Clostridioides Difficile Infection

Identifying Attributes

Care Settings
Rehabilitation Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)
Type of Quality Indicator
Outcome
IOM Quality Dimension
Safety
Domain
Governance

Defining Attributes

Definition

Number of observed hospital onset Clostrioides difficile infections (CDI) compared to expected events.

Numerator

Total number of observed hospital-onset CDI Laboratory Identified (LabID) events among all inpatients in the facility.

Denominator

Total number of expected hospital-onset CDI LabID events determined through the facility's number of inpatient days, bed size, affiliation with a medical school, microbiological test used to identify C. difficile, and community onset CDI admission prevalence rate.

Exclusions

Numerator: well baby-nurseries and NICUs.

Use of Risk Adjustment
Yes
Risk Adjustments

Risk-adjusted with Reliability-Adjusted Rankings (ARM).

Stratifications

Data Attributes

Type of Data Collection
Standardised clinical data
Data Collection Methods

Data submitted via the Centre of Disease Control and Prevention's National Healthcare Safety Network (NHSN). Which is a secure, Internet-based surveillance system that expands and integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention. Some U.S. states use NHSN as a means for healthcare facilities to submit data on healthcare-associated infections (HAIs) and other healthcare measures mandated through their specific state legislation.

Frequency of Data Collection
Quarterly
Frequency of Data Collection in Days
91
Reporting Methods

Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
Indicator Has Recommended Targets
No

Source and Reference Attributes

Evidence Source

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information. Accessed August 3, 2023. Available from: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/irf-quality-reporting/irf-quality-reporting-program-measures-information-.

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual. Accessed August 3, 2023. Available from: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf.

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient rehabilitation facilities - The Measures. Accessed August 3, 2023. Available from: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures.

Centers for Disease Control and Prevention (CDC), United States. National Healthcare Safety Network (NHSN) Multidrug-Resistant Organism & Clostridioides difficile Infection (MDRO/CDI) Module. Accessed August 3, 2023. Available from: www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf.

Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025