530. The Perfect Storm for Improved Standardized Infection Ratio (SIR)—Recognizing More Community-onset Clostridium difficile Infections Increases the Expected Number of C. difficile Cases While also Helping to Decrease the Actual Observed Number of Hospital Onset C. difficile Cases

It is essential to recognize the true burden of community-onset (CO) Clostridium difficile infection (CDI) in hospital, not only because it prevents late recognition of CO CDI as being classified as a hospital-onset (HO) event, but also to assure appropriate contact precautions and therapeutic measures are deployed in a timely fashion. We recognized that our timely diagnosis of CO-CDI was suboptimal and sought to improve early recognition of CO-CDI. We developed an automated daily report of all patients noted to have loose stools documented in the nursing flow sheets during the first 3 days of hospitalization. This report was automatically forwarded to the nurse manager of the unit, as well as was reviewed daily, Monday–Friday, by the infection preventionists (IP) to determine whether stool testing had been sent on these symptomatic patients. If not, then the IP would call the nurse caring for the patient and encourage that a stool sample be sent ASAP and before the third hospital day was completed. With this intervention, we increased early appropriate stool testing for patients with documented loose stools during the first 3 days of hospitalization leading to a marked increase in CO-CDI, as well as a notable decrease in HO-CDI lab ID events (Figure 1). Together, the increased recognition of CO-CDI increased our expected cases/SIR denominator and decreased observed cases/SIR numerator and substantially dropped our CDI SIR from a 2 years preintervention median SIR of 1.47 to 0.95 during the five quarters since the intervention has been in effect. After several years of our CDI SIR remaining stubbornly around 1.5, we developed a system of enhanced recognition of patients who had loose stools early in their admission. This practice aided better recognition of CDI present on admission, substantially increasing our detection of CO-CDI. We also noted decreases in HO-CDI, in part secondary to no longer diagnosing patients who actually had CO-CDI later in their hospitalization and classifying CO-CDI as HO-CDI cases. In turn, we noted a remarkable decrease in our CDI SIR. J. P. Parada, Merck: Speaker’s Bureau, Speaker honorarium. A. Harrington, Biofire: Grant Investigator and Scientific Advisor, Consulting fee, Research grant and Speaker honorarium. Cepheid: Grant Investigator and Speaker’s Bureau, Research grant.