Date of Graduation

Summer 8-9-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Liesel Buckner


Background: This project focused on implementation of clostridium difficile (C. diff) education sessions at Hospital A, a not-for-profit, short-term, acute care hospital serving the Greater Sacramento community. It comprises of 241 staffed beds in the medical-surgical, telemetry, and intensive care units.

Problem: My Clinical Nurse Leader project focused on preventing hospital-acquired C. diff. At Hospital A, there were 19 hospital-acquired C. diff cases for the 2022 performance year. Of the 19 clostridium difficile cases, 12 were related to C. diff testing criteria fall-outs.

Despite huddling with staff on opportunities and providing education through health stream modules, Hospital A continues to see fallouts in their C. diff testing criteria and an increased number of hospital-acquired C. diff cases.

Intervention: To reduce hospital-acquired C. diff, my project was to implement quarterly C. diff education sessions for the medical-surgical/ telemetry staff on Acute Care Units 3 and 4. These education sessions aligned with quarterly staff meetings made up of nurses and patient care technicians.

Outcome Measure: The outcome measure for this quality improvement project was an improvement in the number of hospital-acquired C. diff cases from 19 in performance year 2022 to less than or equal to 15 by July 2023. The primary process measure was to increase C. diff testing criteria compliance from 90% to 98%.

Results: A total of 99 frontline staff across the medical-surgical and telemetry departments at Hospital A completed the C. diff testing criteria survey pre- project implementation. After educating staff on the C. diff testing criteria at the first round of staff meetings, highlighting the key areas of knowledge gaps identified in the C. diff testing survey, we have seen an increase in testing criteria compliance from 96% to 98%. Additionally, hospital-acquired C. diff rates have remained below our baseline of 19 cases in performance year 2023.

Conclusion: The implementation of the C. diff education survey and education has shown to help improve staff knowledge of the C. diff testing criteria through frontline staff engagement and collaboration with key stakeholders. As a result, Hospital A has seen an incremental improvement in their C. diff testing criteria compliance and reduction in overall hospital-acquired C. diff rates compared to the prior performance year.

Keywords: Clostridium difficile, testing criteria, nursing education, hospital-acquired

Available for download on Thursday, August 08, 2024

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