated by the Standardized Infection Ratio (SIR) as required by the National Healthcare Safety Network (CDC, 2018). The SIR is computed by dividing the number of observed CDI infections by the number of predicted infections. If the SIR is >1, then there were more CDI cases than predicted, based on the 2015 national aggregate data (California Health & Human Services Agency, 2017).
The goal is to have less than that (CDC, 2018). According to Pimentel, et al. (2018), "CMS is seeking to shed light on this type of preventable patient harm and raising the stakes by putting financial penalties and a hospital's public reputation at risk" (p.414).
Patients or their families may further damage a hospital's reputation by suing the hospitals because of CDI. If the patient or family can prove that medical negligence was involved, then they have a case (Boeschen, n.d.). In one lawsuit where a patient died due to CDI, the facility had to pay $218,500 (Waldsmith, n.d.).
Reducing CDI rates, hospitals will improve patients' quality of life. Lowering hospitalacquired CDI will decrease length of stay, death, and suffering from symptoms and time spent in isolation (Block et al., 2018). Patients' family members who visit will be at a decreased risk of contracting CDI (Barker et al., 2017). And hospitals will reduce the potential for costly CDIrelated hospital stays and CMS penalties.

Framework of the Problem
For the purpose of this project, the Kurt Lewin Change Theory was utilized (Cumbler et al., 2013). This model has been used previously for this type of project (Shingler-Nace et al., 2019). It has three steps: unfreezing, change, and refreezing (Cumbler, et al., 2013). The unfreezing phase consists of convincing people to change their current pattern of behavior (Cumbler et al., 2013). For the current project, this step involved implementing an evidencebased policy so that CDI testing cannot be repeated within a seven-day period, and educating the staff about the new policy.
Before this policy change, patients who came into the hospital with diarrhea were tested initially for CDI. Then the test happens again within a day or two; most of these patients would have had a Clostridium difficile test orders three times within a three-day period. As described in the Themes from Literature section of this paper such repeated testing is not warranted because it increases false positives. Thus, the practica site's Handling Patients with Clostridium Difficile Infections Policy was changed under the section that states, "Testing will be performed using EIA." A statement was added that if a patient has been tested once, they will not be retested until seven days have passed. This policy can be reviewed in Appendix A.
In the change phase, people are convinced that the new way is better (Cumbler et al., 2013). The nurses at the practica site were shown a brief PowerPoint presentation so that they understood the severity of the CDI testing problem, and why the change was necessary. Then, in the refreezing phase, the change becomes a new and accepted process (Cumbler et al., 2013).
The refreezing step was deemed complete when the staff realized that they are not being reminded to stop reordering the CDI testing. Ongoing monitoring of CDI testing at the facility in question was conducted by the project manager, charge nurses and the infection preventionist.

PICOT Question
The PICOT question for this project was: In acute care patients aged 18-90, does not retesting for CDI for at least seven days compared to retesting in less than seven days reduce the incidence of false positive CDI tests during the first seven days of the hospital stay? The population was adult inpatients on the intensive care unit, telemetry unit and medical surgical unit of an acute care hospital. Any patients aged 18 and over were eligible for inclusion.
Pediatric patients admitted to the medical surgical unit were excluded. The intervention was intended to reduce the number and frequency of repeat CDI test so that patients exhibiting symptoms of CDI (such as diarrhea or abdominal pain) were tested once, and then only retested once more after seven days in the hospital. The comparison intervention was patients admitted one year prior to the intervention period who had an initial test for CDI and were then retested prior to the seven-day period.
The purpose of the study was to compare the number of positive CDI tests in the intervention group (those patients who have repeat testing after seven days) to the number of positive CDI tests in the group who underwent earlier or more frequent repeat testing. The facility uses the Clostridium difficile A & B test, which gives two results: an antigen and a toxin.
A patient is considered positive for CDI if the toxin test comes back positive. Patients who were tested once and had either a negative result or a positive antigen result, and were then retested within three days and have a positive result were deemed "false positive." The desired project outcome was for there to be a reduced number of false positive results for CDI testing, in an attempt to save the hospital thousands of dollars and avoid treating patients for CDI who do not truly need it during the first seven days of their hospital stay.

Literature Search Strategy
A literature review was performed to answer the PICOT question. In acute care patients aged 18-90 (P), does not retesting for CDI for at least seven days (I) compared to retesting in less than seven days (C) reduce the incidence of false positive CDI tests (O) during the first seven days of the hospital stay (T)? The first search was performed on the American Journal of Gastroenterology website. The PICOT question was used as the search phrase. The search resulted in one article. The following search was completed on the Biomed Central Journal. The search term used was "repeat testing for Clostridium Difficile". There were 10 results, and abstracts of the 10 results were reviewed. One article was selected; the other nine results were abstracts from presentations, which are not appropriate for this project.
After these two initial searches, a search was conducted on the Infection Control and Hospital Epidemiology website. The search was limited to open access articles with the date range of 2000-2019, it produced 27 results. All 27 abstracts were reviewed. One article was selected, as this article focuses on repeat CDI testing.
On the PubMed database, the search phrase "repeat testing for Clostridium difficile" was used. This resulted in 72 articles, and all abstracts were reviewed. There were 18 articles pertinent to the topic. Finally, on Search USA, the search term "repeat testing for Clostridium difficile" was used, which produced 17 articles. After the abstracts were reviewed five articles were selected. The search results can be viewed as a PRISMA model in Figure 11.

Literature Search Results and Evaluation
A total of 25 articles were selected based on the inclusion criteria. Six of the articles reviewed were clinical practice guidelines. Each of the guidelines was reviewed using the AGREE tool (Brouwers, et al., 2016). In addition, there were 17 primary research articles and two systematic reviews evaluated using the STROBE model (von Elm et al., 2008).
The evidence table for the primary research articles can be viewed in Appendix B. The evidence table for the systematic reviews can be examined in Appendix C. The articles were analyzed for level of evidence and quality ratings using the method described by Dearholt and Dang (2012). There are seven levels of evidence, ranging from Level I, which is considered to be a systematic review, to Level VII, which is an expert opinion or consensus statement. The diagram in Figure 12 shows all seven levels of evidence.
Overall, the evidence of the 25 articles reviewed for this project can be rated a Level IV.
This rating was given because six of the primary research articles achieved a Level IV evidence rating, but three of the primary research articles only received a VI evidence rating, which brought the overall evidence rating down. In order for the group of articles as a whole to achieve a higher evidence rating, three more primary research articles should have received an evidence rating of Level I.
In regards to quality, the 25 articles reviewed achieved a B for overall quality. This was the case because six of the articles were determined to be A quality, and eight of the 25 articles were rated an A or B for quality. If at least 12 of the articles achieved a rating of A or B, then the whole body of evidence reviewed for this project could have achieved a quality rating of A.
Despite only five articles having an A quality, the level of evidence of the group of articles warranted the practice change.

Themes from the Literature
The consensus among the six clinical practice guidelines reviewed is that CDI testing should only be done seven days after the initial CDI test. Bobenchick et al.'s (2019) systematic review (which earned an evidence Level I and a quality grade of A; see Appendix C) considered six practice guidelines for CDI testing and advocated for retesting only after seven days, specifically because retesting sooner can cause false positive CDI test results. Indeed, repeat testing in less than seven days leads to inappropriate treatment because negative results are more likely to be changed to false positives (Aichinger et al., 2008;Buckel et al., 2015;Gade & Turrett, 2009;Surawicz et al., 2013). Khanna et al. (2012) found that 1,759 patients who were tested twice in the same day, 42 of the results converted to positive. Furthermore, Luo et al. (2013) found that of 2,949 repeated tests, 135 of them converted to positive in six days or less.
The increase in hospital-acquired CDI cases may be due to cases being misdiagnosed from over testing (Grien et al., 2014). This may be because of the sensitivity of the CDI toxin A & B test to result in a false positive (Green et al., 2014;Toltzis et al., 2012). However, Cardona andRand (2008) found that when they tested patients every day for six days, the patients consistently tested either positive or negative each time, lending support to the conclusions that early repeated testing is not only unnecessary, it is not cost effective (Depshande et al., 2010;Mohan et al., 2006;Mostafa et al., 2018).
Hospitals can avoid such false positives, or changes from a negative to a positive result, by limiting CDI testing. Kamboj et al. (2018) showed that out of 31 hospitals, 15 of them have a policy in place restricting repeat CDI testing within seven days. Other studies showed that a hard stop could be added to a facility's medical charting software to prevent CDI retests. For example, both Quan (2018) and Block et al. (2018) did experimental studies showing that a hard stop in the electronic medical record reduced repeat test orders significantly. In addition, Madden et al.
(2018), which was also an experimental study that earned an A rating for quality, demonstrated a 41% reduction in repeat testing.
Regardless of the clear benefits attributed to less frequent CDI testing, some healthcare staff believe that ordering multiple CDI testing is necessary. Both Zilberg et al. (2011) and Blanco et al. (2018) explain that many clinicians order multiple CDI test after the initial is negative. This mindset seems to be an attempt to overcome the testing sensitivity; however, it increases the risk of false positives. The majority of the articles reviewed for this project clearly state that repeat testing should be restricted to five to seven days after the initial test.

Practice Recommendations
Using the available evidence, it is clear that if repeat testing for CDI is restricted to being performed seven days or more after the initial testing, then the risk of creating false positives for hospital-acquired CDI is reduced. All of the clinical practice guidelines reviewed indicated that repeat CDI testing should not be performed until seven days after the initial test. In various primary research studies the same result was also discovered.

Project Setting
The setting for this project was a 117-bed acute care hospital in Southern California. The hospital has been in practice for over 50 years. In 2011, the hospital was purchased by the Avanti company making it part of a four-hospital system in Los Angeles County. In 2018, the hospital was purchased by the Pipeline Company. There are over 270 staff members and 200 physicians.
The hospital is accredited by the Joint Commission for primary stroke, the lab and the facility.
The units consist of an emergency department, an intensive care unit, medical-surgical unit, and telemetry unit. The patient population is 66% Hispanic, 13% Caucasian, 13% Asian, 6% African American, 1% American Indian, and 1% Pacific Islander or other. The top five admitting diagnoses are: abdominal pain, hyperglycemia, heart failure, chronic obstructive pulmonary disease and altered level of consciousness.
The facility's mission statement is "to provide affordable, high-quality healthcare services to our communities with consistency and compassion." The facility vision statement is They are very concerned about this issue. After hearing some ideas on how to address this problem, support was offered. This project was carried out with the assistance of the infection preventionist, educator, and the nursing supervisors.
A SWOT analysis was conducted on 10/4/2019; the results are in Appendix E. Some of the strengths identified were the support from the key stakeholders and the preceptor. The opportunities to address the CDI problem were the strong leadership structure, the new hospital ownership and the heavily involved medical staff. One the main weakness was the restrictions of the electronic medical record. At this time, a hard stop to prevent multiple CDI orders could not be put in place. One of the main threats to the project success is the high nursing turnover rate.

Project Overview
The mission of this project was to reduce the risk of false positive CDI results. The vision of this project was to reduce the number of hospital-acquired Clostridium difficile cases. The project's mission aligns with the mission of the facility, as the mission's focus is on high-quality care. The short-term objective was to change the policy so that patients could not be retested within seven days. One long-term objective was to educate the staff and monitor to ensure that repeat orders are not being done before a 7-day timeframe. Another long-term objective was to decrease costs related to CDI. One example of how this project could help the hospital achieve its mission of high-quality care is that it could help provide appropriate care for patients, so that hospital-acquired CDI does not occur. One possible risk or unintended consequence was the resistance of nurses to the policy change. As an incentive, the facility's staff recognition program was utilized for nurses who are routinely following the new CDI testing policy.

Project Plan
The change model used for this project was the PDCA Cycle (Johnson, 2016; see Appendix F). The PDCA stands for plan, do, check, act. This model was chosen because it was a good fit for the project. It has been used for similar projects like this (Block et al., 2018). This is also the standard model that the facility utilizes, so the staff was familiar with it.

Plan
The plan was to create the new policy. The current infection control manual was reviewed, and the policy was revised to include that a patient tested for CDI will not be retested within seven days of the first test. The policy was changed with the assistance of the Infection Preventionist. Barriers to this change were not expected, because the key stakeholders were very concerned about this topic. The form in Appendix G contains the evidenced-based practice council approval letter and Appendix H contains the signatures of approval from the stakeholders.

Do
The do step involved educating the staff and applying the policy. The ARCS instructional design model was utilized (see Appendix I). This model focuses on getting the nurses attention, showing them the relevant evidence, giving them confidence and raising their satisfaction. A meeting was held with the educator to discuss the education plan for the change. The education was conducted with the assistance of the infection preventionist, educator and the nursing supervisors. Once 80% of the nursing staff had been educated on the new policy, the policy went into effect on 2/27/20. Once the policy was in effect, ongoing monitoring of patients with CDI testing was conducted. The monitoring was completed with the assistance of the charge nurses.
A barrier to this step was the high nurse turnover at the facility. In an effort to combat this, the policy was added to the nursing orientation educational material. This way all new incoming nurses were aware of the policy. The nurses signed an attestation form that they are knowledgeable of the policy change. See Appendix I for the attestation form.

Check
In the check step, the information technology department was requested to create a daily report that tracks patients with the C-diff A & B test ordered. The nurses taking care of these patients were reminded that repeat testing was not permitted until after seven days. A barrier to this step was that nursing did not have access to request a hard stop in the electronic medical record to stop any repeat orders. Thus, nurses who order a repeat test were, reeducated.

Act
The act step included asking the staff their opinions on the change and reviewing the compliance data as well as the CDI rates. The evaluation of the project was conducted from 5/15/20-5/31/20. The schedule for the project is located in Appendix J. The main resources needed were the assistance of at least two of the departmental leaders as well as the nursing staff.
My role as project manager was to lead the project. The nurse educator, infection preventionist, and the project manager worked together to educate the staff. Interprofessional collaboration was needed for this project to be a success.
The budget was based on the situation currently at the practica site. Staffing costs were calculated based on the base rate per position and included 57 staff registered nurses $19,767.60, 14 charge nurses $6,684.72, five nursing supervisors $2,803.20, one nurse educator $320, and one infection preventionist, $224. Supplies included the following: paper, pen, binder, and laminating paper which totaled $361.25. The costs of electricity and the computer are not included as they are normally in use in the facility. Services and Statistician were not used. The budget is shown in Table 1.

Project Evaluation Plan
The project was evaluated by comparing the number of CDI cases before implementation to those after implementation. A comparison of the pre-implementation to postimplementation SIR was completed, and a t-test comparing the two numbers was calculated to determine if any change was significant. These data were based on NHSN criteria.
The hospital's IT department created a report that identified patients who were tested for CDI. A review of the number of patients who were repeat tested was performed. The repeat testing percentages were compared and a significance test was calculated. A table was then developed showing those patients' demographics, including age, gender, and ethnicity. The units the patients were on was included. The emergency department, pediatrics and operating room were not included. The patients' medical record numbers, names, and birthdays were not included to prevent a violation of privacy of health information.
To get a complete picture of the situation before and after implementation, other outcome measures and financial measures were compared: CDI mortalities, length of stay and readmissions. In addition, process measures, including staff education and compliance, were assessed during the project.
Appendix K includes the categories for the data variables. All data were collected onsite and entered into Microsoft Excel in a private office to protect patient privacy. A CDI Detection and Surveillance Assessment was conducted (Minnesota Department of Health, 2018). This tool asks questions about the repeat testing (see Appendix L). If there are multiple "yes" answers on the tool, then the change was successful.

Project Evaluation Results
The data collection took place after 57 (86%) members of the nursing staff were educated by the project manager, nurse educator and infection preventionist. The implementation period for the project was from February 27, 2020 to April 20, 2020. During that time period, a total of     The comparison in the SIR rates is located in Figure 7. For both time periods, there were no CDI readmissions and no mortalities.
The nursing staff compliance with the project was 100%. The CDI Detection and Surveillance Assessment was used for evaluation by the infection preventionist and the student, and it is located in Appendix L. Based on all of these data, this project was a success.

Cost Comparison
Feb-Apr 2020 Feb-Apr 2019

Discussions and Implications
The project asked: In acute care patients aged 18-90, does not retesting for CDI for at least seven days compared to retesting in less than seven days reduce the incidence of false 0 0 This project was a successful attempt to change the practice, as 86% of the nursing staff was educated on, and 100% were compliant with, the new policy. One of the reasons for this achievement was due to the collaboration of the team. Nurses were educated by the educator, infection preventionist and the project manager. The charge nurses were the champions on the units. Only once during the project period was a CDI test ordered that did not follow the new policy. This occurrence was made by a registry nurse, but the order was cancelled by the charge nurse of the unit. As no specimen was collected, this did not result in a policy violation.
The project results aligned with the recent literature, that repeat CDI tests should not be performed until at least seven days have passed since the initial test. There were no positive retests, no mortalities due to CDI, and no readmissions. Possible reasons for these results include the low number of participants and the limited time frame. The low number of patients was most likely due to the COVID-19 pandemic. The pandemic led to a stay-at-home order, which reduced the number of patients coming to the facility.
The findings of this project are relevant to practice. The hospital had fewer cases of hospital-acquired CDI during the project period, which demonstrates increased quality of patient care. Because hospital CDI data is required to be reported and is posted online, patients will be able to see the improvement, and the hospital will gain more reimbursement from CMS. The project also resulted in a total costs savings of $36,437.12, due to reduction in number of tests ordered and no hospital-acquired CDI cases. Due to the success of this project, it should be replicated, but with a longer time period of at least six months. This project should also be carried out at a hospital with a larger patient census.

Plans for Dissemination
The results of the project were shared with the key stakeholders, the CEO, CNO, In addition to local dissemination, the abstract will be submitted to the 16 th World Congress on Infection Prevention and Control which will take place online on September 16, 2020. The Association for Professionals in Infection Control and Epidemiology was cancelled for 2020; however, an abstract will be submitted for 2021. Results will also be submitted for publication in an appropriate journal such as, Prevention Strategist or American Journal of Infection Control. The project will be archived in SOAR@USA and the Virginia Henderson Library.

Conclusion
The intention of this paper was to describe each step of a scholarly project that would result in a reduction of false positive, hospital acquired CDI. Hospital-acquired CDI is tremendously costly as well as detrimental for the patients, their families and the facility. The     2. For patients who meets one criteria each in both category 1 and category 2, patient will be determined as high risk and will be placed on contact isolation and then a stool specimen will be collected if developed loose or watery diarrhea and sent to laboratory for c. difficile testing.
3. This testing will only apply to admission screening and specimen will be tested per screening protocol order. There is no need for an order from the attending physician.
4. Testing is to be done using the following guidelines: Patient has at least one item in Category 1AND at least one item in Category 2: Category 1: a) □History of C. difficile infection. b) □Broad spectrum antibiotic use within last 90 days c) □Extended period in LTAC, SNF or Nursing Home d) □Is seriously immunocompromised e) □Had recent GI or GU surgery f) □Taking medication to reduce stomach acid AND Category 2: a) □Fever b) □High WBC (>11,000) on admission c) □Abdominal pain For these patients with suspected C. difficile infections (High Risk), the patient will be placed in Contact isolation precautions. if the stool was found negative for C. difficile, isolation will be discontinued.
5. Testing will be performed using EIA. Patients who have been tested, will not have a repeat test performed within 7 days. Results are interpreted as: 6. B. Isolation should continue as long as symptoms (diarrhea: more than 2-3 bowel movements daily and loose/watery stools) persist.

Ag Toxin Interpretation
C. Patients with no symptoms of active infections for at least 48 hours may be taken out of isolation upon an order from the treating physician. No testing is needed to discontinue isolation for asymptomatic patients (based on CDC guidelines).

Procedure for disinfection of room:
A. Upon getting an order for discontinuation of isolation of a Clostridium difficile infected patient or if such patient is discharged or transferred, Nursing will inform Environmental Services Department, by phone, of the need for room cleaning post C. difficile isolation. Nursing staff will not remove the isolation sign or the "Wash Hands with soap and water" sign from the room.
B. Nursing should remove all equipment from room prior to arrival of EVS staff. Equipment should be bagged in designated bags before removal from room into soiled utility room.
C. EVS staff assigned to clean the room will bring with them bleach germicidal solution, along with other normal cleaning supplies and equipment.
D. EVS Staff will clean the room utilizing "Terminal Cleaning of Isolation Room" procedures. This procedure must include changing the privacy curtain.
E. After normal cleaning, all surfaces in room and bed will be wiped with bleach germicidal. This step is to destroy any Clostridium difficult spores that may be on these surfaces.
F. Following the completion of the room cleaning, EVS staff will remove the isolation signs and will document the cleaning process in the designated Clostridium Difficile Log at the Nursing Station.
G Equipment taken to the soiled utility room will be picked-up by Central Services Department staff and will be cleaned using bleach containing germicidal.
If room cleaning is to be done while the patient is still in the room, i.e. following discontinuation of isolation, all the above steps will be followed except removal of equipment from the room. Instead, all equipment in the room will be cleaned by nursing using "bleach-based germicidal towels. There is no value in repeat testing for CDI within a seven day period.
There are no diagnostic gains for repeat CDI testing, this should not be routinely done.
Of the 605 who initially tested negative, 20 of them tested positive on the repeat. Blanco, et al., 2018 Level There is no value to repeat testing within the first week of the initial test.
The data supports not repeating CDI tests within two days and limiting it to over seven days.
Of the repeated tests 0.9% were positive on the same day as the initial, and 10.6% were positive seven days afterwards. Gade & Turret, 2009 Level V Grade C

patients
This was a retrospective study of CDI testing. The positive predictive value and negative predictive values were calculated.
Patients are often tested more than needed for CDI.
At least 16% of CDI testing is not necessary.
After the initial test, 11.9% tested positive on the first repeat, 4.1% tested positive on the second repeat, and less than one percent on the fourth repeat. Green, et al. 2014 Level Legend: _X__ not meet the requirements for research as defined in the Federal Register. Your proposal reflects an evidence-based practice change project.
The proposal must be implemented as submitted (changes are not permitted). You may proceed to obtain approvals from the facility where the project will be implemented. Implementation may not begin until you are notified in writing by faculty that you may implement the project.
Questions regarding the USAHS approval process should be addressed to Dr. Douglas Turner at DTurner@usa.edu. Questions regarding the facility approval process should be addressed to course faculty.