health care associated infections in massachusetts acute care hospitals
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Health Care Associated Infections in Massachusetts Acute Care HospitalsFourth Public Update: Calendar Year 2012 January 1, 2012-December 31, 2012Released May 2014
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*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).
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*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.
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*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
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*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
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*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.
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*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
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*Central Line-Associated Bloodstream Infection (CLABSI)
Calendar Year 2012: January 1, 2012 December 31, 2012
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*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
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*
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
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*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)
NT=Not major teachingT= Major teaching
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
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*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.
NT=Not major teachingT= Major teaching
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
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*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.
NT=Not major teachingT= Major teaching
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
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*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
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*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
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*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
Adult & Pediatric 2012
Candida and other Yeast/Fungus2212.57
Coagulase-negative Staphylococcus4022.86
Enterococcus sp.3620.57
Gram-negative bacteria (other)3117.71
Gram-positive bacteria (other)148
Methicillin-resistant Staphylococ95.14
Multiple Organisms137.43
Staphylococcus aureus (not MRSA)105.71
SSI
COUNT
2009201020112012Total
Candida and other Yeast/Fungus13105
Coagulase-negative Staphylococcus172722167
Gram-negative bacteria (other)2431241594
Gram-positive bacteria (other)28422610106
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
Candida and other Yeast/Fungus1315
Coagulase-negative Staphylococcus14272263
Gram-negative bacteria (other)11181140
Gram-positive bacteria (other)19272268
Multiple Organisms30341882
No Organism Identified17202360
Methicillin-resistant Staphylococcus aureus (MRSA)811827
Staphylococcus aureus (not MRSA)394150130
Total139181155475
HYST, VHYS
2009201020112012Total
Candida and other Yeast/Fungus30014
Coagulase-negative Staphylococcus1313131554
Gram-negative bacteria (other)91541038
Gram-positive bacteria (other)30047
Multiple Organisms12127940
No Organism Identified2626271695
Methicillin-resistant Staphylococcus aureus (MRSA)00011
Staphylococcus aureus (not MRSA)31217
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-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
Adult & Pediatric 2012
Candida and other Yeast/Fungus2212.57
Coagulase-negative Staphylococcus4022.86
Enterococcus sp.3620.57
Gram-negative bacteria (other)3117.71
Gram-positive bacteria (other)148
Methicillin-resistant Staphylococ95.14
Multiple Organisms137.43
Staphylococcus aureus (not MRSA)105.71
SSI
COUNT
2009201020112012Total
Candida and other Yeast/Fungus13105
Coagulase-negative Staphylococcus172722167
Gram-negative bacteria (other)2431241594
Gram-positive bacteria (other)28422610106
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
Candida and other Yeast/Fungus1315
Coagulase-negative Staphylococcus14272263
Gram-negative bacteria (other)11181140
Gram-positive bacteria (other)19272268
Multiple Organisms30341882
No Organism Identified17202360
Methicillin-resistant Staphylococcus aureus (MRSA)811827
Staphylococcus aureus (not MRSA)394150130
Total139181155475
HYST, VHYS
2009201020112012Total
Candida and other Yeast/Fungus30014
Coagulase-negative Staphylococcus1313131554
Gram-negative bacteria (other)91541038
Gram-positive bacteria (other)30047
Multiple Organisms12127940
No Organism Identified2626271695
Methicillin-resistant Staphylococcus aureus (MRSA)00011
Staphylococcus aureus (not MRSA)31217
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
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*
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
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*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
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*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
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*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
Candida and other Yeast/Fungus39.38
Coagulase-negative Staphylococcus1237.5
Enterococcus sp.26.25
Escherichia coli515.63
Gram-negative bacteria (other)39.38
Staphylococcus aureus (not MRSA)721.88
BSI
CLABSI Pathogens Identified in NICUs, by Fiscal Year
SSI
CLABSI Pathogens Identified in Adult and Pediatric ICUs, by Fiscal Year
COUNT
2009201020112012Total
Candida and other Yeast/Fungus13105
Coagulase-negative Staphylococcus172722167
Gram-negative bacteria (other)2431241594
Gram-positive bacteria (other)28422610106
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
Candida and other Yeast/Fungus1315
Coagulase-negative Staphylococcus14272263
Gram-negative bacteria (other)11181140
Gram-positive bacteria (other)19272268
Multiple Organisms30341882
No Organism Identified17202360
Methicillin-resistant Staphylococcus aureus (MRSA)811827
Staphylococcus aureus (not MRSA)394150130
Total139181155475
HYST, VHYS
2009201020112012Total
Candida and other Yeast/Fungus30014
Coagulase-negative Staphylococcus1313131554
Gram-negative bacteria (other)91541038
Gram-positive bacteria (other)30047
Multiple Organisms12127940
No Organism Identified2626271695
Methicillin-resistant Staphylococcus aureus (MRSA)00011
Staphylococcus aureus (not MRSA)31217
Total69675357246
00000000
00000000
00000000
00000000
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
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
Candida and other Yeast/Fungus39.38
Coagulase-negative Staphylococcus1237.5
Enterococcus sp.26.25
Escherichia coli515.63
Gram-negative bacteria (other)39.38
Staphylococcus aureus (not MRSA)721.88
NICU 2012
pathtypeCOUNTPERCENT
Candida and other Yeast/Fungus29.09
Coagulase-negative Staphylococcus1150
Enterococcus sp.14.55
Escherichia coli14.55
Gram-negative bacteria (other)14.55
MRSA29.09
Staphylococcus aureus (not MRSA)418.18
BSI
CLABSI Pathogens Identified in NICUs, by Fiscal Year
SSI
CLABSI Pathogens Identified in Adult and Pediatric ICUs, by Fiscal Year
COUNT
2009201020112012Total
Candida and other Yeast/Fungus13105
Coagulase-negative Staphylococcus172722167
Gram-negative bacteria (other)2431241594
Gram-positive bacteria (other)28422610106
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
Candida and other Yeast/Fungus1315
Coagulase-negative Staphylococcus14272263
Gram-negative bacteria (other)11181140
Gram-positive bacteria (other)19272268
Multiple Organisms30341882
No Organism Identified17202360
Methicillin-resistant Staphylococcus aureus (MRSA)811827
Staphylococcus aureus (not MRSA)394150130
Total139181155475
HYST, VHYS
2009201020112012Total
Candida and other Yeast/Fungus30014
Coagulase-negative Staphylococcus1313131554
Gram-negative bacteria (other)91541038
Gram-positive bacteria (other)30047
Multiple Organisms12127940
No Organism Identified2626271695
Methicillin-resistant Staphylococcus aureus (MRSA)00011
Staphylococcus aureus (not MRSA)31217
Total69675357246
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
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*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
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*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
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*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
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*Surgical Site Infections (SSI)
Calendar Year 2012: January 1, 2012 December 31, 2012
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*Surgical Site Infections (SSI)
Coronary Artery Bypass Graft (CABG)Knee Prosthesis (KPRO)Hip Prosthesis (HPRO)
Calendar Year 2011: January 1, 2011 December 31, 2011
Abdominal Hysterectomy (HYST)Vaginal Hysterectomy (VHYS)
Calendar Year 2012: January 1, 2012 December 31, 2012
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.
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*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
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*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
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*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
pathtypeCOUNTPERCENT
Staphylococcus aureus (not MRSA)4433.59
Multiple Organisms2015.27
Coagulase-negative Staphylococcus1712.98
Methicillin-resistant Staphylococcus aureus (MRSA)1712.98
Gram-positive bacteria (other)1612.21
Gram-negative bacteria (other)107.63
No Organism Identified53.82
Other21.53
Chart1
44
33
31
29
25
19
12
SSI
CY2010
pathtypeCOUNTPERCENT
Staphylococcus aureus (not MRSA)4422.56
Coagulase-negative Staphylococcus3316.92
Gram-positive bacteria (other)3115.9
Methicillin-resistant Staphylococcus aureus (MRSA)2914.87
Multiple Organisms2512.82
Gram-negative bacteria (other)199.74
No Organism Identified126.15
Other21.03
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*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
Gram-negative bacteria10%
SSI
CY2011
pathtypeCOUNTPERCENT
0
No Organism Identified2031.25
Gram-negative bacteria (other)1523.44
Gram-positive bacteria (other)1523.44
Multiple Organisms1117.19
Coagulase-negative Staphylococcus11.56
Methicillin-resistant Staphylococcus aureus (MRSA)11.56
Other11.56
Chart1
24
10
8
6
3
1
SSI
CY2010
pathtypeCOUNTPERCENT
No Organism Identified2446.15
Gram-negative bacteria (other)1019.23
Multiple Organisms815.38
Gram-positive bacteria (other)611.54
Methicillin-resistant Staphylococcus aureus (MRSA)35.77
Staphylococcus aureus (not MRSA)11.92
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*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
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*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
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*Summary of SSI ResultsVHYSCABG HPROKPRO HYSTSignificantly Higher than PredictedSame as PredictedSignificantly Lower than Predicted
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*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
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*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
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*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
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*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).
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*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.
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*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
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*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
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*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
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*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
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*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
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*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.
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*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
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*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.
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*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
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*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.
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*Healthcare Associated Infection Prevention
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*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.
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*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.
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*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.
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*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)
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*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.
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*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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