Health Care Associated Infections in Massachusetts Acute Care Hospitals

Health Care Associated Infections in Massachusetts Acute Care HospitalsFourth Public Update: Calendar Year 2012 January 1, 2012-December 31, 2012Released May 2014

*IntroductionThe Massachusetts Department of Public Health (MDPH) developed this data update as a component of the Statewide Infection Prevention and Control Program created pursuant to Chapter 58 of the Acts of 2006.

Massachusetts law provides the Department of Public Health with the legal authority to conduct surveillance, and to investigate and control the spread of communicable and infectious diseases. (MGL c. 111,sections 6 & 7)

The Department implements this responsibility in hospitals through the hospital licensing regulation. (105 CMR 130.000)

This is the fourth in a series of public updates representing a component of larger efforts to reduce preventable infections in health care settings. It presents an analysis of progress on infection prevention within Massachusetts acute care hospitals, and is based upon work supported by state funds and the Centers for Disease Control and Prevention (CDC).

*Background Massachusetts licensure regulations require acute care hospitals to report specific HAI related data to the Centers for Disease Control and Preventions National Healthcare Safety Network (NHSN).

NHSN is a secure, internet-based surveillance system for healthcare facilities to submit information about HAI and to monitor patient safety.

NHSN offers:Use of standardized definitionsBuilt-in analytical tools User training and supportIntegrated data quality checks

NHSN is free to all participants. It is the primary data collection tool used for HAI reporting by more than 3,000 acute care facilities across the country.

*Methods This data summary includes statewide and hospital-specific measures for central line associated bloodstream infections (CLABSI) and specific surgical site infections (SSI) for the 2012 calendar year (January 1, 2012 December 31, 2012).

January 1, 2009January 1, 2011January 1, 2012New State ComparatorCalendar Year 2012Calendar Year 2011Calendar Year 2010Calendar Year 2009January 1, 2010Previous State Comparator All data were extracted from NHSN on July 29, 2013

Central line associated bloodstream infection National baseline data are from 2010 State comparator data has been shifted to January 1, 2010 through December 31, 2011

Surgical site infectionNational baseline data are based on a statistical risk model derived from national data

*Central Line Associated Bloodstream Infections (CLABSI)Comparisons made to state comparator and national baseline

Surgical Site Infection (SSI) Comparison made to the national baseline only (smaller sample size)

Standardized Infection Ratio (SIR)*

* When the actual number is equal to the predicted number the SIR = 1.0Central Line Utilization Ratio

Measures

*What is an SIR?The standardized infection ratio (SIR) is a summary measure used to track HAIs over time. It compares actual HAI rates in a facility or state with baseline rates derived from aggregate data in NHSN. The CDC adjusts the SIR for risk factors that are most associated with differences in infection rates. In other words, the SIR takes into account that different healthcare facilities treat patients with differences in disease type and severity.

What does it mean?

Please visit the CDC NHSN website for more information: http://www.cdc.gov/nhsn/Understanding SIRs

SIR is less than 1SIR is 1SIR is greater than 1The number of infections reported is lower than the number of predicted infections.The number of infections reported is the same as the number of predicted infections.The number of infections reported is higher than the number of predicted infections.May represent robust HAI prevention strategies.May reflect a need for stronger HAI prevention efforts.

*How to Interpret SIRs and 95% Confidence Intervals (CIs)The green horizontal bar represents the SIR, and the blue vertical bar represents the 95% confidence interval (CI). The 95% CI measures the probability that the true SIR falls between the two parameters. If the blue vertical bar crosses 1.0 (highlighted in orange), then the actual rate is not statistically significantly different from the predicted rate. If the blue vertical bar is completely above or below 1.0, then the actual is statistically significantly different from the predicted rate.Not significantly different than predictedSignificantly lower than predictedSignificantly higher than predicted

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*Acute Care Hospital Statewide Summary

*Central Line-Associated Bloodstream Infection (CLABSI)

Calendar Year 2012: January 1, 2012 December 31, 2012

*CLABSI Criteria DefinitionsNHSN groups CLABSIs into three categories:

Criterion 1 infectionRecognized true pathogen from one or more blood cultures Organism is not related to an infection at another site

Criterion 2, 3 infectionPathogen identified is commonly found on the skinOrganism causing infection is found in two or more blood cultures drawn on separate occasionsPatient is symptomatic of blood infectionCriteria 3 applies only to patients 1 year of age

*

Massachusetts Criteria 1, 2, and 3 CLABSI Rates Compared to National Baseline Rate, by ICU Type January 1, 2012-December 31, 2012

Key Findings

Four ICU types had a significantly lower rate of infection compared to the national baseline: Medical (T)Medical/surgical (NT)Pediatric medical/surgicalSurgical (T)

One ICU type had a significantly higher rate of infection compared to the national baseline:Burn

NT=Not major teachingT= Major teaching

Chart1

4.371.362.56

3.210.10.89

1.470.550.94

0.850.420.61

0.90.390.61

1.30.340.71

1.410.190.61

1.270.330.69

2.40.010.43

10.240.53

0.890.40.61

2.470.010.44

1.240.430.77

1.180.120.46

Upper limit

Lower limit

SIR

ICU Type

SIR

Sheet1

ICU TypeBurnMedical (NT)Medical CardiacMedical (T)Medical/surgical (NT)Medical/surgical (T)NeurosurgicalPediatric CardiothoracicPediatric MedicalPediatric Medical/SurgicalSurgical (T)Surgical (NT)Surgical CardiothoracicTrauma

Upper limit4.373.211.470.850.91.31.411.272.410.892.471.241.18

Lower limit1.360.10.550.420.390.340.190.330.010.240.40.010.430.12

SIR2.560.890.940.610.610.710.610.690.430.530.610.440.770.46

*Massachusetts Criterion 1 CLABSI Rates Compared to National Baseline Rate, by ICU Type January 1, 2012-December 31, 2012Key Findings

Criterion 1 rates of infection mirror those of Criteria 1, 2, and 3 combined (see previous slide)


Chart1

4.371.292.5

3.80.121.05

1.280.380.74

0.690.280.46

0.520.20.34

1.30.250.63

1.460.150.57

1.560.40.85

2.680.010.48

0.880.120.38

0.920.370.61

3.090.010.56

0.530.150.3

1.20.080.41

Upper limit

Lower limit

SIR

ICU Type

SIR

Sheet1

ICU TypeBurnMedical (NT)Medical CardiacMedical (T)Medical/surgical (NT)Medical/surgical (T)NeurosurgicalPediatric CardiothoracicPediatric MedicalPediatric Medical/SurgicalSurgical (T)Surgical (NT)Surgical CardiothoracicTrauma

Upper limit4.373.81.280.690.521.31.461.562.680.880.923.090.531.2

Lower limit1.290.120.380.280.20.250.150.40.010.120.370.010.150.08

SIR2.51.050.740.460.340.630.570.850.480.380.610.560.30.41

*Massachusetts Criteria 1, 2 and 3 CLABSI Rates Compared to State Comparator*, by ICU Type January 1, 2012-December 31, 2012Key Findings

CLABSI rates by ICU type are comparable to or lower than the state comparator

*The state comparator is calculated from data reported by Massachusetts acute care hospitals to NHSN during calendar years 2010-2011.


Chart1

2.60.811.53

1.270.470.81

1.110.390.68

1.120.560.81

0.910.390.62

1.440.370.79

1.050.270.57

2.470.341.06

1.9300.35

1.060.480.73

2.150.220.84

Upper limit

Lower limit

SIR

ICU Type

SIR

Sheet1

ICU TypeBurnMedical CardiacSurgical CardiothoracicMedical (T)Medical/surgical (NT)Medical/surgical (T)Pediatric Critical CareNeurosurgicalSurgical (NT)Surgical (T)Trauma

Upper limit2.61.271.111.120.911.441.052.471.931.062.15

Lower limit0.810.470.390.560.390.370.270.3400.480.22

SIR1.530.810.680.810.620.790.571.060.350.730.84

*Massachusetts Criterion 1 CLABSI Rates Compared to State Comparator*, by ICU Type January 1, 2012-December 31, 2012Key Findings

CLABSI criterion 1 rates by ICU type are comparable to the state comparator

*The state comparator is calculated from data reported by Massachusetts acute care hospitals to NHSN during calendar years 2010-2011.


Chart1

2.540.751.46

1.390.410.8

1.140.330.66

1.090.450.73

1.070.420.69

1.440.280.7

10.170.46

3.260.341.27

5.150.020.93

1.650.671.09

2.450.170.84

Upper limit

Lower limit

SIR

ICU Type

SIR

Sheet1

ICU TypeBurnMedical CardiacSurgical CardiothoracicMedical (T)Medical/surgical (NT)Medical/surgical (T)Pediatric Critical CareNeurosurgicalSurgical (NT)Surgical (T)Trauma

Upper limit2.541.391.141.091.071.4413.265.151.652.45

Lower limit0.750.410.330.450.420.280.170.340.020.670.17

SIR1.460.80.660.730.690.70.461.270.931.090.84

*Massachusetts Criteria 1, 2, and 3 CLABSI Infection Rates Significantly Different from State Comparator* January 1, 2012-December 31, 2012*The state comparator is calculated from data reported by Massachusetts acute care hospitals to NHSN during calendar years 2010-2011.

HospitalICU TypeBSICentral Line DaysBSIs per 1,000 Central Line daysPredicted EventsState Baseline RateSIR & 95% Confidence IntervalCompared to PredictedHeywood HospitalMedical/ surgical (not major teaching)35495.460.540.995.54 (1.14-16.19)HigherUMass Memorial Medical Center Medical (major teaching)17,2610.149.911.370.10 (0.00 - 0.56)Lower

*Massachusetts Criterion 1 CLABSI Infection Rates Significantly Different from State Rate January, 1 2012-December 31, 2012

HospitalICU TypeBSICentral Line DaysBSIs per 1,000 Central Line daysPredicted EventsState Baseline RateSIR & 95% Confidence IntervalCompared to PredictedBoston Childrens HospitalPediatric Medical/Surgical26,2160.327.501.210.27 (0.03 0.96)LowerUMass Memorial Medical CenterMedical (major teaching)17,2610.146.940.960.14 (0.00 0.81)Lower

*CLABSI Adult & Pediatric ICU Pathogens for CY2011 and CY2012Calendar Year 2011January 1, 2011 December 31, 2012n=175Calendar Year 2012January 1, 2012 December 31, 2012n=208

Chart1

32

50

39

28

15

14

11

19

Gram-negative bacteria16%

Gram-positive bacteria (other)5%

MRSA5%

BSI

Adult & Pediatric 2011

PathtypeCOUNTPERCENT

Candida and other Yeast/Fungus3215.38

Coagulase-negative Staphylococcus5024.04

Enterococcus sp.3918.75

Gram-negative bacteria (other)2813.46

Gram-positive bacteria (other)157.21

Methicillin-resistant Staphylococ146.73

Multiple Organisms115.29

Staphylococcus aureus (not MRSA)199.13






Gram-positive bacteria (other)148




SSI

COUNT

2009201020112012Total

Candida and other Yeast/Fungus13105

Coagulase-negative Staphylococcus172722167

Gram-negative bacteria (other)2431241594


Methicillin-resistant Staphylococcus aureus (MRSA)333418489

Multiple Organisms2932309100

No Organism Identified34373516122

Staphylococcus aureus (not MRSA)4242521137

Total20824820857721

COUNT

2009 (n=208)2010 (n=248)2011 (n=208)2012 (n=57)Total

Candida and other Yeast/Fungus0%1%0%0%5

Coagulase-negative Staphylococcus8%11%11%2%67

Gram-negative bacteria (other)12%13%12%26%94

Gram-positive bacteria (other)13%17%13%18%106

Multiple Organisms14%13%14%16%100

No Organism Identified16%15%17%28%122

Methicillin-resistant Staphylococcus aureus (MRSA)16%14%9%7%89

Staphylococcus aureus (not MRSA)20%17%25%2%137

Total20824820857721

CABG, KPRO, HPRO

200920102011Total









Total139181155475

HYST, VHYS

2009201020112012Total









Total69675357246

SSI

0.00480769230.08173076920.11538461540.13461538460.13942307690.16346153850.15865384620.2019230769

0.01209677420.10887096770.1250.16935483870.12903225810.14919354840.13709677420.1693548387

0.00480769230.10576923080.11538461540.1250.14423076920.16826923080.08653846150.25

00.01754385960.26315789470.17543859650.15789473680.28070175440.07017543860.0175438596

Candida and other Yeast/Fungus

Coagulase-negative Staphylococcus

Gram-negative bacteria (other)

Gram-positive bacteria (other)

Multiple Organisms

No Organism Identified

Methicillin-resistant Staphylococcus aureus (MRSA)

Staphylococcus aureus (not MRSA)

SSI Pathogens Identified Among All Procedure Types, by Fiscal Year

3

27

18

27

34

20

11

41

0

0

0

0

0

0

0

0

Chart1

22

40

36

31

14

9

13

10


Gram-positive bacteria (other)5%

MRSA5%

BSI


PathtypeCOUNTPERCENT


















SSI

COUNT

2009201020112012Total









Total20824820857721

COUNT

2009 (n=208)2010 (n=248)2011 (n=208)2012 (n=57)Total









Total20824820857721

CABG, KPRO, HPRO

200920102011Total









Total139181155475

HYST, VHYS

2009201020112012Total









Total69675357246

SSI

0.00480769230.08173076920.11538461540.13461538460.13942307690.16346153850.15865384620.2019230769

0.01209677420.10887096770.1250.16935483870.12903225810.14919354840.13709677420.1693548387

0.00480769230.10576923080.11538461540.1250.14423076920.16826923080.08653846150.25

00.01754385960.26315789470.17543859650.15789473680.28070175440.07017543860.0175438596





Multiple Organisms





3

27

18

27

34

20

11

41

0

0

0

0

0

0

0

0

*

All Massachusetts NICUs are required to report CLABSI data to NHSN (n=10)

CLABSI data are presented for each of five birth-weight categories:Neonatal Intensive Care Units (NICU)

750 g751-1,000 g> 2,500 g1,001-1,500 g1,501-2,500 g

*Massachusetts Criteria 1, 2, and 3 Central Line Infection Rates in NICUs compared to National Baseline Rates, by Birth Weight Category January 1, 2012-December 31, 2012Key Findings

CLABSI rates are not significantly different than national baseline rates.

Chart1

2.10.541.14

1.380.090.47

1.970.210.77

2.230.010.4

2.10.010.38

Upper limit

Lower limit

SIR

Birth Weight

SIR

Sheet1

Birth Weight Category750 g751-1000 g1001-1500 g1501-2500 g>2500 g

Upper limit2.11.381.972.232.1

Lower limit0.540.090.210.010.01

SIR1.140.470.770.40.38

SAS table: national_bybw_cl_allcrit_nicu

*Massachusetts Criteria 1, 2 and 3 Central Line Infection Rates in NICUs compared to State Comparator Rates, by Birth Weight Category January 1, 2012-December 31, 2012Key Findings

Infants weighing 751-1000g had a significantly lower rate of infection in 2012 as compared to 2010-2011 state data.

Chart1

1.820.480.99

10.070.34

1.270.140.5

1.230.010.22

5.080.020.91

CI_HI

CI_LO

SIR

Birth Weight

SIR

Sheet1

Birth Weight Category750 g751-1000 g1001-1500 g1501-2500 g>2500 g

CI_HI1.8211.271.235.08

CI_LO0.480.070.140.010.02

SIR0.990.340.50.220.91

SAS table: state_bybw_cl_allcrit_nicu

*CLABSI NICU Pathogens for 2011 and 2012Calendar Year 2011January 1, 2011 December 31, 2011n=32Calendar Year 2012January 1, 2012 December 31, 2012n=22

Chart1

3

12

2

5

3

7

BSI

NICU 2011




Escherichia coli515.63



BSI

CLABSI Pathogens Identified in NICUs, by Fiscal Year

SSI

CLABSI Pathogens Identified in Adult and Pediatric ICUs, by Fiscal Year

COUNT

2009201020112012Total









Total20824820857721

COUNT

2009 (n=208)2010 (n=248)2011 (n=208)2012 (n=57)Total









Total20824820857721

CABG, KPRO, HPRO

200920102011Total









Total139181155475

HYST, VHYS

2009201020112012Total









Total69675357246

00000000

00000000

00000000

00000000





Multiple Organisms





0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Chart1

2

11

1

1

1

2

4

BSI

NICU 2011







NICU 2012

pathtypeCOUNTPERCENT






MRSA29.09


BSI

CLABSI Pathogens Identified in NICUs, by Fiscal Year

SSI

CLABSI Pathogens Identified in Adult and Pediatric ICUs, by Fiscal Year

COUNT

2009201020112012Total









Total20824820857721

COUNT

2009 (n=208)2010 (n=248)2011 (n=208)2012 (n=57)Total









Total20824820857721

CABG, KPRO, HPRO

200920102011Total









Total139181155475

HYST, VHYS

2009201020112012Total









Total69675357246





Multiple Organisms





*State Central Line (CL) Utilization Ratios*Key FindingsEfforts are being made to discontinue unnecessary CLs to reduce the risk for infection.

CL utilization in adult and pediatric ICU types has remained relatively unchanged since the start of public reporting. Neonatal ICUs have decreased their CL utilization by 22% since 2009.

*The CL utilization ratio is calculated by dividing the number of CL days by the number of patient days.

Chart1

0.540.530.23

0.530.530.21

0.530.550.2

0.520.560.18

Adult

Pediatric

Neonatal

Calendar Year

Utilization Ratio

Sheet1

2009201020112012

Adult0.540.530.530.52

Pediatric0.530.530.550.56

Neonatal0.230.210.20.18

*State CLABSI SIRKey Findings

Documented progress toward CLABSI elimination

Aggregated data for adult, pediatric, and neonatal ICUs had an SIR below 1 in 2012, indicating that fewer infections were seen at Massachusetts ICUs than predicted by national baseline data

Chart1

1.011.441.55

0.850.631.22

0.830.591.14

0.70.590.75

Adult

Pediatric

Neonatal

Calendar Year

SIR

Sheet1

2009201020112012

Adult1.010.850.830.7

Pediatric1.440.630.590.59

Neonatal1.551.221.140.75

*CLABSI SummaryThe majority of Massachusetts ICUs have rates of infection significantly lower than, or comparable to, 2010 national baseline rates published by the CDC in 2011. Adult and pediatric ICUs have a significantly lower rate of infection as compared to the national baseline for the past three years (2010-2012). Massachusetts 47 medical/surgical ICUs (non-teaching) achieved a significantly lower rate of infection during the 2012 calendar year. 47% reduction in the rate of infection over the past two years Massachusetts experienced a significantly higher rate of infection among burn ICUs in 2012, compared with the national baseline

*Surgical Site Infections (SSI)


*Surgical Site Infections (SSI)

Coronary Artery Bypass Graft (CABG)Knee Prosthesis (KPRO)Hip Prosthesis (HPRO)


Abdominal Hysterectomy (HYST)Vaginal Hysterectomy (VHYS)


Procedures with ImplantsProcedures without ImplantsProcedures with implants of foreign bodies (such as artificial joints) are subject to later presentation of SSI, so they were followed for one year rather than the three months used as a follow-up period for procedures without implants. This delays the analyses of infection rates in these procedures.

*Procedures Requiring 1 Year of Surveillance

ProcedureCalendar YearHospitals ReportingSSIsProceduresPredicted EventsSIR & 95% Confidence IntervalCompared to PredictedCoronary Artery Bypass Graft201014453,80548.550.93 (0.67 1.24)Same201114133,25841.500.31 (0.16 0.53)LowerKnee Prosthesis2010676913,27371.490.97 (0.75 1.22)Same2011657213,16370.041.03 (0.80 1.29)SameHip Prosthesis201067649,81174.340.86 (0.66 1.09)Same201165509,77873.550.68 (0.50 0.89)Lower

*Procedures Requiring 30 Days of Surveillance

ProcedureCalendar YearHospitals ReportingSSIsProceduresPredicted EventsSIR & 95% Confidence IntervalCompared to PredictedAbdominal Hysterectomy201062435,38838.051.13 (0.81 1.52)Same201159305,05638.400.78 (0.52 1.11)Same201260385,72243.020.88 (0.62 1.21)SameVaginal Hysterectomy201055212,11611.751.79 (1.10 2.73)Higher201157242,06611.192.15 (1.37 3.19)Higher201258241,97610.302.33 (1.49 3.46)Higher

*CABG, KPRO, HPRO Pathogens for 2010-2011Calendar Year 2010January 1, 2010 December 31, 2010n=195Calendar Year 2011January 1, 2011 December 31, 2011n=131

Chart1

44

20

17

17

16

10

5

SSI

CY2011





Methicillin-resistant Staphylococcus aureus (MRSA)1712.98



No Organism Identified53.82

Other21.53

Chart1

44

33

31

29

25

19

12

SSI

CY2010









Other21.03

*HYST, VHYS Pathogens for 2011-2012Calendar Year 2011January 1, 2011 December 31, 2011n=52Calendar Year 2012January 1, 2012 December 31, 2012n=64

Chart1

0

20

15

15

11

1

1


SSI

CY2011


0







Other11.56

Chart1

24

10

8

6

3

1

SSI

CY2010








*Statewide SSI Trends by YearStatistically Higherthan PredictedStatistically the Sameas PredictedStatistically Lower than PredictedCABGKPROHPROKey Findings

CABG statistically lower than predicted in 2011

KPRO statistically the same as predicted for all years

HPRO statistically lower than predicted in 2011

Trend for CABG, KPRO and HPRO, 2009 - 2011

Chart1

2

2

1

CABG

Statewide_FEB2013

Massachusetts 2012 HAI Data Report

Statewide Hospital Summary

Report Release Date: April 2013

Hospital Survey Statistics 2011

Small HospitalMedium HospitalLarge Hospital

*Statewide SSI Trends by YearTrend for HYST and VHYS, 2009 - 2012 Statistically Higherthan PredictedStatistically the Sameas PredictedStatistically Lower than PredictedCABGKPROHPROKey Findings

HYST statistically the same as predicted for all years

VHYSsignificantly higher than predicted for all years

HYSTVHYS

Chart1

3

3

3

3

VHYS

Statewide_FEB2013

Massachusetts 2012 HAI Data Report

Statewide Hospital Summary

Report Release Date: April 2013

Hospital Survey Statistics 2011

Small HospitalMedium HospitalLarge Hospital

*Summary of SSI ResultsVHYSCABG HPROKPRO HYSTSignificantly Higher than PredictedSame as PredictedSignificantly Lower than Predicted

*Vaginal Hysterectomy Workgroup Comprised of 18 key stakeholders and representatives from hospitals identified as outliers and high performers.Regional representation from both large and small hospitals.Workgroup provided guidance and direction on the approach to understanding the significance of elevated SIRs for VHYS procedures.Infection PreventionHealth Care QualityEpidemiologySurgeonsWorkingGroup

*Vaginal Hysterectomy WorkgroupFacilitated by MDPH staff, the work group developed a mission statement, defined the scope of work and assisted in the development and pilot testing of survey and audit instruments.

Gather hospital-based information about policy, best practices, pre- and post-operative care, and reporting mechanismsGather detailed procedure-specific information beyond what is provided by NHSN

*IP and Surgeon Surveys

Surgeon-specific Experience and training Procedure type and volume Operative techniques utilized

Procedure-specific Antibiotic usage Pre-op bathing and skin prep Post-operative patient instruction

Policy-specific SSI prevention methods Tracking SSI Reporting SSI

*IP and Surgeon SurveysA total of 60 hospitals were eligible for the survey.

Received 45 surveys from infection preventionists* (representing 47 hospitals) for a response rate of 75%.

Received 108 completed surveys from eligible surgeons.

Analyses of the survey and audit tool are intended to identify surgical procedural issues or lapses in the implementation of prevention best practices that may be contributing to the higher than expected rate of infections and ultimately lead to recognition of areas for targeted improvement.

*Infection preventionists are trained in the principles of hospital epidemiology and are responsible for the surveillance, analysis, interpretation, reporting and prevention of healthcare associated infections (HAI).

*Audit Hospitals were asked to complete audits of up to five patients who developed a post-surgical infection in the 30 days following an abdominal or vaginal hysterectomy procedure, as well as two corresponding controls per case.

*Audit: Status UpdateReceived completed audits from 36 of 42 eligible hospitals (86% compliance)110 cases and 222 controls in all170 abdominal hysterectomy (HYST) and 162 vaginal hysterectomy (VHYS)

Preliminary data analysis completeNeed to further analyze the data and incorporate survey results to see bigger picture

*Audit: Procedure TypesVHYS162 audits53 cases // 109 controlsCases represent 60% of all VHYS infections over the included timeframeHYST170 audits57 cases // 113 controlsCases represent 44% of all HYST infections over the included timeframe

Procedure typeFrequency%Total vaginal9127.4Lap-assisted (laparoscopic)8124.4Lap-assisted (open incision)6118.4Total abdominal8826.5Other/missing113.3

*Audit: AnalysisAssessed if the high state rate was being driven by a small number of poor performersDetermined the effect of cases being misclassified as the wrong procedure typeAnalyzed potential risk factors for infectionCancer statusBody Mass Index (BMI)Robotic surgeryExplored potential causes for the higher than expected number of infections seen in VHYS procedures

*Audit: OutliersWhen the 5 hospitals with the highest VHYS SIRs are removed from the state totals the SIR is still significantly higher than expected. The high state SIR is not being driven exclusively by outliers.

Determine if a small number of hospitals with high SIRs are inflating the state total

Hospitals# Procedures# InfectionsSIR95% CIAll9,7491132.121.74 2.54Removing 5 hospital with the highest SIRs7,886811.911.51 2.37

*Audit: Case MisclassificationAs Coded in NHSNCorrectedOdds Ratio = 0.9695% CI = 0.61 1.52Odds Ratio = 0.9695% CI = 0.61 1.53When corrected for misclassification, there is no change in the likelihood of infection following a VHYS procedure.

CaseControlVHYS53109HYST57113

CaseControlVHYS61120HYST4993

*Audit: MisclassificationOnly a sample, but it does not appear that misclassification is the cause.

Reveals the challenge in properly coding these events.

Will reach out to hospitals with misclassified procedures to correct this.

*Audit: Potential Risk Factors Body Mass Index (BMI)BMI was not found to be significantly different between VHYS cases and controls.Comparing BMI in VHYS cases and controls (as coded in NHSN)

TypenMeanp-valueControl7529.80.63Case4029.1

*Audit: Potential Risk FactorsCancerCancer status for all procedures (as coded in NHSN)Cancer was noted in 14% of the study populationOdds Ratio = 0.7195% CI = 0.35 1.44Cancer was not found to have a significant effect on the likelihood of developing a SSI following a hysterectomy procedure.

*Audit: Potential Risk Factors Robotic SurgeryOdds Ratio = 0.72 95% CI = 0.31 1.70Robotic surgery status for all procedures (as coded in NHSN)Robotic surgery was noted in 9% of the study populationRobotic surgery was not found to have a significant effect on the likelihood of developing a SSI following a hysterectomy procedure.

CaseControlRobot821No Robot99188

*Audit Findings

Current findings:Analyses to date have not revealed a conclusive cause for the higher than expected rate of VHYS

Next steps:MDPH will continue to analyze patient and procedural risk factors and their interactions to determine causation for this finding, and will continue to work with providers to address high infection rates.

*Healthcare Associated Infection Prevention

*Prevention Activity Since 2009, MDPH has sponsored programs to support HAI infection prevention.

Early efforts led to a 25% reduction in C. difficile infections (CDIs) among participating programs.

Leveraging statewide prevention, surveillance and reporting activities, MDPH expanded HAI prevention initiatives by developing and implementing a cross-continuum approach to infection prevention and antibiotic resistance.

Current efforts address the challenge of unnecessary antibiotic use in elderly long term care residents, decreasing an important risk factor for CDI and antibiotic resistance.

*2012-2013 Collaborative MDPH has partnered with the MA Coalition for the Prevention of Medical Errors and Mass Senior Care on this initiative;

Participants include improvement teams from 31 long term care facilities (LTCFs) and 10 hospital emergency departments;

The goal of this work was to reduce unnecessary urine testing and subsequent antibiotic use for suspected urinary tract infection (UTI), in the context of a high false positive rate for urine tests in elderly LTCF residents.

*2012-2013 Collaborative MethodsLeveraging existing relationships;

Convening a program team with critical skill sets for success;

Engaging committed multi-disciplinary teams from facilities across the continuum of care;

Encouraging a QI approach with small tests of change and ongoing measurement to monitor progress;

Offering multiple opportunities for learning;

Providing individual coaching;

Developing materials and tools based on principles of behavioral science and adult learning to support facility level efforts and decision making;

Data collection and analysis to evaluate progress.

*2012-2013 LTCF Results:

Comparison of baseline (July October 2012) to program period (November 2012 June 2013)*28% decrease in urine cultures;33% reduction in reported UTIs;47% reduction in healthcare acquired C. difficile after intervention. *Data are for 17 Long-Term Care Facilities with complete reporting

Incidence Rate RatioConfidence IntervalC. difficile Cases0.55(0.39-0.78)Urinary Tract Infections0.67(0.55-0.72)Urine Culture Rate0.73(0.66-0.79)

*Next Steps

2013-2014 initiative will be a continuation of work to reduce unnecessary urine testing and subsequent antibiotic use for suspected UTI.

Program expansion to include patients in long term acute care hospitals.

*Data Update Dissemination Plan

MDPH has contacted CQOs (or CMOs) at facilities that were high and low outliers prior to public release

MDPH will continue to work with hospitals and additional state and national organizations in a comprehensive effort to address these largely preventable infections.

This update will be available on the MDPH website:www.mass.gov/dph/dhcq

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Documents

Health Care Associated Infections in Massachusetts Acute Care Hospitals