Hospital-Acquired Infections - New York State 2014
HOSPITAL-ACQUIREDINFECTIONSNew York State20144New York StateNew York State Department of Health, Albany, NYOctober 2015
Table of ContentsList of Abbreviations . 3Executive Summary . 5Background . 25Hospital‐Acquired Surgical Site Infections (SSIs) . 27Colon Surgical Site Infections. 29Coronary Artery Bypass Graft (CABG) Surgical Site Infections . 38Hip Replacement/Revision Surgical Site Infections . 48Abdominal Hysterectomy Surgical Site Infections . 57Central Line‐Associated Bloodstream Infections (CLABSIs) . 71Catheter‐Associated Urinary Tract Infections (CAUTIs) . 82Clostridium difficile Infections (CDI) and Multi-drug Resistant Organisms . 85Clostridium difficile Infections (CDI) . 85Multidrug Resistant Organisms (MDROs) . 101Carbapenem‐resistant Enterobacteriaceae (CRE) Infections . 102Methicillin‐resistant Staphylococcus aureus (MRSA) Infections . 116Other MDROs . 118Mortality related to CDI and MDROs . 119MDRO Prevention Practices . 120Antimicrobial Stewardship . 121Comparison of NYS HAI Rates with National HAI Rates. 123Infection Prevention Resources . 124HAI Prevention Projects . 131Hospital Success Stories . 135Recommendations and Next Steps . 139Appendix 1: Glossary of Terms . 141Appendix 2: Methods . 147Data Validation . 147Risk Adjustment . 149Costs . 151Attributable Mortality of CDI/MDROs . 151Comparison of NYS and CMS HAI Reporting. 152Appendix 3: Central line‐associated bloodstream infection rates by ICU type . 154Appendix 4: List of Hospitals by County . 166Acknowledgements . 171References . 1722
List of AbbreviationsASA – American Society of Anesthesiologists’ classification of physical statusASP – Antimicrobial stewardship programBMI – Body mass indexBSI – Bloodstream infectionCABG – Coronary artery bypass graft surgeryCAUTI – Catheter-associated urinary tract infectionCDC – Centers for Disease Control and PreventionCDI – Clostridium difficile infectionC. difficile – Clostridium difficileCeph – CephalosporinCHG –Chlorhexidine gluconateCI – Confidence intervalCIC – Certified in infection controlCL – Central lineCLABSI – Central line-associated bloodstream infectionCLSI - Clinical Laboratory Standards InstituteCMS – Centers for Medicare and Medicaid ServicesCNS – Coagulase negative staphylococcusCO – Community onsetCO-NMH – Community onset-not my hospitalCO-PMH – Community onset-possibly my hospitalCRE – Carbapenem-resistant EnterobacteriaceaeCSRS – Cardiac Surgery Reporting SystemDOH –Department of HealthDU– Device utilizationDUA – Data use agreementEVD – Ebola Virus DiseaseEIA – Enzyme immunoassayEMR – Electronic medical recordHAI – Hospital-acquired infectionHO – Hospital onsetICD-9 – International Classification of Diseases, Ninth RevisionICU – Intensive care unitIP – Infection preventionistIQR – Inpatient quality reportingLabID – Laboratory identifiedLOS – Length of stayLTAC – Long term acute careLTCF – Long term care facilityMDRO – Multidrug resistant organismMRSA – Methicillin-resistant Staphylococcus aureusMSSA – Methicillin sensitive Staphylococcus aureusNAAT – Nucleic acid amplification testNICU – Neonatal intensive care unit3
NHSN – National Healthcare Safety NetworkNYS – New York StateNYSDOH – New York State Department of HealthNYSPQC – New York State Perinatal Quality CollaborativeOR – Operating roomOS – Organ/space InfectionPAD – Peripheral artery diseasePDS – Post-discharge surveillancePHL – Public health lawRFA – Request for applicationsRPC – Regional Perinatal CenterSIR – Standardized infection ratioSPARCS - Statewide Planning and Research Cooperative Systemspp – species (plural)SSI – Surgical site infectionTAW – Technical Advisory WorkgroupUTI – Urinary tract infectionVRE – Vancomycin-resistant Enterococci4
Executive SummaryHospital-acquired infections (HAIs) result in prolonged hospital stays, unnecessary deaths,increased antimicrobial resistance, greater healthcare costs, and added emotional and personalcosts to patients and their families. This report summarizes HAI rates in New York State (NYS)hospitals in 2014. It is the eighth annual report to be issued since reporting began in 2007following the implementation of Public Health Law 2819. All NYS HAI reports are available ospital/hospital acquired infections/. These dataare available for download at https://health.data.ny.gov/.In 2014, 178 NYS acute care hospitals reported HAI data to meet NYS requirements. Hospitalsreport to NYS using the Centers for Disease Control and Prevention’s (CDC’s) NationalHealthcare Safety Network (NHSN). This online system allows hospitals, NYS, and CDC toconcurrently monitor the same data. Table 1 summarizes the number of infections and infectionrates by type of infection in 2014 and identifies whether the data were required by NYSDOH, theCenters for Medicare and Medicaid Services (CMS), or both. Community-onset infections (i.e.infections identified on the first three days of a hospital admission and therefore likely acquiredbefore admission) are not the primary focus of the HAI Reporting Program, but they impact thedevelopment of HAIs in the hospital setting. The most common type of HAI reported wasClostridium difficile infections (CDIs), followed by surgical site infections (SSIs), catheterassociated urinary tract infections (CAUTIs), methicillin-resistant Staphylococcus aureus(MRSA) bloodstream infections (BSI), central line-associated bloodstream infections(CLABSIs), and carbapenem-resistant Enterobacteriaceae (CRE) bloodstream infections.5
Table 1. Infections reported by New York State hospitals in 2014Type of infectionNumberBClostridium difficile infections (CDIs) among inpatientsHospital-onset, incident8,890Community onset9,913Surgical site infections (SSIs) followingColon surgeryB1,361BAbdominal hysterectomy surgery361N319Hip replacement or revision surgeryN183Coronary artery bypass graft (CABG) - chest siteNCABG - donor site53Catheter-associated urinary tract infections (CAUTIs)in intensive care unitsC1,703Methicillin-resistant Staphylococcus aureus (MRSA)bloodstream infections among ntral line-associated bloodstream infections (CLABSIs)in intensive care unitsB546Carbapenem-resistant Klebsiella and E. colibloodstream infections among 7.2/10,000 patient days4.6/1,000 admissions7.1/100 procedures1.9/100 procedures1.0/100 procedures1.7/100 procedures0.6/100 procedures2.6/1,000 catheter days0.66/10,000 patient days1.0/1000 admissions0.9/1,000 line days0.22/10,000 patient days0.05/1,000 admissionsN required by NYS, C required by Centers for Medicare and Medicaid Services (CMS; these data are accessiblethrough a data use agreement but cannot be used for public reporting or regulatory action), B required by both NYSand CMS.TrendsAll reportable HAI rates have declined since public reporting began. Many factors have likelycontributed to the decline, including the attention drawn to HAIs through public reporting,ongoing efforts by infection preventionists (IPs) and other healthcare workers to improveinfection prevention practices, and the support of external partners including professionalsocieties, government agencies, and other associations. Estimates of the number of infectionsprevented and the cost savings associated with the declining HAI rates are provided in Table 2.6
Table 2. Cost savings associated with decline in HAI ratesIndicatorBaselineTotalDecline # PreventedDeclineper YearInfectionsDirect CostSavings1in 2014 dollarsColon SSICABG Chest SSICABG Donor SSIHip SSIHysterectomy SSICLABSICDI (HO)CRE (HO 10%15%57%32%13%5%7%2%7%8%8%13%N/A*N/A*557 10 to 28 million251 4 to 13 million165 3 to 8 million96 2 to 5 million3,432 37 to 147 million10,380 98 to 139 million38N/A*** Not available due to definition change. ** Costs not available for CRE BSIs.1 Cost ranges from Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits ofprevention. CDC, Division of Healthcare Quality Promotion, Atlanta GA, March 2009. Report CS200891-A.http://www.cdc.gov/HAI/pdfs/hai/Scott CostPaper.pdf. Updated to 2014 dollars.Hospital Rate SummaryTable 3 summarizes HAI rates by hospital in 2013 and 2014. The 2013 data are included againthis year in order to visualize patterns of repeated high and low performance and because therehave been some modifications as a result of further auditing of the data. The table highlightshospitals that performed significantly better (shaded blue) or worse (shaded red) than the NYSaverage, after adjusting for differences in patients’ risk for infection. Table 3 provides asummary of all hospital rates at a glance. More detailed figures in the body of this report ploteach hospital rate and confidence interval (the range around the measurement that shows howprecise the measurement is). Those graphs can make it easier to understand why similar ratesmay or may not be flagged as significantly different because they graphically show both the rateand the width of the confidence interval compared to the state average.Across 16 indicators in the 178 facilities, there were 79 (2.7%) red flags (57 of these were red forthe first year, 21 were red for two consecutive years, and one was red for three consecutiveyears). IPs were required to submit improvement plans to NYSDOH to address each red flag.The details of the response and NYS involvement increase based on the number of consecutiveyears flagged high, following the NYSDOH HAI Reporting Program’s Policy for Facilities withConsecutive Years of High HAI Rates.Additional HighlightsInfection Prevention Staffing Resources – The average full time equivalent (FTE) IP in NYS isresponsible for 125 acute care beds, or an aggregate measure equivalent to 239 acute care bedsafter including other hospital locations such as dialysis centers. Facilities with low IP resources,defined in this report by the 15th percentile, are encouraged to review the responsibilities of their7
IPs to ensure that staffing levels are appropriate. The review should take into consideration therange of the clinical programs, the risks of the patient population, the scope of the duties coveredby the IPs, and the availability of information technology to assist with surveillance functionsand reporting requirements.Mortality – NHSN does not collect information on whether or not HAIs result in death. Basedon estimates of the percent of patients who die as a result of HAIs from literature review,approximately 2,000 deaths were attributable to community- and hospital-onset CDIs andmultidrug resistant organism (MDRO) infections in 2014. This greatly exceeds the number ofdeaths due to other well-known infections such as AIDs and influenza.Data Validation – NYS continued to audit the NHSN data to ensure that the data in this reportare accurate and meaningful. In the last complete year of audits (July 2013 to June 2014), over6,000 records from 50% of hospitals were reviewed, and auditors agreed with the reported data93% of the time. Disagreements were discussed with the IPs and corrected in NHSN. Accuracywas lowest for our newest indicator, CRE. NYS reviewed CRE surveillance definitions with allhospitals and provided suggestions to improve collaboration between infection prevention andthe clinical microbiology laboratory.Comparison of NYS HAI rates with national HAI rates – CDC reports suggest that NYS HAIrates are higher than national HAI rates. However, the intensity of auditing performed byNYSDOH exceeds the intensity of auditing performed by other states and CMS in terms of thenumber of hospitals audited, the number of records audited in each hospital, and the methodsused to efficiently target records most likely to have errors. In general, the data validationprocess is likely to increase HAI rates because missed infections are identified and entered intothe NHSN, and training efforts increase the skills of the hospital IPs, leading to betteridentification of HAIs.HAI Prevention Projects – NYS funded five new HAI Prevention Projects with non-profit healthcare organizations starting in April 2014. These projects seek to reduce CDI and MDROinfection rates.Success Stories – NYS highlighted the achievements of two hospitals for their outstanding workin preventing HAIs in 2014: Upstate University Hospital for preventing CLABSIs, andChamplain Valley Physicians Hospital for preventing CDIs.8
Recommendations and Next StepsNYSDOH will continue to monitor and report hospital HAI rates to encourage continuedreduction in HAIs. Following the NYSDOH HAI Program’s policy on hospitals that havesignificantly high rates (available ospital/hospital acquired infections/), HAI staffwill continue to work with hospitals that are underperforming to ensure that they implementeffective improvement plans and show progress in decreasing rates. HAI staff will also continueto notify hospitals of current issues in surveillance and infection prevention practices throughemail communication and webinars.NYSDOH will continue to work with the HAI Technical Advisory Workgroup (TAW) to seekguidance on the selection of reporting indicators, methods of risk adjustment, presentation ofhospital-identified data, and overall planning for the reduction in HAIs in NYS.NYSDOH will continue to conduct medical record audits to verify appropriate use ofsurveillance definitions and accurate reporting by hospitals. Valid data are important for theanalysis of variation in HAI rates within the state, as well for the analysis of NYS rates incomparison with other states’ rates. Differences in audit coverage and thoroughness across thecountry currently results in inequitable comparisons of hospital and state average rates.NYSDOH will continue to discuss audit methodology with CDC and CMS and advocate thatinformation on auditing be incorporated into performance evaluations.Because CDI impacts the greatest number of people in NYS, reducing CDI rates continues to be ahigh priority. NYSDOH will continue to monitor the improvement plans of the hospitals flaggedwith high CDI rates to encourage improvement and provide assistance as requested. NYSDOHstarted a new project to improve infection prevention during nursing home and hospital caretransitions. Through use of webinar presentations, NYSDOH will continue to educateparticipants on evidence-based infection prevention and control practices.Efforts to combat the spread of CRE in NYS healthcare facilities have expanded as a result ofnew CDC funding. An Antimicrobial Resistance/CRE Workgroup has been established with theintent of creating a statewide CRE/MDRO surveillance and response plan. Strategies to enhanceoutbreak investigation reporting and response; improve surveillance; implement and evaluateepidemiologic public health practice, prevention, and control strategies; and sustain and enhancelaboratory diagnostic capacity for CRE have been put in place. Healthcare facilities will beprovided with updated information regarding hospital, regional and statewide CRE rates as wellas CRE prevention resources. Those facilities identified with high CRE rates will be contactedand offered assistance by the state CRE Prevention Coordinator. These visits will includediscussion on a variety of topics including facility-wide CRE surveillance and preventionpractices, barriers to implementation, antibiotic stewardship activities, and other strategiesintended to reduce facility incidence rates.9
Antimicrobial resistance is a growing concern in NYS. Hospitals and long term care facilitiesare encouraged to review their antimicrobial stewardship efforts, compare them with CDCguidelines, and take action to implement programs concordant with those guidelines.Involvement and engagement of clinical leadership and technical experts are critical toestablishing a successful stewardship program. N
1.0/100 procedures 1.7/100 procedures 0.6/100 procedures Catheter-associated urinary tract infections (CAUTIs) in intensive care unitsC 1,703 2.6/1,000 catheter days Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections among inpatientsC Hospital-onset Community-onset 858 2,324 0.66/10,000 patient days 1.0/1000 admissions
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Various infection control programmes and organizations help to lower the risk of an infection during and after the period of hospitalization. Key-words: Urinary tract infections, Hospital Acquired Infections, Ro
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