A US inpatient nephrology unit was able to reduce hospital-acquired Clostridioides difficile (C. diff) infections by 90% after implementing nurse-driven protocols, reports MedPage Today.
Between January and April 2023, Detroit’s Henry Ford Hospital nephrology unit recorded a hospital-onset C. diff infection (HO-CDI) rate of 34 per 10 000 patient-days – far above the hospital average of 3.8, Rachel Smith, RN, and colleagues reported in an NEJM Catalyst Innovations in Care Delivery case study.
After targeted interventions in May and June 2023, the unit’s HO-CDI rate fell to nine per 10 000 patient-days by November, representing a 73% drop in cases. From December 2023 to December 2024, the unit maintained this reduced rate, averaging 3.34 cases per 10 000 patient-days, reflecting a 90% reduction.
C. diff causes severe gastrointestinal symptoms, leading to nearly 500 000 US infections and 29 000 deaths annually. “Patients with chronic kidney disease and end-stage renal disease are at particularly high risk as a result of frequent antibiotic exposure, altered immunity, and gastric acid suppression,” Smith’s group wrote.
“A root cause analysis helped to identify that nephrology patients were at an increased risk of C. diff. However, it also revealed a fault in education and accountability that allowed gaps in nursing care.”
A detailed review revealed that five of eight early cases were actually community-onset C. diff (CO-CDI), which occurs within the first three hospital days, indicating infection at the time of admission. Missing documentation caused these cases to be misclassified as HO-CDI, which occurs on or after the fourth hospital day.
“In these cases, missing documentation delayed recognition of CO-CDI, leading to cases being erroneously classified as HO-CDI,” Smith and co-authors wrote. “This delay was problematic for two reasons: because it created an inaccurate picture of the risk of hospital-acquired infection and because it increased risk of transmission and delayed potential treatment.”
The two types of infections together “created a disproportionate burden of C. diff in the nephrology unit and signalled a need for targeted intervention”, they added.
Although the hospital had an electronic health record advisory and a protocol allowing registered nurses to order C. diff testing and isolation without a physician co-signature, nurses didn’t always follow it. Staff cited being too busy to implement the recommendations and a lack of perceived clinical significance.
“This highlighted the need for targeted efforts to reinforce adherence to best practices and increase awareness among nursing staff,” Smith and co-authors noted.
To address this, nursing leaders and hospital teams launched a co-ordinated intervention that involved:
- Multidisciplinary cleaning that introduced ‘Scrub-down Sundays’ to bleach-clean shared equipment and high-touch surfaces;
- Interactive education led by infection prevention and unit leadership that used real case studies to highlight missed opportunities;
- ‘Badge Buddies’ that provided staff with reference cards outlining the C. diff protocol; and
- A culture shift that enforced accountability around proper personal protective equipment (PPE) and infection control peer coaching.
Through 2025, the unit maintained a rate of 3.5 cases per 10 000 patient-days. “Of course, we still see cases occasionally: fluctuations in the data typically represent one patient with HO-CDI who has an extended length of stay,” the authors noted. “High staff turnover and high patient acuity during influenza season may also cause an increase in cases.”
Frequent re-education regarding strong infection control practice was essential to maintain great results, they added. “This strong culture of accountability, coaching, and collaborative teamwork has proven to be pivotal in the implementation of early detection strategies.”
Smith and co-authors acknowledged barriers to implementation, including nurses feeling too busy to document stool consistency or initiate isolation, and some employees viewing the protocol as extra work.
“Peer-led discussions reframed early testing as a time-saving measure that prevented downstream complications such as room moves, terminal cleans, and prolonged PPE use,” they noted.
“By empowering frontline staff, aligning workflows, and strengthening relationships, the unit … created a model that can be adapted across other units and clinical domains.”
Study details
How an Inpatient Nephrology Unit Achieved a 90% Reduction in Hospital-Onset Clostridioides difficile Infections
Rachel Ciroski, Rachel Smith, Catrice Canty-Pope, Jessica Malm and Swati Verma.
Published in NEJM Catalyst Innovations in Care Delivery on 19 August 2026
Abstract
Clostridioides difficile (C. diff) infection is one of the most common hospital-acquired infections. These highly contagious bacteria colonise the intestinal tract after normal gut flora has been disrupted, such as with the use of antibiotics or immunosuppressive agents. Patients who are experiencing an active C. diff infection often exhibit gastrointestinal symptoms, such as loose, watery stools. C. diff infection is an increasingly frequent cause of morbidity and death among adult hospitalised patients. A disproportionate number of hospital-acquired C. diff infections were attributed to a nephrology unit at Henry Ford Hospital. Through early detection, interdisciplinary collaboration, and culture change, the unit was able to reduce hospital-acquired C. diff infections by 90%.
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