Here’s How One Nephrology Unit Cut Hospital-Acquired C. Diff by 90%

An inpatient nephrology unit reduced hospital-acquired Clostridioides difficile (C. diff) infections by 90% after implementing nurse-driven protocols.

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 9 per 10,000 patient-days by November, representing a 73% drop in cases. From December 2023 through 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 U.S. 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 explained.

“A root cause analysis helped to identify that nephrology patients were at an increased risk of C. diff,” they wrote. “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 3 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 explained. “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 signaled 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 coordinated 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
• 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 is “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,” they stated.