Intended for healthcare professionals

Practice Quality Improvement Report

Reducing Clostridium difficile infection in acute care by using an improvement collaborative

BMJ 2010; 341 doi: (Published 21 July 2010) Cite this as: BMJ 2010;341:c3359
  1. Maxine Power, national improvement adviser1,
  2. Neil Wigglesworth, specialty registrar in public health2,
  3. Emma Donaldson, quality improvement fellow3,
  4. Paul Chadwick, consultant microbiologist3,
  5. Stephen Gillibrand, pharmacist3,
  6. Donald Goldmann, professor of paediatrics; senior vice president45
  1. 1Department of Health, London SE1 6LH
  2. 2NHS East Lancashire, Nelson BB9 8AS
  3. 3Salford Royal NHS Foundation Trust, Salford M6 8HD
  4. 4Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
  5. 5Institute for Healthcare Improvement, 20 University Road, Cambridge, MA 02138
  1. Correspondence to: M Power maxine.power{at}


    Problem In 2006, despite a focus on infection control, Salford Royal had the fourth highest rate of Clostridium difficile infection in north west England.

    Design Interrupted time series in five collaborative wards (intervention group) and 35 non-collaborative wards (control group).

    Setting University teaching hospital with 850 acute beds.

    Key measures for improvement Number of cases of C difficile infection per 1000 occupied bed days.

    Strategies for change In February 2007, a newly formed antimicrobial team led the implementation of revised guidelines in all wards and departments. From March to December 2007, five wards participated in an improvement collaborative. Since December 2007, the changes from the collaborative have been collated and implemented throughout the organisation.

    Effects of change At baseline the non-collaborative wards had 1.15 (95% CI 1.03 to 1.29) cases per 1000 occupied bed days. In August 2007 cases reduced 56% from baseline (0.51, 0.44 to 0.60), which has been maintained since that time. In the collaborative wards, there were 2.60 (2.11 to 3.17) cases per 1000 occupied bed days at baseline. A shift occurred in April 2007 representing a reduction of 73% (0.69, 0.50 to 0.91) from baseline, which has been maintained.

    Lessons learnt Careful use of antimicrobial drugs is important in reducing the number of cases of C difficile infection. A collaborative learning model can enable teams to test and implement changes that can accelerate, amplify, and sustain control of C difficile.


    • We thank E Francis Cook, Harvard School of Public Health, Boston, and the departments of infection control and performance, Salford Royal Hospitals NHS Trust, for their help and support.

    • Contributors: MP and NW were involved in the design and delivery of the programme and analysis of data; ED and SG were involved in analysis of the data and management of knowledge; PC was involved in the design and delivery of the antimicrobial interventions and analysis of data; DG was involved in the design of the programme and analysis of data. All authors were involved in manuscript preparation. MP and DG are guarantors.

    • Funding: Salford Royal NHS Foundation Trust.

    • Competing interests: All authors have completed the unified competing interest form at (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

    • Ethics approval: Not needed.

    • Provenance and peer review: Not commissioned; externally peer reviewed.

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