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Indicator Metadata

NameIn-Hospital Infections Due to Clostridium difficile (C. difficile)
Short/Other Names

In-Hospital C. difficile Infections

DescriptionRisk-adjusted rate of Clostridium difficile (C. difficile) infections identified during a hospital stay
InterpretationA lower rate for this indicator is desirable. However, higher rates should be interpreted with caution, as they may indicate better surveillance.
HSP Framework Dimension

Health System Outputs: Safe

Areas of Need

Getting Better

Geographic Coverage

All provinces/territories

Reporting Level/Disaggregation

National, Province/Territory, Region, Facility

Indicator Results

Accessing Indicator Results on Your Health System: In Depth

Identifying Information
NameIn-Hospital Infections Due to Clostridium difficile (C. difficile)
Short/Other Names

In-Hospital C. difficile Infections

Indicator Description and Calculation
DescriptionRisk-adjusted rate of Clostridium difficile (C. difficile) infections identified during a hospital stay
Calculation: Description

The risk-adjusted in-hospital C. difficile infection rate is calculated by dividing the observed number of discharges with in-hospital C. difficile infections in each hospital by the expected number of discharges with in-hospital C. difficile infections in the hospital and multiplying by the Canadian average in-hospital C. difficile infection rate.

The indicator is expressed as the number of hospital discharges with a post-admission diagnosis of C. difficile infection per 10,000 patient days.

The unit of analysis is a hospital discharge.

Calculation: Geographic Assignment

Place of service

Calculation: Type of Measurement

Rate - Rate — per 10,000 patient days

Calculation: Adjustment Applied

The following covariates are used in risk adjustment:
Age, sex, immunocompromised states, comorbidity score, transfer from acute care hospitals

For detailed descriptions of the above covariates and the risk-adjustment method, please refer to the In-Hospital Infections Appendices.

Calculation: Method of Adjustment

Logistic regression

Denominator

Description:
Number of patient days in an acute care institution within a fiscal year
Inclusions:
1. Admission to an acute care institution (Facility Type Code = 1)
2. Sex recorded as male or female
3. Length of stay of 3 days and longer
Exclusions:
1. Abstracts with an invalid age
2. Abstracts with invalid admission or discharge dates
3. Abstracts with admission category of stillbirths and cadaveric donors (Admission Category Code = R or S)
4. Abstracts with selected mental health diagnoses (i.e., most responsible diagnosis ICD-10-CA code of F10–F99)
5. Infants younger than 1 year at admission

Numerator

Description:
Discharges with enterocolitis due to C. difficile identified during a hospital stay
Inclusions:
Enterocolitis due to C. difficile (ICD-10-CA: A04.7) as type (2)

Background, Interpretation and Benchmarks
Rationale

C. difficile infections are associated with longer patient lengths of stay, higher mortality rates and increasing health care costs. The transmission of C. difficile can be effectively controlled by following best practices (e.g., hand hygiene) and implementing other infection control standards.

This indicator measures the risk-adjusted rate of enterocolitis due to C. difficile identified during a hospital stay in all acute care hospitals across Canada. CIHI engaged with clinical expert advisors across the country to develop definitions and risk-adjustment methodologies that will ensure comparability of the indicator results across acute care facilities.

The Canadian Nosocomial Infection Surveillance Program (CNISP) network provides crude rates and trends of health care–associated infections from 60 sentinel Canadian facilities using standardized definitions. Many jurisdictions have surveillance programs to capture hospital-acquired C. difficile infections, and some submit the data to their ministries; however, each jurisdiction has its own set of case definitions, thus hampering comparability across jurisdictions. Where possible, case definitions for CIHI’s in-hospital indicators were aligned with definitions developed and revised by the CNISP.

CIHI’s suite of in-hospital infections indicators is not a replacement for surveillance programs
because of the different purposes of both data sets. Rather, these indicators will complement existing surveillance programs by
–Enabling pan-Canadian reporting at the national, provincial, regional and facility levels;
–Helping facilities and jurisdictions monitor their in-hospital infections rates and allowing them
to compare against the Canadian average (for jurisdictions) or against the national peer group average (for facilities);
–Enabling facilities/jurisdictions to track changes over time and measure the effectiveness of their improvement strategies to reduce in-hospital infections; and
–Enabling facilities and jurisdictions with limited capacity to monitor and report on in-hospital infections and to learn from others in a more efficient and less resource-intensive manner.

Interpretation

A lower rate for this indicator is desirable. However, higher rates should be interpreted with caution, as they may indicate better surveillance.

HSP Framework Dimension

Health System Outputs: Safe

Areas of Need

Getting Better

Targets/Benchmarks

Not applicable

References

Agency for Healthcare Research and Quality. Technical Specifications: Patient Safety Indicators, Appendices — Version 4.5 (PDF 5.42 MB). 2013.

Canadian Institute for Health Information. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada, Version 2015. 2015.

Daneman N, Stukel TA, Ma X, Vermeulen M, Guttmann A. Reduction in Clostridium difficile infection rates after mandatory hospital public reporting: findings from a longitudinal cohort study in Canada (PDF 534.03 KB). PLOS Medicine. July 2012.

Drosler S. Health Care Quality Indicators Project, Patient Safety Indicators Report 2009: Annex (PDF 748.20 KB). 2009.

Forster AJ, Taljaard M, Oake N, Wilson K, Roth V, van Walraven C. The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital. CMAJ. January 2012.

Ghantoji SS, Sail K, Lairson DR, et al. Economic healthcare costs of Clostridium difficile infection: a systematic review. The Journal of Hospital Infection. April 2010.

Miller MA, Hyland M, Ofner-Agostini M, et al. Morbidity, mortality, and healthcare burden of nosocomial Clostridium difficile–associated diarrhea in Canadian hospitals. Infection Control & Hospital Epidemiology. March 2002.

Oake N, Taljaard M, van Walraven C, et al. The effect of hospital acquired Clostridium difficile infection on in-hospital mortality. Archives of Internal Medicine. November 2010.

Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. American Journal of Epidemiology. March 2011.

Availability of Data Sources and Results
Data Sources

DAD, HMDB

Available Data Years

Type of Year:
Fiscal
First Available Year:
2015
Last Available Year:
2015

Geographic Coverage

All provinces/territories

Reporting Level/Disaggregation

National, Province/Territory, Region, Facility

Result Updates
Update Frequency

Every year

Indicator Results

Web Tool:


URL:
Accessing Indicator Results on Your Health System: In Depth

Updates

Not applicable

Quality Statement
Caveats and Limitations

There may be inconsistencies in the data that could limit interpretation of the indicator; these inconsistencies may be the result of differences in facility C. difficile testing/screening procedures and how the information is recorded on patient charts. Information regarding timing of the diagnosis is not available in the administrative data; therefore, the exact origin of infection cannot be established. In addition, this indicator does not measure the number of patients who tested positive for C. difficile, but rather the infections that resulted during hospital stay. We control these limitations by selecting only infections captured as post-admission diagnoses and excluding hospital stays shorter than 3 days. However, due to lack of timing of diagnosis, it is also not possible to distinguish newly diagnosed infections from recurrent infections.

A good correlation between C. difficile rates using administrative data and the Ontario surveillance program has been published (Daneman et al., 2012). In collaboration with clinical expert advisors and representatives from provincial surveillance programs, CIHI undertook a series of correlation studies between provincial surveillance programs and the administrative database. An excellent correlation was found between C. difficile cases reported by the New Brunswick surveillance program and those identified by the administrative database. A similar correlation was observed between C. difficile cases reported by the Alberta surveillance program and in-hospital C. difficile infection cases identified in the administrative database (unpublished results).

Although we acknowledge the data limitations of administrative data to report on in-hospital infections, results of this indicator can be viewed as a starting point for tracking progress on patient safety and data quality of both surveillance and administrative databases.

Trending Issues

Not applicable

Comments

Not applicable