HOSPITAL-ACQUIRED INFECTIONS New York State 2011 New York State New York State Department of Health, Albany, NY September 2012 Table of Contents Executive Summary 3 Background 25 Hospital-Acquired Surgical Site Infections 26 Colon Surgical Site Infections 27 Coronary Artery Bypass Graft Surgical Site Infections 36 Hip Replacement/Revision Surgical Site Infections 47 Central Line Associated Blood Stream Infections (CLABSIs) 63 Clostridium difficile Infections 91 Comparison of NYS HAI rates with National HAI Rates 104 Cost of Hospital Acquired Infections and Savings from Reductions 106 Regional Differences 108 Infection Prevention Resources 110 NYSDOH Funded HAI Prevention Projects 118 CDC Funded HAI Prevention Project 120 Lessons Learned 121 Next Steps 122 Appendix 1: List of Abbreviations 124 Appendix 2: Glossary of Terms 126 Appendix 3: Methods 132 Appendix 4: List of Hospitals by County 140 References 142 Acknowledgements 143 2 Executive Summary This report summarizes hospital-acquired infection (HAI) rates in New York State (NYS) hospitals in 2011. It is the fifth annual report to be issued since reporting began in 2007 following implementation of Public Health Law 2819. All New York State (NYS) HAI reports are available at the following web site: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/ HAIs are infections acquired as a result of treatment in a hospital. According to the Centers for Disease Control and Prevention (CDC), there were an estimated 1.7 million healthcare- associated infections and 99,000 deaths from those infections in 2002.1 A recent CDC report estimated the annual medical costs of healthcare-associated infections in U.S. hospitals to be between $28 and $45 billion, adjusted to 2007 dollars.2 In 2011, NYS hospitals were required to report central line-associated blood stream infections (CLABSIs) in intensive care units (ICUs), surgical site infections (SSIs) following colon, hip replacement, and coronary artery bypass graft (CABG) surgeries, and Clostridium difficile (C. difficile) infections. In 2011, 177 acute care hospitals reported HAI data. Hospitals report to NYS using the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). This online system allows hospitals, NYS, and CDC to concurrently monitor the same data. The NHSN has become the standard for reporting in the United States, with 28 states using the NHSN for mandatory reporting. All states use the same surveillance definitions when reporting via NHSN. Additional information about the NHSN can be found at http://www.cdc.gov/nhsn/. Surgical Site Infection (SSI) Rates SSIs are infections that occur after an operation in the part of the body where the surgery took place.  Colon surgery is a procedure performed on the lower part of the digestive tract, which is called the large intestine or colon. In 2011, the NYS colon SSI rate was 5.3 infections per 100 procedures; this rate was 10% lower than the NYS 2007 baseline rate of 5.9 infections per 100 procedures. This decline occurred in 2008, and the NYS colon SSI rate has been stable since then.     3  Coronary artery bypass graft (CABG) surgery is a procedure performed for heart disease in which a vein or artery from the chest or another part of the body (termed the “donor site”) is used to create an alternate path for blood to flow to the heart, bypassing a blocked artery. In 2011, the NYS CABG chest site SSI rate was 1.9 infections per 100 procedures; this rate was 29% lower than the NYS 2007 baseline rate of 2.7 infections per 100 procedures. In 2011, the NYS CABG donor site SSI rate was 0.7 infections per 100 procedures; this rate was 39% lower than the NYS 2007 baseline rate of 1.1 infections per 100 procedures.  Hip replacement or revision surgery involves removing damaged cartilage and bone from the hip joint and replacing or resurfacing them with new, man-made parts. In 2011, the NYS hip SSI rate was 1.2 infections per 100 procedures; this rate has not changed since reporting began in 2008. Central Line-Associated Blood Stream Infection (CLABSI) Rates A central line is a tube that is placed into a large vein, usually in the neck, chest, arm or groin, that is used to give fluids and medications, withdraw blood, and monitor the patient’s condition. A CLABSI occurs when bacteria or other organisms enter the bloodstream through this line. CLABSI rates are monitored in eight types of intensive care units (ICUs). NYS hospitals have demonstrated dramatic improvement in CLABSI rates since reporting began. The 2011 CLABSI rates and progress compared to the NYS 2007 baselines follow:  Cardiothoracic surgery ICU: 0.9 CLABSI per 1,000 central line days; 46% reduction  Coronary ICU: 1.4 CLABSI per 1,000 central line days; 25% reduction  Medical ICU: 1.5 CLABSI per 1,000 central line days; 45% reduction  Medical-surgical ICU: 1.4 CLABSI per 1,000 central line days; 34% reduction  Neurosurgical ICU: 1.3 CLABSI per 1,000 central line days; 48% reduction  Surgical ICU: 1.4 CLABSI per 1,000 central line days; 57% reduction  Pediatric ICU: 2.2 CLABSI per 1,000 central line days; 31% reduction  Neonatal ICUs o Regional Perinatal Centers: 1.8 CLABSI per 1,000 central line days; 49% reduction o Level 3 and 2/3 ICUs: 2.9 CLABSI per 1,000 central line days; 17% reduction Clostridium difficile Infection Rates C. difficile is a type of bacteria that causes diarrhea, most commonly among the elderly and those who have recently taken antibiotics. Diagnosis of C. difficile infection is made when an 4 individual has a positive laboratory test performed on stool and compatible symptoms. C. difficile cases are separated into reporting categories based upon whether the onset of illness occurred in the community or in a hospital. Cases termed “community-onset not my hospital” are cases in which the positive stool sample was obtained during the first three days of the patient’s hospital admission and more than 4 weeks after any previous discharge from that same hospital. These cases are presumed unrelated to the patient’s stay in that hospital. Cases termed “community-onset possibly related to my hospital” are cases in which a patient who was discharged from the same hospital within the previous 4 weeks is readmitted to that hospital with a new positive C. difficile test during the first three days of admission. In these cases, it is not certain whether the C. difficile infection occurred as a result of the recent hospitalization or whether it is related to other exposures outside of the hospital. Hospital-onset cases are cases in which a positive stool sample was obtained on day four or later during the hospital stay. In 2011 hospitals reported a total of 21,374 cases of C. difficile among 2.3 million hospital admissions. 10,381 of the reported C. difficile cases were hospital-onset cases, for a hospital- onset incidence rate of 8.5 cases per 10,000 patient days in 2011. This was a 3% increase compared to 2010. Part of this increase may be secondary to an increase in the number of hospitals using highly sensitive tests to detect C. difficile. There are many approved methods available to laboratories to test for the presence of C. difficile in stool. The optimal approach will vary by hospital and depends on hospitals’ choices regarding sensitivity (ability to detect a true positive), specificity (ability to detect a true negative), timeliness, and cost of their testing strategy. Highly sensitive testing methods are more likely to detect C. difficile in the stool. Between January 2010 and December 2011, the percent of hospitals using certain highly sensitive tests increased from 10% to 41%. Cost of Hospital-Acquired Infections HAIs vary in severity. For example, deep SSIs are more complicated and expensive than superficial SSIs. For this reason, ranges are used to estimate the approximate costs of HAIs and cost savings since the inception of the HAI program2. Overall SSI rates decreased by 13% between 2007 and 2011, resulting in a cost savings estimated to be between $9 million and $27 million since 2007. Overall CLABSI rates decreased by 41% between 2007 and 2011, resulting in a cost savings estimated to be between $12 million and $48 million since 2007. For C. difficile, no cost savings were achieved because the hospital-onset C. difficile rate increased by 3%. However, the C. difficile statewide baseline rate is not yet stable because many hospitals are adopting more sensitive laboratory testing methods. 5 Infection Prevention Resources To measure the impact of mandatory HAI reporting on infection prevention personnel and programs, an infection prevention resource survey is conducted annually. In 2011, the average infection preventionist in NYS was responsible for 130 acute care beds. Staffing levels have been stable over the past four years. Data Validation The NYS Department of Health (NYSDOH) ensures the accuracy of the data by performing monthly checks for data consistency and by reviewing medical records during audits. NYS HAI staff attempt to audit most hospitals every year, but because of recent staffing shortages the percent of hospitals audited has declined from 97%, 89%, 89%, 74%, to 68% between 2007 and 2011. NYSDOH developed a process to conduct some audits via off-site access to electronic medical records (EMRs). In 2011, off-site audits were accomplished in 20 hospitals in the Western and Central regions, saving travel time and money. The 2011 audit results will be summarized in the next annual report. In 2010, NYSDOH staff reviewed over 7,000 records, and agreed with the hospital-reported infection status 94% of the time. Disagreements were discussed and corrected in NHSN. The data validation process slightly increases HAI rates, since missed infections are identified and entered into NHSN, and training efforts increase the skills of the hospital IPs, leading to better identification of HAIs. Hospital Rate Summary The following table (Table 1) summarizes HAI rates by hospital in 2010 and 2011. The 2010 data are included again this year both because there have been some modifications as a result of further auditing of the data and in order to visualize patterns of repeated high and low performance. For SSIs and CLABSIs, this table highlights hospitals that performed significantly better (shaded blue) or worse (shaded red) than the NYS average, after adjusting for differences in patients’ risk for infection. For C. difficile, hospital rates are not compared to the state average because insufficient data exists to perform risk-adjustment. Hospital rates may differ because of different patient risk factors and different hospital testing methods, and thus cannot be fairly compared. C. difficile rates are intended to be used by hospitals as a baseline for tracking C. difficile within their own hospital over time. Therefore, the 2011 rate for each hospital is compared to that hospital’s 2010 baseline rate. Because of the impact changes in test methods can have on rates, a 6 statistical comparison was not made for the 34 hospitals that changed to a more sensitive test during this time period. Table 1 provides a summary of all the hospital rates at a glance. More detailed figures in the body of this report plot each hospital rate along with a bar showing the precision of the rate; those graphs can make it easier to understand why similar rates may or may not be flagged as significantly different. Generally, only hospitals that perform a lot of procedures or use a lot of central lines can be highlighted as significantly higher or lower than the state average. In most cases, hospitals are only flagged as significantly better or worse than average in one or two categories. In addition, it is uncommon for a hospital to be flagged in the same category for multiple years. NYSDOH is developing a policy to address repeated under-performance. Lessons Learned Changing C. difficile laboratory testing practices may influence an individual hospital’s rates, and the ability to assess trends over time both within a hospital and statewide. The increase in C. difficile rates in NYS was likely related in part to increased use of more sensitive testing methods. Continued annual surveys of laboratory and reporting practices are important to assess the stability of the C. difficile baseline rate. Hospitals with elevated HAI rates were routinely provided with feedback by telephone and through written summaries of their data and infection rates over time. Most infection preventionists from these hospitals indicated that they shared this additional input with their clinical staff and hospital administration. The prevention efforts were consistently multidisciplinary, which engaged clinicians (intensive care, surgical, and other), support staff, and administration. These infection rates often declined in the following one to two years, which suggests that the use of NHSN data and public reporting is useful to drive efforts to reduce infection rates. By auditing the HAI data of 20 hospitals through off-site access to electronic medical records (EMRs), NYSDOH learned that data could be effectively and efficiently validated through off- site audits. Infection preventionists who participated in this process endorsed this method, and communication and education were successfully provided through phone conferences. Regional differences in health information exchange systems affect the capability to perform off-site audits throughout NYS. Many groups (such as NYS, NHSN, Centers for Medicaid and Medicare Services (CMS), Agency for Healthcare Research and Quality (AHRQ), LeapFrog, and Consumer Reports) are now publically reporting HAI data. In some cases, these reports are based on similar underlying 7 data, yet result in different conclusions. It is important that all reports accurately describe the underlying data and the methods used for analysis. Recommendations and Next Steps In 2013, NYSDOH will continue to track the same indicators that were reported in 2012. Also, NYSDOH plans to monitor voluntarily reported catheter-associated urinary tract infection (CAUTI) data beginning in 2013. Monitoring of CAUTIs will initially be via data use agreement with CDC, which allows use of the data by State departments of health for quality improvement purposes. Individual hospital-identified data obtained via data use agreement will not be included in the NYSDOH annual report. Depending on the progress made in decreasing CAUTIs in NYS, this indicator may be selected for inclusion in NYS mandatory reporting in the future, at which time it would be included in the annual report. Because almost all hospitals have already been reporting this indicator to CMS since 2012, this will place no extra burden on those hospitals. The NYSDOH will continue to conduct audits to verify appropriate use of surveillance definitions and assess accuracy of reporting. The process will be examined in relation to needs for efficiency, fair comparison of hospital performance within NYS and fair comparison of NYS to national rates. Efficiencies will be sought through the use of EMRs and other alternative methods. In addition, the NYSDOH will continue to:  Focus on hospitals with the highest and lowest infection rates to identify risk factors for infection and opportunities for improvement.  Develop and disseminate to hospitals a policy describing how NYSDOH will respond when hospitals have high HAI rates for multiple years.  Monitor the accuracy and timeliness of data being submitted, discuss findings with hospitals, ensure corrective action is taken, and provide technical assistance as needed.  Provide hospitals with education and information about risk factors, strategies, and interventions and encourage adoption of policies and procedures to reduce risk and enhance patient safety.  Evaluate and monitor the effect of prevention practices on infection rates and seek opportunities to enhance patient safety.  Provide HAI data electronically on METRIX, and further develop the presentation of the data on the DOH website.  Collaborate with other NYSDOH staff to investigate outbreaks and evaluate emerging trends. 8  Consult with infection preventionists, hospital epidemiologists, surgeons, neonatologists, and the Cardiac Advisory Committee to identify risk factors and prevention strategies to reduce infections.  Monitor HAI prevention projects for compliance with program objectives, fiscal responsibility and potential applicability to other hospitals or healthcare settings.  Work with the TAW and seek guidance on the selection of reporting indicators, evaluation of system modifications, evaluation of potential risk factors, methods of risk adjustment and presentation of hospital-identified data. Conclusion Since NYS hospitals have been reporting HAIs to the NYSDOH, it has become clear that the NHSN is a useful tool to monitor HAI rates and evaluate the effectiveness of prevention strategies. Hospitals have continuous access to their own data and can compare their rates to national levels and monitor trends over time. In addition, the NYSDOH has continuous access to the data reported by the hospitals for consistent real-time surveillance, identification of trends, and provision of technical assistance as needed. The collected data for the HAIs selected for mandatory reporting in NYS are made available to the public annually, allowing the public to review hospitals’ performance for these particular procedures. Decisions regarding healthcare quality should not be based on these data alone. Consumers should consult with doctors, healthcare facilities, health insurance carriers, and reputable healthcare websites before deciding where to receive care.   The public reporting of HAIs, which began in 2007, has been a factor in significant reductions in SSIs and CLABSIs. NYS surveillance of C. difficile is still new, hospitals are adjusting to advances in laboratory methodology, and C. difficile rates are increasing. While part of the increase is due to more sensitive laboratory methods, additional education and collaborative efforts are needed to reduce C. difficile rates. NYSDOH will continue to address trends and support strategies to further reduce the incidence of HAIs. 9 This page was intentionally left blank. 10