May 20, 2019

For this post, we asked one of our Department of Quality and Safety medical directors, Marc Pimentel, MD, MPH, CPPS, to discuss hospital-acquired health conditions, specifically quality measurement for Clostridium difficile (C. difficile), an infection that can occur in the hospital after receiving antibiotic medicine.

We use quality measures to drive improvements in caring for our patients — focusing our efforts on preventing patient falls, blood clots and infections. Quality measures, such as how often we wash our hands, help us focus efforts on our trouble spots. Quality measurement is not perfect, but what if a hospital’s measured rate of patients who get a C. difficile infection was off by 20–40 percent? Could we still use this quality measurement for improvement?

In an article published last year in BMJ Quality and Safety, Brigham Health experts wrote about how pursuing a seemingly imperfect measurement still led to improved care. During hospital stays, up to 15 percent of patients will have diarrhea, usually from medication side effects or their own illness.

For some of our patients, there’s another reason: C. difficile infection, which causes up to 20 percent of inpatient diarrhea, usually as a complication of receiving antibiotic medicine. When patients have diarrhea in the hospital, we often send a test for C. difficile in hopes of identifying a treatable cause for the diarrhea.

Unfortunately, the test (like most) is not perfect. Because C. difficile is part of the normal gut flora, at least one out of five patients will have a false-positive test result for C. difficile. Despite this issue, we still count every positive C. difficile result toward our infection rate to allow hospitals to compare their performance to each other, without having to review every single case. Unfortunately, this method of reporting can lead to artificially inflated rates of C. difficile infections in our quality measures.

A team at the Brigham took the time to understand all our care processes that contribute to our positive C. difficile tests. We found several items to address, such as our clinician education for proper testing and interpreting the results. After this and other efforts were performed, such as improving our room disinfection practices, we were able to reduce our measured infection rate by 30 percent, while improving the accuracy of our quality improvement data.

This work has led to more transparency and trust from our patients that we are ensuring delivery of high-quality care and their safety, always.