2013 Healthcare‐Associated Infections in North Carolina Quarterly Report – January 2013 Healthcare Consumer Version N.C. Department of Health and Human Services NC Division of Public Health, HAI PreventNio.nC .P Hroegarlathmc a re‐AssociatedN ICn HfeAcIt Qiounasr tPerrelyv Reenptioornt ‐P Jraonguraarym 2 013 N.C. Communicable Disease Branch Introduction The U.S. Centers for Disease Control and Prevention (CDC) estimates that 5 percent of all hospital admissions result in a healthcare‐associated infection, culminating in approximately 1.7 million infections and 99,000 deaths each year1 as well as $28–33 billion in excess costs.2 In North Carolina, approximately 33,000 individuals contract healthcare‐associated infections in acute care hospitals each year, resulting in approximate direct costs to facilities ranging from $281 million to $779 million dollars.3 These numbers likely underestimate the true burden of healthcare‐ associated infections because they include only a subset of acute care hospitals and healthcare‐ associated infections. The prevention of healthcare‐associated infections is a public health priority in North Carolina and is a collaborative effort among the healthcare and public health communities. This January 2013 Healthcare‐Associated Infections Quarterly Report is an important product of this collaboration and represents the first public reporting of healthcare‐associated infections statewide, as required by North Carolina General Statute 130A‐150 and North Carolina Administrative Code Rule 41A .0106. Included in this report is information about infections occurring in North Carolina acute care hospitals during January 1st –June 30th, 2012. Data included in this report are preliminary and subject to change. While this report only includes data from acute care hospitals, other facility types including rehabilitation, long term acute care, and state psychiatric will be added to future reports. These reports will be released on a quarterly basis, during the months of January, April, July, and October. The next quarterly report will provide an annual summary of 2012 healthcare‐associated infections in acute care hospitals. This report focuses on three important types of healthcare‐associated infections that may occur while patients are hospitalized: central line‐associated bloodstream infections, catheter‐associated urinary tract infections, and surgical site infections (specifically those following abdominal hysterectomies or colon surgeries). These three types of infections account for a large proportion of illnesses and deaths attributed to healthcare, but they do not represent the full spectrum of healthcare‐associated infections. Information about other types of healthcare‐associated infections ‐ including those caused by methicillin‐resistant Staphylococcus aureus (MRSA) and by Clostridium difficile ‐ will be included in future reports. This report was prepared by the North Carolina Healthcare‐Associated Infections Prevention Team, which is located in the Communicable Disease Branch of the Epidemiology Section of the North Carolina Division of Public Health. The NC Healthcare‐Associated Infections Prevention Program works to eliminate preventable infections in health care settings by: 1 Klevens RM, Edwards JR, Richards CL, Jr., et al. Estimating health care‐associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. Mar‐Apr 2007;122(2):160‐166. Available at http://www.cdc.gov/hai/burden.html. 2 Scott R. The Direct Medical Costs of Healthcare‐Associated Infections in U.S. Hospitals and the Benefits of Prevention. Internal Report. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention; February 2009. Available at http://www.cdc.gov/hai/burden.html. 3 NC‐DHHS. Estimates for Cost of Healthcare‐Associated Infections (HAIs) in North Carolina Acute Care Hospitals: Report from the Economic Impact Subgroup of the North Carolina Department of Public Health HAI Advisory Group; 2011. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 i 1. Conducting statewide surveillance for selected HAIs; 2. Providing useful, unbiased information to health care providers and consumers; 3. Promoting and coordinating prevention efforts; and 4. Responding to outbreaks in health care settings. We hope that the information in this report will be useful to healthcare consumers. Data are intended to provide readers with an understanding of the burden of healthcare‐associated infections in N.C. as well as an opportunity to evaluate infection rates across the state. Prevention tips are also provided so readers can take steps to minimize their risk of a healthcare‐associated infection. A separate healthcare provider version with additional details is also available at http://epi.publichealth.nc.gov/cd/diseases/hai. We welcome your feedback to improve the usefulness of future reports ([email protected]). For more information on Healthcare‐Associated Infections and the N.C Healthcare‐Associated Infection Prevention Team, please visit http://epi.publichealth.nc.gov/cd/diseases/hai. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 ii Acknowledgements The North Carolina Healthcare‐Associated Infection Prevention Team would like to acknowledge and thank hospital infection preventionists across the state who work tirelessly to protect patients from infection. They provided the data used to create this report and worked with their hospital colleagues to identify and reconcile any potential problems with the data. The recent successes in fighting healthcare‐associated infections would not have been possible without their continuing efforts, dedication, and collaboration. The Healthcare‐Associated Infection Prevention Team would also like to recognize the contributions of the Healthcare‐Associated Infections Advisory Group members listed in Appendix A. In particular, the team is grateful to the Subgroup on Reporting and Surveillance for their thoughtful feedback on the presentation and content of the Quarterly Reports. Finally, the team would like to acknowledge our partners from the North Carolina Hospital Association (NCHA), the North Carolina Statewide Program for Infection Control and Epidemiology (NC SPICE) and the North Carolina Chapter of the Association for Professionals in Infection Control and Epidemiology (APIC) who have been important leaders and strong supporters of surveillance and prevention programs for healthcare‐associated infections in North Carolina. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 iii Table of Contents Introduction ................................................................................................................................................................................. i  Acknowledgements ............................................................................................................................................................... iii  Definitions ................................................................................................................................................................................... v  Acronyms .................................................................................................................................................................................. vii  I.  Surveillance for Healthcare‐Associated Infections in North Carolina ..................................................... 1  II.  Overview of the Hospital‐Specific Summary Reports ..................................................................................... 2  Section Overview ................................................................................................................................................................ 2  Section 1 – General Hospital Information ............................................................................................................ 2  Section 2 – Central line‐associated bloodstream infections (CLABSI) .................................................... 3  Section 3 – Catheter‐associated urinary tract infections (CAUTI) ............................................................ 4  Section 4 – Surgical site infections (SSI) .............................................................................................................. 5  Section 5 – Commentary from Hospital ................................................................................................................ 6  III.  Hospital‐Specific Summary Reports ................................................................................................................. 7  APPENDIX A. N.C. Healthcare‐Associated Infections Advisory Group APPENDIX B. Similarly‐Sized Hospitals in North Carolina, 2011 National Healthcare Safety Network Annual Facility Survey NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 iv Definitions Term Definition ASA Class Anesthesiologist’s pre‐operative assessment of the patient’s physical condition, using the American Society of Anesthesiologists’ (ASA) Classification of Physical Status. 1. Normally healthy patient 2. Patient with mild systemic disease 3. Patient with severe systemic disease that is not incapacitating 4. Patient with an incapacitating systemic disease, constant threat to life 5. Patient not expected to survive for 24 hours with or without the operation Beds The number of staffed beds in a facility or patient care location. This may be different from the number of licensed beds. Catheter days A daily count of the number of patients with an indwelling urinary catheter. For example, one patient with an indwelling catheter in place for two days or two patients with indwelling catheters in place for one day each would both result in two catheter days. This number is used when presenting rates of catheter‐associated urinary tract infections. Catheter‐associated Urinary tract infection (UTI) that occurs in a patient who had an urinary tract infection indwelling urinary catheter in place within the 48‐hour period before the onset of the UTI. Central line A catheter (tube) that doctors place in a large vein in the neck, chest, or groin to give medication or fluids or to collect blood for medical tests. Also known as a central venous catheter. Central line‐associated A bloodstream infection (BSI) that occurs in a patient who had a central bloodstream infection line within the 48‐hour period before the onset of the BSI and is not related to an infection at another site. Central line days A daily count of the number of patients with a central line. For example, one patient with a central line in place for two days or two patients with central lines in place for one day each would both result in two central line days. This number is used when presenting rates of central line‐associated bloodstream infections. Device days A daily count of the number of patients with a specific device (e.g., central line, umbilical catheter, ventilator, or urinary catheter) in the patient care location. Healthcare‐associated Healthcare‐associated infections (HAI) are infections caused by a wide infections variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 v Term Definition Infant An individual ≤ 1 year of age. Intensive care unit A nursing care area that provides intensive observation, diagnosis, and therapeutic procedures for adults and/or children who are critically ill. Also referred to as critical care unit. Medical affiliation Affiliation with a medical school. There are four categories. Major – Hospital is an important part of the teaching program of a medical school and the majority of medical students rotate through multiple clinical services. Graduate – Hospital used by the medical school for graduate training programs only (i.e., residency and/or fellowships). Limited – Hospital used in the medical school’s teaching program to a limited extent. No – Hospital not affiliated with a medical school. Patient days A daily count of the number of patients in the patient care location during a specified time period. Rate Describes the speed with which disease or events occur. Surgical site infection Infection that occurs after surgery, in the part of the body where the surgery took place. Urinary catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system. Validity (data) The extent to which reported cases of a disease or event correspond accurately to cases of a disease or event in the real world. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 vi Acronyms APIC Association for Professionals in Infection Control and Epidemiology ASA American Society of Anesthesiologists CAUTI Catheter‐associated urinary tract infection CDC Centers for Disease Control and Prevention CMS Centers for Medicare and Medicaid Services CLABSI Central line‐associated bloodstream infections CDB Communicable Disease Branch CI Confidence interval DHHS Department of Health and Human Services DPH Division of Public Health HAI Healthcare‐associated Infections ICU Intensive care unit NCHA North Carolina Hospital Association NC SPICE North Carolina Statewide Program for Infection Control and Epidemiology NHSN National Healthcare Safety Network NICU Neonatal critical care unit SSI Surgical site infection NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 vii I. Surveillance for Healthcare‐Associated Infections in North Carolina Healthcare‐associated infections are infections caused by a variety of germs while receiving medical care. Hospitals report specific types of healthcare‐associated infections to the North Carolina Division of Public Health via a Centers for Disease Control and Prevention (CDC) internet‐based electronic database. These infections include central line‐associated bloodstream infections, catheter‐associated urinary tract infections, and surgical site infections occurring after an abdominal hysterectomy or colon surgery. These infections are only reported for patients in the hospital and not for patients in outpatient settings such as clinics, outpatient surgical centers or dialysis facilities. By North Carolina law, hospital reporting requirements are based on the reporting requirements established by the Centers for Medicare and Medicaid Services. The first healthcare‐associated infection reporting requirement went into effect on January 1, 2012, when acute care hospitals began reporting central line‐associated bloodstream infections, catheter‐associated urinary tract infections, and surgical site infections. Additional hospital types – long‐term acute care hospitals and rehabilitation hospitals – began reporting central line‐associated bloodstream infections and catheter‐associated urinary tract infections in October 2012; this information will be included in future quarterly reports. In January 2013, acute care hospitals will begin reporting laboratory confirmed bloodstream infections caused by methicillin‐resistant Staphylococcus aureus (MRSA) and infections caused by Clostridium difficile (C. diff). This information will also be included in future quarterly reports. To learn more about central line‐associated bloodstream infections, catheter‐associated urinary tract infections, and surgical site infections, please visit the N.C. Healthcare‐Associated Infections – Facts & Figures website at http://epi.publichealth.nc.gov/cd/hai/figures.html. In addition to information about specific infections, there is a link to the October 2012 Quarterly Report, which contains background information on healthcare‐associated infections surveillance in N.C. and detailed information on statistics commonly used to describe and summarize healthcare‐associated infections. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 1 II. Overview of the Hospital‐Specific Summary Reports The following pages are the hospital‐specific summary reports for healthcare‐associated infections that acute care hospitals reported from January to June, 2012. Before reviewing the hospital‐ specific summary reports, please read this section which contains helpful information and explanations. Each hospital has a one‐page summary that contains five sections: 1) general hospital information, 2) central line‐associated bloodstream infections, 3) catheter associated urinary tract infections, 4) surgical site infections, and 5) commentary from the hospital. These sections are described in detail below. Before elaborating on each section, two clarifications about the data need to be made: 1. The data are preliminary. Although efforts were made by hospitals and the N.C. Healthcare‐ Associated Infections Prevention Program to ensure that the data were accurate and complete, a formal validation of the data has not been performed. Data validation is a process by which data from hospitals are carefully reviewed to ensure that they meet established criteria and standards for reporting. If these criteria and standards are not met, over‐reporting or under‐ reporting can occur giving a distorted presentation of what is occurring in the hospital. Until data validation is completed, data are preliminary and should be interpreted with caution. Collaboration with partners is anticipated in the coming year to discuss data validation options. 2. The rates of infections are not included in some places. Approximately 25% of reporting hospitals in N.C. are small hospitals with less than 100 beds. These hospitals are likely to have low numbers of central line days, catheter days, and surgeries. Calculating rates with small numbers in the denominator can be misleading. Therefore the N.C. Healthcare‐Associated Infections Prevention Program chose to present only the actual number of infections for units, hospitals, and/or surgeries that did not meet a minimum threshold value for the reporting period; rates are not presented. The minimum threshold numbers for the reporting period are based on CDC recommendations for reporting healthcare‐associated infection data.  Central‐line associated bloodstream infections: 50 central line days  Catheter‐associated urinary tract infections: 50 catheter days  Surgical site infections: 20 surgeries Section Overview Tables and figures from hospital‐specific summary reports have been included in the following sections to provide a pictorial representation of data. These tables and figures do not represent one single hospital and are used as examples to highlight key points. Section 1 – General Hospital Information This section contains general information about the hospital and includes a map of where the hospital (blue “H” icon) is located in N.C. Data in this section are from the National Healthcare Safety Network (NHSN) 2011 Annual Hospital Survey. The surveys are completed once a year; the 2012 Annual Hospital Survey will be completed by hospitals in 2013. NC Division of Public Health, HAI Prevention Program NC HAI Quarterly Report ‐ January 2013 2