NURS-FPX6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal: sample paper, in real form

Reading Two Years of Hospital-Onset Clostridioides difficile Data Honestly: A Diagnostic and Antimicrobial Stewardship Proposal for a 28-Bed Medical Unit

Student Name

School of Nursing and Health Sciences, Capella University

NURS-FPX6016: Quality Improvement of Interprofessional Care

Instructor Name

Month Day, Year

What the Dashboard Reports

The infection prevention and stewardship dashboard at this 240-bed nonprofit hospital is reviewed quarterly by the quality committee and carries four panels: hospital-onset Clostridioides difficile infection, antimicrobial use, environmental services audit results, and hand hygiene observation. Read across eight quarters, the first panel moved in the wrong direction. In year 1 the hospital recorded 34 hospital-onset events across 61,480 patient days, a rate of 0.55 per 1,000 patient days and a standardized infection ratio of 0.88 under National Healthcare Safety Network definitions (Centers for Disease Control and Prevention, 2024). In year 2 it recorded 49 events across 63,110 patient days, or 0.78 per 1,000 patient days, with a standardized infection ratio of 1.24. The rate rose 41 percent and the ratio crossed 1.0.

The antimicrobial panel moved with it. Total antibiotic days of therapy rose from 641 to 688 per 1,000 days present between the two years, a 7 percent change that on its own would be unremarkable. The high-risk subset did not behave that way. Fluoroquinolones, third and fourth generation cephalosporins, and carbapenems rose from 168 to 214 days of therapy per 1,000 days present, a 27 percent increase, and these are the agents the treatment guidelines identify as carrying the strongest association with C. difficile infection (McDonald et al., 2018). The environmental panel shows a terminal clean pass rate of 71 percent across 340 audited rooms in year 2 against a 90 percent internal standard, and a separate audit of 84 terminal cleans of contact precautions rooms found a sporicidal agent used in 62 percent.

The events are not distributed the way a house-wide rate implies. Twenty-one of the 49 year 2 events occurred on one 28-bed medical unit that accounts for 9,880 of the 63,110 patient days, or 16 percent of the census. That is 2.1 hospital-onset events per 1,000 patient days on that unit against 0.53 per 1,000 across the rest of the hospital, a fourfold difference the aggregate number makes invisible. The same unit carries the highest high-risk antibiotic use in the building at 268 days of therapy per 1,000 days present and the lowest terminal clean pass rate at 64 percent. Three panels of this dashboard point at the same 28 beds, and no panel is drawn at unit level, so nobody had seen that until this analysis.

What the Dashboard Conceals and What It Never Measured

An honest reading has to say that part of the rise is measurement rather than disease. Testing volume rose from 511 nucleic acid amplification tests in year 1 to 902 in year 2, a 76 percent increase, while positivity fell from 6.7 percent to 5.4 percent. A rate that rises while positivity falls is the signature of testing more rather than transmitting more, because the tested population expanded faster than the count of positives. A review of the 902 year 2 tests found 268 of them, 30 percent, collected from patients who had received a laxative or an osmotic agent within the preceding 48 hours, which the guidelines describe as testing that cannot separate infection from colonization (McDonald et al., 2018). Reporting the 41 percent rise without that testing history would be a true number used to support a false conclusion.

Saying part of the rise is artifact is not the same as saying the problem is imaginary, and a dashboard read carelessly in either direction fails the organization. The standardized infection ratio adjusts for facility characteristics and for testing method, and it still moved from 0.88 to 1.24 (Centers for Disease Control and Prevention, 2024). Absolute counts rose by 15 cases against a census that grew by 3 percent. The 27 percent rise in high-risk antibiotic days of therapy is an exposure change, not a counting change. The concentration on one unit that also holds the worst cleaning audit in the building is a transmission pattern, not a laboratory pattern. The conclusion is layered: the size of the increase is overstated by testing behavior, and a real increase remains after that correction.

Two things this dashboard does not measure deserve to be named before any initiative is proposed. Nothing on it records the interval between a contact precautions order and the moment precautions are actually in place, so the organization cannot say whether an identified patient is isolated in two hours or in ten. Nothing on it separates community-onset from hospital-onset cases at unit level, so a unit that admits cases looks the same as a unit that generates them. Both gaps decide whether a proposed intervention could ever be shown to work. A dashboard is not only a report on performance; it is a statement about which failures an organization has decided it is able to detect (Provost & Murray, 2022).

Proposed Initiative, Measures, and Interprofessional Ownership

The initiative the data justifies is narrow, staged, and aimed at the 28-bed unit first. Its aim is to reduce hospital-onset C. difficile infection on that unit from 2.1 to 1.0 per 1,000 patient days within twelve months while reducing high-risk antibiotic days of therapy house-wide from 214 to 170 per 1,000 days present. The first intervention is diagnostic stewardship, because the fastest correction available is to stop ordering tests that cannot be interpreted: an order entry rule blocks C. difficile testing when a laxative has been given within 48 hours or the stool is documented as formed, with an override requiring a recorded discussion with the infectious diseases pharmacist. The second is twice-weekly prospective audit and feedback on the target unit plus a mandatory antibiotic time-out at 48 to 72 hours (Centers for Disease Control and Prevention, 2019; Agency for Healthcare Research and Quality, 2022).

The third intervention is environmental and belongs to environmental services rather than to nursing: a sporicidal agent for daily as well as terminal cleaning of every room under contact precautions, with 20 audited rooms per unit per month and results posted by unit. The fourth builds the missing measure by timestamping the contact precautions order and the arrival of the isolation cart, with a target of 90 percent within two hours. Ownership crosses four budgets and is named accordingly. The infectious diseases pharmacist owns audit and feedback, the microbiology laboratory director owns the test rule, the environmental services director owns cleaning, and the unit nurse manager owns isolation timing, with all four reporting into one antimicrobial stewardship committee (The Joint Commission, 2022). The incremental cost is near $82,000 a year for a 0.5 full-time equivalent pharmacist and sporicidal supplies, which twelve avoided cases would repay at the finance office estimate of $14,800 per hospital-onset case.

Measurement is where a proposal earns or loses its credibility. Six measures run monthly against the two-year baseline described above: unit hospital-onset rate per 1,000 patient days, house-wide standardized infection ratio, high-risk days of therapy per 1,000 days present, the proportion of tests meeting appropriateness criteria, sporicidal use in contact precautions cleans, and isolation within two hours. Two balancing measures keep the diagnostic rule honest, because a rule that blocks tests lowers the rate whether or not it lowers infection: the count of patients whose test was deferred and who then test positive within seven days, and time from admission to treatment for confirmed cases. The committee should be told in advance which result would be a false success. If the rate falls while the deferred-test count rises, this initiative has improved counting rather than care, and the next cycle has to start from that finding.

References

Agency for Healthcare Research and Quality. (2022). AHRQ safety program for improving antibiotic use: Acute care. U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention. (2019). Core elements of hospital antibiotic stewardship programs. U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention. (2024). National Healthcare Safety Network (NHSN) patient safety component manual. U.S. Department of Health and Human Services.

McDonald, L. C., Gerding, D. N., Johnson, S., Bakken, J. S., Carroll, K. C., Coffin, S. E., Dubberke, E. R., Garey, K. W., Gould, C. V., Kelly, C., Loo, V., Shaklee Sammons, J., Sandora, T. J., & Wilcox, M. H. (2018). Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66(7), e1-e48.

Provost, L. P., & Murray, S. K. (2022). The health care data guide: Learning from data for improvement (2nd ed.). Jossey-Bass.

The Joint Commission. (2022). New and revised requirements for antibiotic stewardship (R3 Report). The Joint Commission.