• Some community onset cases will be assigned to trusts
  • Headline figures for trusts likely to increase
  • One trust’s medical director warns of “very stretching target”

The number of cases of C difficile reported by hospitals is expected to increase after changes in how cases are measured. 

From 1 April, cases arising in the community but in patients who have been an inpatient within the last four weeks have been treated as healthcare associated and included in acute trusts’ objectives. Cases assigned to trusts now also include patients who develop C difficile within two days of admission rather than within three days of admission, as was the case up to this year.

These changes are expected to cause the proportion of healthcare associated C difficile cases assigned to hospitals to increase to about 65 per cent of the total. Public Health England figures show just under 36 per cent of cases were assigned to hospitals for 2017-18.

Cases where the patient was not an inpatient during the last four weeks and cases where the patient has been in hospital for less than two days and had not been an inpatient in the last four weeks will continue to be recorded as community onset.

NHS Improvement announced the changes last year and detailed guidance was published this February. For many trusts, this means a dramatic increase in the number of cases which will fall within their objective. East Kent Hospitals University Foundation Trust had 41 cases last year but its objective has now increased to 95.

The trust’s medical director Paul Stevens said: “Clearly this is a very stretching target but we will continue to do everything we can to continue to reduce cases of C difficile.”

The trust was below its objectives last year and its rate is below the national average, Dr Stevens added.

Pat Cattini, president of the Infection Prevention Society, said: “Trusts should not be fearful of this. It is about continuous improvement and getting infection control right at the grassroots level.”

However, she suggested the changes may affect trusts differently depending on their patient base. Those with lots of elderly care beds were more likely to have patients who were in and out of hospital regularly so more community onset cases might be assigned to them, although this would be reflected in higher objectives.

C difficile cases have fallen significantly over the last decade as trusts have focused on better antibiotic stewardship. However, numbers have started to level out recently. “There is always going to be a low level [of cases] but I’m not sure anyone really knows what the irreducible minimum would be,” said Ms Cattini.

Trusts could also face pressure to test more patients for C difficile from next year after NHSI announced a review of testing. It said preliminary work on this indicated “marked variation” which might mask poor patient outcomes. Areas with high levels of C difficile but low levels of testing would be a particular focus.

NHSI has also said it will review financial sanctions and the “lapse in care” process ahead of its 2020-21 objective setting.