S368 Inpatient Clostridiodes difficile Disposition and Isolation: A Performance Metrics and a Quality Improvement Project

Introduction: Clostridioides difficile is a highly contagious infection affecting over 500,000 individuals annually, with 30,000 deaths. CDC guidelines recommend initiating contact isolation when C. difficile is suspected. At our hospital, isolation is triggered automatically when a C. difficile test is ordered. However, tests are often ordered after just 1–2 loose stools, sometimes in patients on stool softeners, leading to potentially unnecessary isolation and delayed dispositions—particularly in the Emergency Department—impacting hospital flow and metrics. This quality improvement (QI) project evaluates the appropriateness of holding patient disposition and initiating isolation solely based on C. difficile test orders, aiming to assess whether physicians can override these holds when clinical suspicion is low. Methods: We conducted a retrospective electronic health record review of C. difficile test orders from August 11, 2024 to September 10, 2024. Each case was assessed for alternative diagnoses, prior C. difficile history, and risk factors. Physician documentation was reviewed to determine if C. difficile was an active clinical consideration. Positive polymerase chain reaction and/or toxin tests confirmed diagnosis. Descriptive analysis was performed using Microsoft Excel. Results: A total of 93 patients with C. difficile test orders were identified during the study period, with 2 excluded due to unclear or insufficient documentation. Of the remaining cases, 59 (65%) showed that providers were actively considering C. difficile as a diagnosis. Risk factors were present in 65 (71%) patients, 72 (79%) had a potential alternative diagnosis, and only 8 (9%) had a prior history of C. difficile. Providers correctly suspected C. difficile in 24 (41%) cases, while 8 (25%) cases were not initially suspected. Interestingly, 20 (28%) patients diagnosed with C. difficile had clinical notes suggesting an alternative diagnosis, and only 4 (50%) C. difficile positive patients had a prior history of the infection. Conclusion: Our study suggests that providers often face challenges in accurately predicting C. difficile infections based on patient history, symptoms, and previous infections. When a C. difficile test is ordered, the patient should be placed in isolation right away. If the patient is in a shared room, arrangements should be made for their transfer to a private room. While patient flow is a critical metric in the emergency department, if a C. difficile order is placed, it is essential to temporarily pause disposition until a private room becomes available for the patient's safety.