Hospitals are, first and foremost, a place for healing—but for far too many patients, they can quickly become a source of serious infection. Every day, healthcare teams work to safeguard people at their sickest and most vulnerable. Still, invisible threats can slip through the cracks.
One of the most persistent, prevalent, and dangerous risks is Clostridioides difficile, or C. diff, a bacterium that causes an infection of the colon. If introduced to the body through the mouth, the bacteria multiply and cause symptoms ranging from watery diarrhea to life-threatening colon damage. C. diff is most commonly contracted in hospital settings where germs spread easily, and people are already at a high risk of infection.1
Understanding C. diff, how it spreads, and why it thrives in care settings is key to reducing its impact on patients. At Presbyterian Rust Medical Center in New Mexico, Josh Moffitt, an Advanced Clinical Performance Nurse with Sound, helped develop and implement a multidisciplinary protocol with the hospital’s quality, infection control, and infectious disease teams. The protocol uses targeted, evidence-based prevention strategies to help reduce hospital-onset C. diff cases, protect patients, and reinforce the most fundamental clinical promise: to do no harm.
Five steps to help reduce C. diff in a hospital:
1. Lock test-ordering to clinicians.
Effective C. diff prevention begins with disciplined testing practices. By locking C. diff test ordering to clinicians and enforcing a “no verbal order” policy, hospitals can limit unnecessary or inappropriate tests before they happen. Requiring an infection prevention (IP) huddle after each order is another important testing norm. The huddle creates a natural pause point and brings clinicians, nursing staff, and infection prevention teams together to review risk factors and symptoms. The collaboration reinforces testing stewardship and ensures testing is reserved only for clinically indicated cases. The result: fewer false positives, more accurate diagnoses, and system-wide commitment.
2. Adopt a “first three midnights” rule.
Based on guidance from the National Healthcare Safety Network, hospitals looking to reduce C. diff should allow testing of initial diarrheal stool only during the first three midnights. If colonization/community onset is detected, teams can start contact/spore precautions as soon as possible. Sticking to the three-midnight window is critical, so revert to stricter testing criteria and isolation precautions once that window has closed. Other things to remember: no testing on formed stool and avoid repeating tests.
3. Run mandatory case reviews.
If a C. diff case emerges in the hospital, hold case reviews within seven days of diagnosis. To close the loop with the prescribing clinician and nurse, use a standardized checklist to screen for high-risk factors. These factors include issues addressed above—verbal testing orders, inappropriate stool sample testing, and unnecessary testing.
4. Stand up cross-functional C. diff governance.
Creating a hospital committee dedicated to upholding norms and clinical culture around C. diff reduction builds accountability, strengthens support, and increases adherence to guidelines. Committees like this bring together infection prevention, nursing, physicians, environmental services, and pharmacy teams. By meeting monthly as a diverse caregiver collective, multiple perspectives can review test orders, results, epidemiology, and unit hygiene. Teams stay informed, and individuals stay aligned on prevention processes.
5. Implement a 5×5 cleaning protocol.
This hygiene protocol is the best way to destroy C. diff bacteria before they have a chance to make patients sick. Every five hours, have nursing teams wipe down five high-touch areas around their patients’ hospital rooms. Common infection-spreading spaces include bed rails, overbed tables, door handles, light switches, and keyboards. Audit the practice regularly and build incentives by posting results and celebrating wins.
Making a difference, one step at a time
Since implementing this protocol in 2021, Presbyterian Rust Medical Center saw a 47% decrease in C. diff cases over three years. Read the full case study on their efforts here.
Improvement is possible, and a solution to C. diff thrives when teams share governance and accountability, build reliable routines over time, and have clear and structured processes around testing and hygiene.
1Information courtesy of Mayo Clinic