results

Combined use of Clinical, Administrative & surveillance Data to CharacterizeIncidence and Outcomes of Healthcare Associated Infections (HAI) in aHighly Computerized Integrated Healthcare system

David J. Pombo, MD1, Bert K. lopansri, MD2, Michelle Keane, Bs, MBA3, Caroline taylor, rN, MsN, CIC1, ruth Kleckner, rN1, sharon sumner, rN, BsN1, rajesh r. Mehta, rPh, Ms and John P. Burke, MD1, (1)lDs Hospital, salt lake City, ut, (2)Infectious Diseases, Intermountain Healthcare, Murray, ut, (3)enterprise Analysis Corporation, stamford, Ct

1096

Background: HAIs increase morbidity, hospitalization, and cost. Increased scrutiny has been placed on HAIs associated with use of invasive medical devices. We describe the incidence, cost, and outcomes for device and non-device related HAIs.

Methods: HAIs were detected using an electronic surveillance tool & verified using standard NHSN definitions by 3 experienced infection preventionists for all inpatient encounters, >=18 years old, between July 1, 2008 and September 30, 2010. Cases were verified by review of electronic medical records and entered into a database at two urban hospitals comprising 640 beds. Clinical, cost, and demographic data were abstracted from the Enterprisewide Data Warehouse.

results: There were 79,839 admissions from 62,647 patients representing 319,149 patient days. We identified 2707 HAIs among 2240 admissions in 2080 patients. HAIs developed in 3.3% of all patients with a rate of 8.5 HAIs/1000 patient days. A total of 1876 (90.2%) & 364 (9.8%) admissions resulted in a single or multiple HAIs, respectively. Eighty percent of all HAIs in patients who experienced a single infection were attributed to five infections: catheter associated UTIs (29.6%), surgical site infections (26%), Clostridium difficile infection (10.6%), non-ventilator healthcare associated pneumonia (8%), non-catheter associated UTIs (7.7%). The length of stay and total costs associated with these infections were (median length of stay [25th & 75th percentile], median daily total cost [25th, 75th percentile]): catheter-associated UTIs 11 days [7,18], $2,775 [$2,050, $3,835]; surgical site infections 16 days [4,11], $1,849 [$1,904, $3,224]; Clostridium difficile infection 13 days [7,19], $2,972 [$2,163, $4,011]; non-ventilator healthcare associated pneumonia 13 days [8,20], $3,606 [$2,673, $4,577]; non-catheter associated UTIs 16 days [8,25], $1,849 [$1,618, $2,436]. The median duration of hospitalization for encounters with HAI was 12 days [6,21], with a median total cost of $33,626/ patient [$15,060, $68,716].

Conclusion: Catheter associated UTIs and surgical site infections remain as the most common cause of HAIs. Clostridium difficile has become the most common microbial cause of HAIs. Nearly half of all HAIs were non-device related.

Current surveillance for HAIs in US hospitals focuses on high risk conditions, medical devices, and procedures and on the prevalence of MDROs. There are scant data on the overall incidence of HAIs that occur hospital wide although an estimated 5% of patients have HAIs(1). The CDC/Emerging Infections Program has recently reported aggregated point prevalence results for HAIs from a large number of sites(2).

The overall goal of our study is to assess the potential for enhanced targeted infection prevention based on improved understanding of underlying conditions and risk factors predisposing to HAIs. The current study provides HAI incidence rates and an analysis of both device- and non-device associated infections as well as infections due to MDROs across the entire healthcare system.

ABstrACt MetHODs

INtrODuCtION

1. Ansell Healthcare, Iselin, NJ, Jamie Ashworth and Dr. Michael Zedalis for sponsoring the study. The sponsor had no role in design, conduct or analysis or interpretation of the data. The sponsor did aid in poster preparation.

2. Susan Farber and Emery Stephans at Enterprise Analysis Corp, Stamford, CT for contribution to study design, data analysis and interpretation.

3. The Enterprise Data Warehouse team at Intermountain Healthcare.

1. Burke, J.P., Infection control - a problem for patient safety. N Engl J Med, 2003. 348(7): p. 651-6.

2. Magill S, Reassessing the burden of HAIs in U.S. hospitals. Presented in session 108: New insights in evaluating Healthcare-associated infections in the U.S. ID Week 2012, San Diego.

For this study we excluded patients with multiple HAI acquired during a hospital stay. Such patients represent a substantial segment of all HAI, but we chose to analyze single HAI occurrences initially in order to more easily define comorbidities and outcomes data for individual HAI categories. Therefore this study very clearly underestimates the actual extent of the HAI problem and costs.

We present estimates of HAI incidence in a modern, tertiary care referral center based on hospital wide surveillance for all types of infections.

Our analysis provides estimates for device and non-device associated infections, as well as for MDRO and routinely susceptible organisms across the spectrum of HAI.

One half of all HAI were non-device related. Among device related infections the highest incidence were CAUTI and CLABSI respectively, with VAP accounting for a minimal number of cases.

Catheter associated UTIs and surgical site infections were the most common cause of HAIs in our our populations. We used active surveil-lance for detection of CAUTI, and NHSN definitions current at the time of data collection.

Clostridium difficile has become the most common microbial cause of HAI.

Further analysis of underlying conditions and procedures associated with HAI, with comparison to the underlying population, can permit the development of more sophisticated prediction models for HAI.

ACKNOwleDgeMeNts

refereNCe

lIMItAtIONs

CONClusION

Contact InformationDavid J. Pombo, M.D, D(ABMM)

david.pombo@imail.org

The HELP (Health Evaluation and Logical Processing) hospital information system (HIS) serves as the clinical computing system to all of the Intermountain hospitals. We collected the data from the Enterprise Data Warehouse systems that stores clinical/surveillance data from the HELP system in addition to the administrative & finance data related to each patient encounter.

All patients >= 18 years age, admitted to LDS Hospital or Intermountain Medical Center, inpatient service between July1, 2008 and September 30, 2010 were included in the study.

Infection preventionists at Intermountain Healthcare use a locally developed database program to detect, record and confirm nosocomial infections using standard Centers for Disease Control and Prevention (CDC) definitions.

Underlying conditions and procedures were determined using ICD9 codes (International Statistical Classification of Diseases and Related Health Problems) assigned upon discharge. Most assignments such as Diabetic (Type II) include several ICD9 codes which were reviewed, grouped and confirmed by the study team.

CAUTI SSI GIT UTI VAP SSTI BSI PNEU CLABSI

N 556 487 198 145 40 122 32 150 131

Daily cost, median

[25th, 75th percentile]

$2,775[$2,050, $3,799]

$2,436 [$1,904, $3,224]

$2,972 [$2,163, $4,011]

$1,849 [$1,618, $2,436]

$4,626 [$3,777, $5,581]

$2,129 [$1,644, $3,132]

$2,530 [$2,014, $2,957]

$3,606 [$2,673, $4,577]

$3,241 [$2,690, $4,112]

Length of Stay, daysmedian

[25th, 75th percentile]

11[7, 18]

5 [4, 11]

13 [7, 19]

16 [8, 25]

21 [15, 28] 5 [2, 12] 10

[6, 15]13

[8, 20]20

[14, 35]

Mortality 3.4% 0.6% 7.1% 0.0% 22.5% 0.0% 9.4% 18.0% 9.9%

MeDIAN [INterquArtIle rANge] DAIly COst, leNgtH Of stAy AND MOrtAlIty fOr tHe HAIs.HAI retrOsPeCtIve OutCOMe stuDy

BACTERIA

Gram Negative Bacteria

Gra

m N

egat

ive

Bac

teria

Gram Positive Cocci

Gra

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ram

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fae

cium

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(A

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)

MR

SA

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ph A

Sta

phyl

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Sta

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epid

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ram

Pos

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C. D

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Bac

teriod

es fra

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Ana

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All

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Esch

eric

hia

coli

Kle

bsie

lla *

CAUTI 165 63 12 53 2 21 68 384 85 4 24 11 2 17 0 17 16 176 0 0 0 0 52 6

SSI 28 9 3 15 0 15 22 92 38 9 6 97 30 16 37 5 8 246 1 25 21 52 14 231

GIT 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 197 0 0 197 0 0

UTI 58 19 7 10 0 5 13 112 17 0 2 3 0 7 2 4 1 36 0 0 0 0 4 6

VAP 3 7 0 2 0 1 18 31 0 0 0 10 0 1 6 0 0 17 0 0 0 0 2 3SSTI 1 1 1 5 0 0 2 10 2 0 0 14 4 5 9 0 0 34 0 0 1 2 3 85

BSI 0 4 0 1 1 0 1 7 3 2 0 12 0 2 3 0 2 24 0 2 0 3 2 0

PNEU 5 3 0 6 7 3 25 49 1 0 1 19 10 2 14 0 1 48 0 0 0 0 0 83

CLABSI 8 3 0 6 0 3 2 22 5 5 0 6 21 40 4 10 18 109 0 0 3 3 6 4

URI 0 0 0 0 0 0 0 0 2 0 0 4 1 0 0 0 0 7 0 0 1 1 0 4

OTHER 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 3

269 109 23 98 10 48 152 709 153 20 33 176 68 90 75 37 46 698 198 27 26 258 83 418

Fungi

DIstrIButION Of MICrOOrgANIsMs IDeNtIfIeD By tyPe Of HAI

PR

OC

EDU

RA

L A

CTI

VIT

IES

AN

D I

NTE

RV

ENTI

ON

S

SSI GIT UTI VAP SSTI BSI PNEU CLABSI URI Other

321 88 32 32 37 8 80 31 7 1

242 68 24 17 29 6 71 19 4 0

68 16 8 11 7 1 7 8 2 0

11 4 0 4 1 1 2 4 1 1

160 99 51 26 39 20 80 32 6 3

55 71 17 40 19 9 95 47 9 0

15 53 7 38 4 7 63 37 7 0

40 18 10 2 15 2 32 10 2 0

7 34 7 26 3 4 70 27 5 0

73 27 9 8 5 2 20 19 0 1

21 19 4 7 5 3 19 10 3 0

11 25 10 6 4 2 16 13 0 2

62 15 4 4 1 3 9 4 0 0

64 10 3 4 9 1 4 5 0 1

63 10 4 2 2 1 9 7 1 0

6 18 0 10 2 1 29 17 1 0

7 7 2 6 5 2 11 8 4 0

3 7 3 6 10 2 14 4 3 0

0 7 4 14 2 2 14 11 2 0

60 0 1 0 5 0 2 0 0 0

2 4 2 0 1 0 5 26 1 0

0 1 2 0 3 1 8 3 0 0

4 7 6 4 1 2 9 3 1 0

123 86 28 29 20 12 74 99 6 2

17 21 15 16 21 4 29 11 3 0

CAUTI

211

159

43

9

317

173

87

86

68

42

48

36

22

18

14

12

41

41

17

2

9

13

34

181

106

65 85 23 11 9 4 2 27 8 0 1

Surgery

Surgery: 1 Surgery

Surgery: 2 or 3 Surgeries

Surgery 4 or more Surgeries

ER Entry

On Ventilator

On Ventilator >96 Hours

On Ventilator <96 Hours

Endotrachial Tube Insertion

Intestinal Surgery

Pleural Incision

Hemodialysis

Laparoscopy

Wound Debridement

Abdominal Paracentesis

Endoscopic Bronchial Biopsy

Cardiac Catheterization

Coronary Arteriography

Tracheostomy

C-Section

Bone Marrow Biopsy

Stent Placement

Head CT

Transfusion

Cardiothoracic Surgery

Orthopedic Surgery

PAtIeNt HAI rIsK AssessMeNt usINg ADMINIstrAtIve ICD9 PrOCeDure CODes

754

607

293 247

217 209 160

118 75

28%

50%

61%

70%

78%

86%

92% 96%

99%

0%

20%

40%

60%

80%

100%

0

100

200

300

400

500

600

700

800

CAUTI SSI GIT PNEU UTI CLABSI SSTI BSI VAP

80% of HAIs at IMC and LDS fall within these categories

Catheter Associated

Urinary Tract Infection

Surgical Site Infection

Gastro-Intestinal Infection

Ventilator Associated Pneumonia

Blood Stream Infection

Urinary Tract Infection

Skin and Soft Tissue

Infection

Central Line Associated

Blood Stream Infection

Pneumonia

Note: Upper Respiratory Infections (n=22) and Other Infections (n=4) were excluded from in-depth analysis

BreAKOut Of HAIs: All PAtIeNts, N=2,707

2,240 encounters

ITU2178%

ITUAC754 28%

ISB118 4%

GIT 293 11%

ISS607 22%

VAP 75 3%

ITSS160 6%

ISBALC209 8%

PNEU 247 9%

Bone Marrow

Transplant 87

Floors 49

Medical Surgery ICU

15

Floors 165

Neurology 107

Shock Trauma ICU

100 13%

OR 391

Labor & Delivery

86

Bariatric Surgery

64

Floors 105

Shock Trauma ICU

42

Bone Marrow

Transplant 31

Floors 59

Shock Trauma ICU

27

Bone Marrow

Transplant 26

Bone Marrow

Transplant 85

Shock Trauma ICU

27

Floors 26

Labor & Delivery

57

Cath Lab 22

Physical Therapy

12

Operating Room

26

General Floors

23

Shock Trauma ICU

12

Shock Trauma ICU

32 22% 40% 64% 36% 24% 41% 36% 22% 43%

Thoracic ICU 14

14% 23% 14% 14% 11% 13% 14% 19% 19%

Neurology/Post Stroke

14 7% 11% 11% 11% 12% 8% 10% 19%

20% or Higher

HAIs At IMC AND lDs HOsPItAl By DePArtMeNtOverAll stAtIstICs

Starting date for retrospective study July 2008

Ending date for retrospective study September 2010

Calendar time covered by study 26 months

Patients admitted during this period 62,647(IMC and LDS)

Total admissions during period 79,839(Multiple encounters for some patients at IMC and LDS)

Total patient days accumulated by patients 319,149(IMC and LDS)

Overall average length of stay 4.0 days(All patients and encounters at IMC and LDS)

Number of patients who developed HAI 2,080 3.3%

Number of HAIs acquired 2,707

Number of admissions resulting in HAIs 2,240 2.8%

LOS for HAI patients 16.42 days

Number of HAIs per 1,000 patient days 8.48